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Based on observation, document review, and staff interview the facility failed to timely implement preventative maintenance for one hospital medical unit identified for corrective actions related to environmental conditions and patient safety. This had the potential to affect all patients, visitors, and staff of the six bed in-patient unit during the ten month period 01/01/15 through 10/01/15. The hospital census was 569.

Findings include:

On 09/30/15 at 1:30 PM a tour of the Blood and Marrow Transplant Unit was conducted including observations of an in-patient room. The room included an overhead air vent for air conditioning and a wall unit for heat. The air conditioner was in operation with cool air blowing from the overhead vent.

On 09/30/15 the hospital provided a document entitled, Scope of Care for the Blood and Marrow Transplant Unit, revised 04/2014. The document identified the Blood and Marrow Transplant Unit (BMTU) as a six bed in-patient advanced/critical care oncology unit specializing in the care of adults with cancer undergoing autologous peripheral; blood stem cell or bone marrow transplant. The Scope of Care documented the process to minimize fungal spore counts included high-efficiency particulate air (HEPA) filtration used along with directed room airflow which is a positive air pressure in patient rooms in relation to the corridor air pressure. The system allows air from patient rooms to flow into the corridor.

On 10/01/15 at 11:30 AM the Director of Plant Services and Engineering, Staff B, stated the BMTU had not been shut down during the last seven years for any reason other than construction from 10/13/11 through 02/06/12.

Staff B stated the construction included new steam heating coils, new steel boxes to contain the heating coils, new room wall thermostats, cleaning and installation of sidewall supply grilles, cleaning of exhaust grilles and installation of new air conditioning boxes. Staff B stated an independent contractor, Hayden Safety Engineers, completed air testing certification for the Blood and Marrow Transplant Unit including rooms 5518, 5517, 5516, 5514, 5512, and 5510 on 01/30/12 and 01/31/12. All air tests results were within normal limits. Staff B also stated routine preventative maintenance for the BMTU had included monthly maintenance for the air handler unit which supplies air to the six in-patient rooms.

Staff B identified a patient and family expressed concern regarding the BMTU air quality during the month of January 2015. An internal investigation of the unit's air system resulted in new preventative maintenance initiatives to be implemented monthly, quarterly, semi-annually, and every three year.

Staff B stated the new preventative maintenance identified would include monthly maintenance with changing all air filters, pre-filters, and secondary filters, greasing all bearings and replacing V-belts within the air handling unit. Quarterly maintenance would include cleaning all air diffusers in the Bone and Marrow Transplant Unit and check operation of all room thermostats, cleaning all radiant wall heaters, and notify the nurse manager of any identified issues. Semi-annual maintenance would include changing secondary filters and HEPA filters within the air handling unit. Three year maintenance would include system duct cleaning of the air handling unit per manufacturers recommendations.

The patient safety concerns raised with the BMTU air quality resulted in an internal investigation with implementation of new preventative maintenance and schedules. The preventative maintenance logs for the BMTU for 2015 were requested for verification however, the hospital failed to provide documented evidence of the maintenance. Staff B stated the preventative maintenance schedule was to begin starting October 2015, ten months after the patient safety concerns for the BMTU were addressed.

Based on record review and staff interview, the facility failed to ensure care needs were assessed regarding catheterization needs for one of one patient reviewed (#19) who had orders for intermittent catheterization. The facility census was 569.

Findings include:

Review of the medical record of Patient #19 revealed an admission date of 09/14/15. The physician's orders were reviewed on 09/29/15 on the electronic medical record. A physician's order dated 09/15/15 for straight catheterization every 4 hours, as needed, was noted.

Review of the nursing flow sheet records revealed a straight catheterization was completed on 09/25/15 at 7:48 PM and 700 cc of urine was obtained. The next catheterization was not completed until 09/26/15 at 7:12 AM. It was noted 1400 cc of urine was obtained. The next catheterization was noted on 09/26/15 at 6:00 PM and 900 cc of urine was obtained. Review of nursing documentation on 10/01/15 at 12:05 PM with Staff G revealed no documentation of nursing staff assessing the patient every four hours to determine the need for a catheterization.
This was confirmed with Staff G.

Based on observation and staff interview it was determined the facility failed to ensure all medical records were protected against destruction by water. The active census was 569.

Findings include:

On 10/01/15 at 11:25 AM a tour of the medical records department was conducted. An observation determined paper medical records were being stored in manila file folders on six large open shelves with no lid or enclosure to protect the records in the event of activation of the sprinkler system. Staff E stated in an interview the medical records were discharges from 2008 through 2009. Staff F confirmed on 10/01/15 at 11:37 AM the 77,868 medical records being stored on the shelves had not yet been scanned into the electronic health records.

Based on staff interview and review of the Medial Staff Bylaws it was determined the facility failed to ensure medical records were completed within thirty (30) days of discharge. This affected 537 medical records reported in September 2015. The active census was 569.
Findings include:
Review of the Medical Staff Rules and Regulations (Page 12) revealed medical records of discharged patients shall be completed within a period of time that will in no event exceed thirty (30) days following discharge. The Medical Staff Bylaws state practitioners would be notified and privileges suspended due to delinquent medical records. Reinstatement of privileges would then be based upon completion of all delinquent records. The medical records data for 2014 through 2015 consistently included three hundred to six hundred monthly medical records not completed within thirty days of discharge. This finding was confirmed with Staff E on 10/01/15 at 11:20 AM.

Based on observation, interview, and record review, the facility failed to maintain two hour barrier between nonconforming buildings, to ensure its corridor doors with gaps had astragals, rabbets, or bevels, to maintain the rating of the barriers protecting vertical openings, to ensure access to exits were marked with approved readily visible signs,to maintain the rating of its smoke barriers, to ensure each door in its smoke barrier closed completely, to ensue each hazardous area had a self closing door, to maintain the rating on its barriers protecting stairways and other exit components, to include all personnel in participating in fire drills, to ensure its fire alarm system complied with National Fire Protection Association 72, 1999 edition, to maintain its automatic sprinkler system in accordance with National Fire Protection Association 13 and 25, to ensure space heaters were appropriately used and not in patient care areas, to maintain ratings of smoke barriers penetrated by ducts, to maintain one hour rating on wall between itself and other building occupants, to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101 and to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101, and to use power strips in accordance with National Fire Protection Association 70, 1999 edition. (A709)

Based on observation, interview, and record review, the facility failed to maintain two hour barrier between nonconforming buildings, to ensure its corridor doors with gaps had astragals, rabbets, or bevels, to maintain the rating of the barriers protecting vertical openings, to ensure access to exits were marked with approved readily visible signs,to maintain the rating of its smoke barriers, to ensure each door in its smoke barrier closed completely, to ensue each hazardous area had a self closing door, to maintain the rating on its barriers protecting stairways and other exit components, to include all personnel in participating in fire drills, to ensure its fire alarm system complied with National Fire Protection Association 72, 1999 edition, to maintain its automatic sprinkler system in accordance with National Fire Protection Association 13 and 25, to ensure space heaters were appropriately used and not in patient care areas, to maintain ratings of smoke barriers penetrated by ducts, to maintain one hour rating on wall between itself and other building occupants, to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101 and to ensure exit discharges are arranged and marked in accordance with 7.7.3, National Fire Protection Association 101, and to use power strips in accordance with National Fire Protection Association 70, 1999 edition. (A709)

Findings include:

Please refer to LSC for detailed information.
K11 Failed to maintain a two hour rated barrier between two non-conforming buildings.
K18 Failed to ensure self closers and latching hardware on doors that protected corridor openings closed and latched the doors.
K20 Failed to maintain protective construction around vertical openings.
K22 Failed to ensure access to exits were marked by approved, readily visible signs.
K25 Failed to maintain protective ratings of its smoke barriers.
K27 Failed to ensure that doors in rated smoke barriers with self closing and latching hardware closed and latched the doors and were rated as stated for the barrier itself.
K29 Failed to ensure each of its sprinklered, hazardous areas were able to resist the passage of smoke.
K33 Failed to ensure stairways used as exit components had doors that closed, latched and were rated to the rating of the construction protecting the stairway.
K39 Failed to maintain a clear width of at least 8 feet in exit access corridors.
K50 Failed to hold fire drills on third shift at varying times.
K51 Failed to ensure each of its smoke detectors were unobstructed and tested yearly.
K54 Failed to have its smoke detectors' sensitivity tested biannually.
K62 Failed to ensure the sprinklers in its system were clean and items were at or greater than 18 inches beneath them.
K63 Failed to maintain a water supply which provided continuous and adequate pressure to its sprinkler systemK64 Failed to deploy a class k fire extinguisher in accordance with NFPA 10 to the kitchen in its physician lounge.
K67 Failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4.
K71 Failed to maintain the stated rating of the protective construction of rooms in which chutes terminate.
K72 Failed to document the time the alarm was activated and the time the monitoring company received an alarm signal as in accordance with National Fire Protection Association 72.
K130 Failed to have a one hour barrier between itself and the rest of the occupants in the building housing its detached emergency department and failed to maintain the stated rating of its smoke barrier.
K147 Failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition.

Based on observation, staff interview, and policy review the facility failed to follow manufacturers directions for dialysis water testing and failed to ensure proper operating condition of dietary equipment. This had the potential to affect all patients and visitors utilizing dietary services and all dialysis patients. The hospital census was 569.

Findings include:

1. On 09/28/15 at 2:45 PM Staff H was observed to conduct a chlorine/ chloramine check of the water on the in-patient dialysis center. Staff H turned on the RO water and allowed to run less than five minutes prior to obtaining the water for the test from the first carbon tank. Staff H filled a 240 cc cup with water and dipped the test strip into the water and removed and read the strip. The directions on the container of strips labeled Low level Chorine/ Chloramine read that the strip was to be held for 30 seconds under a slow running stream of test water. Staff N confirmed Staff H had not completed the water test as per the manufacturer of the water testing strips. The facility identified 11 patients on in-center dialysis.

2. On 09/30/15, tours of the dietary kitchens were completed. At 11:05 AM the conveyor dish washing machine in the lower level kitchen was observed. The manufacturer's instructions on the machine noted the final rinse temperature of 180 degrees Fahrenheit. The dish machine was running at the time of the observation and it was noted the final rinse temperature did not maintain a temperature of 180 degree or greater during the final rinse cycle. The rinse temperature ran from between 170 and 176 degrees. The temperature did reach a high of 184 degrees but as the dish conveyor continued, the temperature did not return above 180 degree.

Review of the temperature dish machine temperature log for September, 2015 revealed the final rinse temperatures were not being logged during the rinse cycle and were recorded as low as 82 degrees for a final rinse. Staff O stated the logs reflected "sitting" temperatures. During an interview with Staff I on 09/29/15 at 12:30 PM, Staff I stated the temperatures logged should reflect temperatures as dishes are going through the final rinse, steam, process.



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Based on observations, staff interview and policy review, the facility failed to ensure staff completed hand hygiene following direct patient care, as appropriate. The facility also failed to ensure gloves were changed when appropriate and failed to ensure an environment remained free of an accumulation of dust. This had the potential to affect all 569 patients of the facility.

Findings include:

1. On 09/28/15 at 1:30 PM, Staff K was observed to enter the room of Patient #4 wearing isolation gown and gloves. The patient was in contact isolation. Staff K conducted the task which required patient contact. When the task was completed, Staff K removed the gown and gloves and exited the room. Staff K failed to perform hand hygiene upon leaving the room. This finding was confirmed with Staff K at 1:45 PM on 09/28/15.

2. On 09/29/15 at 10:15 AM, a dressing change for Patient #17 was observed. Staff J was observed to remove the soiled dressing from the patient's upper right thigh area. Staff J did not remove gloves and perform hand hygiene prior to cleaning the area with soap and water. After Staff J patted the area dry, Staff J placed the ordered dressing on the area. Staff J then removed gloves and put on another pair of clean gloves but did not perform hand hygiene prior to putting on the clean pair of gloves.

Review of a policy provided on 10/01/15 at 2:45 PM from Staff G revealed under area; Cleaning the wound : Remove and discard the old dressing, Inspect and measure wound, irrigate the wound, and Remove and discard your gloves, perform hand hygiene, and then put on a new pair of gloves.

3. On 09/30/15 at 12:00 PM, Staff L was observed to take a food tray into a room of a patient who was noted to be in contact isolation. Staff L put on an isolation gown and gloves and brought the tray into the room. Staff L removed gloves and washes hands and then stepped out of the room with the gown on looking for a place to discard it once removed. Staff L then stepped back into the room and removed and discarded the gown. Staff L then proceeded to push the food cart down the hall, without washing hands after removing the gown. This was verified with Staff I at the time of the observation.


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4. The NICU was toured on 09/28/15 at 11:00 AM. Noted on the ceiling in room 1051, the negative pressure room, were two dime-shaped, tannish-brown circles. These tannish-brown circles were easily wiped off by an Environmental Services staff member using a damp cloth. The same tannish-brown circles were noted on the ceiling in room 1052. The same circular stains were noted on the ceiling in room 1071, occupied by a neonate.

The Newborn Nursery on the Postpartum Unit was toured on 09/28/15 at 01:45 PM. A thick layer of dust was noted to fall down from the top of a warmer in the nursery. Thick dust was also noted on top of a warmer in room 2102 of the Family Beginnings, a birthing center.

The facility policy titled Room Cleaning was reviewed on 09/29/15 at 12:15 PM. According to the policy staff are instructed to clean/disinfect furniture, sills, telephones, ledges and and other open surfaces with a damp cloth using germicidal cleaning solution. These findings were confirmed with Staff A on 09/29/15 at 01:30 PM.

5. An Environmental Services staff member was observed to enter the conference room where surveyors were meeting on 09/28/15 at 05:05 PM. The staff member was noted to be wearing a pair of blue, disposable gloves. After asking the surveyors if it was alright to empty the garbage can in the kitchenette, the Environmental Services staff member emptied the garbage can in the kitchenette of the conference room. This staff member then left the kitchenette, wearing the same blue disposable gloves, just before leaving the conference room, Staff A stopped him/her instructing him/her to discard the disposable gloves.

An Environmental Services staff member was observed pushing a cleaning cart just in front of the facility elevators. This staff member was noted to be wearing a pair of blue, disposable gloves. He/She was then observed walking to the Information Desk, leaving the cleaning cart in front of the elevators. The staff member stopped at the Information Desk leaning over the desk, resting his/her hands on the ledge of the desk. He/She was noted to be wearing the same blue, disposable gloves. After conversing with his/her coworkers, he/she went back to the cleaning cart, pushing it down the hall.

The facility policy titled Orientation to Environmental Services was reviewed on 09/30/15 at 10:45 AM. According to the policy staff are instructed to change gloves at the frequency of every patient room. These facts were confirmed with Staff A on 09/30/15 at 10:50 AM.