HospitalInspections.org

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Based on record review and interview, the facility failed to ensure that an Incident Report was completed after each "Security / Manpower Code Blue" as required by facility Policy for eighteen (18) out of eighteen (18) "Code Blues".

Findings:

Review of the facility's Policy titled "Security / Manpower Code" (Policy developed to ensure response to unsafe situations and the need for additional staff in the facility) dated 10/2013, states an "Incident Report" will be prepared by the Director of Security, the Administrator on Duty, or the Nursing Supervisor including all pertinent information relevant to the security emergency, the nature of the emergency, the names of the involved individuals, the location and time. Security Personnel will make entries in the Security Log Book.

Review of the "Security Log Book" from 02/06/14 to 09/15/14 revealed that the Security Personnel responded to thirty (30) Code Blues which were documented by the Security Officers (SO). Review of the thirty (30) entries revealed that eighteen (18) responses involved patients. However, none of the entries contained all of the information required by the Policy.

Review of the Security Log Book entry on 03/18/14 at 9:03PM documented "Operator announced a 'Code Blue' to 'T' Unit, Room #20; Bed #2. SO (Security Office) responded. Patient wanted to leave, confused. Medical staff put on arm restraints. Code ended at 9:33PM." However, there was no Incident Report completed.

Review of the Security Log Book entry on 07/14/14 at 9:45PM documented "Code Blue called in SDU Room #3. SO (Security Office) responded to Room #3. Patient was out of control. Patient in restraint at this time." However, there was no Incident Report completed.

Review of the Security Log Book entry on 08/20/14 at 12:57PM documented "Operator called a 'Code Blue' in CCU (Cardiac Care Unit). SO (Security Office) and staff responded. Patient confused and wanted to leave." However, there was no Incident Report completed.

Review of the "Incident Report Log" from 04/01/14 to 09/28/14 revealed no Incident Reports related to "Security / Manpower Code Blue".

During an interview with Staff #1 in the afternoon on 10/02/14, the staff member stated that the Security Officers do not apply the actual restraint but they would provide physical assistance as needed. He then stated that "he has not been completing Incident Reports as describe in the Policy, he has only had the Security Staff document in the Log Book" and "he has not reviewed the Log entries to ensure that they were completed with the information required in the Policy".
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Based on record review and staff interview, the facility failed to ensure that the Nursing staff documented Physician notification that Orders for restraints were not implemented, as required by facility Policy for two (2) out of (7) Restraint Records reviewed (Patients #46 and #47).

Findings:

Review of Medical Record #46 revealed that the Physician Order Sheet documented on 07/08/14 at 3:10PM that the Physician ordered the patient be placed in a jacket / vest violent restraint due to a danger to self. The Order was acknowledged by the Nurse at 3:32PM. A Nursing Note at 3:46PM then documented that the patient was alert, confused, out of bed to chair with no sign of discomfort noted.

The Record lacked documented evidence that the patient was placed in a vest restraint or that the Practitioner was notified that the Order for the restraint was not implemented.

Review of Medical Record #47 revealed that the Physician Order Sheet documented on 08/29/14 at 6:34AM, that the Physician ordered the patient be placed in a bilateral soft wrist violent restraint due to a danger to self. The Order was acknowledged by the Nurse at 6:56AM. A Nursing Note at 10:01AM then documented that the patient was "NOT on wrist restraints when received from ED Nurse".

The Record lacked documented evidence that the patient was placed in wrist restraints or that the Practitioner was notified that the Order for the restraint was not implemented.

Review of the Supervisors' "Restraint / Supervision 1:1 Coverage" Shift Reports for 07/08/14 and 08/29/14 confirmed that neither Patient #46 nor #47 were placed in restraints.

During interview on 10/03/14 at 12:24PM, Staff #7 confirmed these findings.

The facility Policy titled "Restraint Policy for Non-Violent, Non-Self Destructive Behavior and Violent Self Destructive Behavior" dated 06/2014 states in (F.) "Discontinuation of Violent-Self Destructive Behavior Restraints states when the patient meets the behavior criteria for the discontinuation of the restraint the Licensed Independent Practitioner (LIP) must be notified".
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Based on record review and staff interview, the facility failed to ensure that: a) the Nursing staff consistently documented care given to patients with central lines for two (2) out of (3) Records reviewed (Patients #25 and #27), and b) there was consistent documentation of a multi-disciplinary approach included in the tentative Discharge Plan in the Interdisciplinary Patient Care Coordination Rounds (ICC Rounds) for two (2) out of (10) Records reviewed (Patients #13 and #33).

Findings:

a) Patient #25 was admitted on 09/19/14 with the diagnosis of Pneumonia and Respiratory Failure. The patient had a sub-clavian central line in place for intravenous antibiotics and fluids.

During review of Patient #25's Medical Record on 10/01/14 at 11:10 AM, it was revealed that the Medical Record lacked documented evidence that the patient was receiving a daily Chlorhexidine bath as per facility Policy.

This was confirmed with Staff #3 in the presence of Staff #2 at the time of Record review.

Patient #27 was admitted on 09/23/14 with the diagnosis of Muscular Dystrophy with Respiratory Failure. The patient had a sub-clavian central line in place for intravenous antibiotics and fluids.

During review of Patient #27's Medical Record on 10/01/14 at 11:30 AM, it was revealed that the Medical Record lacked documented evidence that the patient was receiving a daily Chlorhexidine bath as per facility Policy.

This was confirmed with Staff #4 in the presence of Staff #2 at the time of Record review.

Review of the facility Policy titled "Chlorhexidine (CHG) Bath" dated 08/2014 noted under the Section titled "For all patients with a central line": #1 "All patients with a central line will be bathed daily with CHG solution 4%".

b) Review of the Medical Record for Patient #13 revealed that the patient was admitted to the facility on 09/24/14 with a UTI (Urinary Tract Infection) and was receiving intravenous antibiotics. The Social Worker documented in the "Psychosocial Initial Screen Flow-Sheet" that the patient lived in a private residence with her family members and her expected discharge location was the same. The area for Home Care and Community Services was initially left blank.

Review of the Multi-Disciplinary Problems Care Plan documented on 09/25/14 that the Nurse made a referral to "Home Care, Care Management / Social Services" which was confirmed by review of the "Clinical Notes" documented by the Home Care Nurse on 09/25/14 at 12:52 PM.

Review of the electronic ICC (Inter-Disciplinary Care Coordination) Flow-Sheet revealed that the Nursing staff incorrectly documented on 09/26/14, 09/27/14 and 09/29/14 that the patient would be discharged to a private residence (home) instead of home with Home Care. The Discharge Plan area on 09/28/14 was blank.

On 09/30/14 an interview with Staff #5 revealed that the Discharge Plan was for the patient to return home with Home Care and that a referral had been made by the Nurse caring for the patient on 09/25/14.

Review of the Medical Record for Patient #33 revealed that the patient was admitted on 07/10/14 with a Cerebral Vascular Accident (CVA) and Dysphagia. The patient then required placement of a PEG (Percutaneous Endoscopic Gastrostomy) and was started on tube feedings.

Review of the Social Service Notes, documented on 07/14/14 at 3:41 PM, revealed that the patient's daughter met with the Social Worker and that the patient would be returning home. The Social Worker documented the patient is a new feeding tube and that referrals were made to Home Care.

Review of the ICC Rounds Flow-Sheet revealed that the Nursing staff and the Social Worker incorrectly documented on 07/14/14 and 07/15/14 that the patient would be discharged to a private residence (home) instead of home with Home Care.

This was confirmed with Staff #6 on 10/02/14.

Review of the Policy titled "Interdisciplinary Patient Care Rounds (ICC Rounds) dated 07/2014 revealed that "ICC Rounds will be documented in the Electronic Health Record. Patient priority goals, strategy to facilitate favorable outcomes and Discharge Planning will be part of the ICC Rounds. And in the area labeled "Procedure" the Policy states (#5) that the Team Caregivers communicate critical information focusing on priority areas including (f.) Discharge Plan and (#8) the patient priority goals and outcomes are documented in the Electronic Health Record in the ICC tab. The Policy does not designate which staff member is responsible for documenting this information.
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Based on record review, observation and staff interview, the Food Service Director failed to take responsibility for the daily management of the service to ensure that: a) proper safety practices for handling food were maintained, and b) implementation of the Policy and Procedure for the maintenance of food and supplies in the event of a disaster.

Findings:

a) Review of the Freezer Logs for July, August and September 2014 noted that the temperatures taken daily were recorded outside of the acceptable range. Temperatures were noted to range from 5 (five) degrees Fahrenheit to 19 (nineteen) degrees Fahrenheit.

Additionally, the Nutritional Services Daily Refrigerator and Freezer Temperature Log Sheets list the range for the freezer as 15 (fifteen) degrees Fahrenheit to 20 (twenty) degrees Fahrenheit.

The acceptable temperature range for the freezer is 0 (zero) degrees and below.

These temperatures were recorded out of range for three (3) months.

On 10/03/14 at approximately 11:30AM a revisit was made to the Main Kitchen to check the freezer temperatures. The freezer temperatures were noted as follow:

Freezer Temperature

#5 10 (ten) degrees Fahrenheit

#4 6 (six) degrees Fahrenheit

#10 10 (ten) degrees Fahrenheit

These findings were confirmed with Staff #8 when the observations were identified.

b) Review of Nutrition Service Department Policy #6.2 titled "Departmental Disaster / Emergency Preparedness Plan" on 10/01/14, it was noted that based on a an average patient census of eighty to one hundred (80-100) patients, the Department maintains four (4) days' worth of supplies. The list includes twenty (20) cases of paper goods, eighty (80) cases of canned dry goods, one hundred forty-four (144) cases of refrigerated foods and one hundred forty (140) cases of nutritional supplies.

Observation during the Kitchen tour on 09/29/14 revealed that the facility's emergency food supplies were not kept separate from the regular food supplies.

The Nutrition Service Disaster / Preparedness Plan does not include a Disaster Menu Plan. There is no Menu describing the type and amount of foods to be used for special Diets, example: Puree Diet. There was no list for enteral feeding.
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Based on staff interview, review of Menus and nutrient analysis of the Menus, it was determined that the Food and Nutrition Department failed to ensure that: a) Physician Prescribed Diets met the nutritional needs of patients, and b) the current Menu is posted in the Kitchen.

a) Review of the facility Menus and nutrient analysis of the Menus was conducted on 10/01/14. It was noted that nutrient analysis was done for Low Sodium, Low Fat, Low Potassium and 1800 Calorie Diets and not on all the Diets served in the facility.

The remaining diets were not analyzed to assess the compliance to the national standard titled "Recommended Daily Intakes".

Therefore, the nutrition adequacy of these Menus is unknown. Due to the lack of nutrient analysis calculated for these Menus, there is no way to verify that the Diet Orders are provided as prescribed by the Practitioner(s) responsible for the care of the patients.

This finding was confirmed by Staff #8.

b) A tour of the Kitchen was conducted on 09/29/14 at approximately 10:45AM. During the tour it was noted that the current Menu was not posted in the Kitchen as required. When asked why the Menu was not posted, Staff #8 stated that the Menus are on CBOARD (Food Service Software) and that a Tally Sheet is sent to the Cooks.
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Based upon observations, interviews and review of the facility's Policies and Procedures and other facility documents, it was determined that the facility failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings:

The facility failed to meet Life Safety Code Standards (See Tag A 710).

The facility failed to ensure that all ceiling tiles, light fixtures and ventilation ducts in the facility building were maintained in good repair and/or a clean condition and that walls that enclose designated Airborne Infection Isolation Rooms were sealed to prevent air from infiltrating the environment from the outside or from other spaces (See Tag A 722).
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Based on record review, observations and interviews, the facility failed to ensure that the Life Safety Code for Fire Requirements was met.

Findings:

See Life Safety Code Survey

K11 - The facility failed to ensure that the building containing healthcare occupancy maintained a common wall that is has at least a two (2) hour fire resistant rating.

K17 - The facility failed to ensure that corridor walls form a barrier to prevent the transfer of smoke.

K18 - The facility to ensure that all corridor doors were provided with positive latching hardware.

K20 - The facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a one (1) hour resistance rating.

K21 - The facility failed to ensure that doors in smoke barriers were self-closing and kept in the closed position.

K25 - The facility failed to ensure that existing smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating.

K27 - The facility failed to ensure that smoke barrier doors were self-closing.

K29 - The facility failed to ensure that all newly constructed hazardous areas were enclosed with at least a one (1) hour fire resistance rated walls and are protected by self-closing positive latching doors.

K46 - The facility failed to ensure that battery-powered fixtures were maintained.

K48 - The facility ensure that all staff were aware of the locations of smoke barrier walls.

K54 -The facility failed to ensure that smoke detectors were properly maintained.

K56 - The facility failed to ensure that the automatic sprinkler protection was provided in all required areas.

K62 - The facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and free of foreign materials.

K67 - The facility failed to ensure that vertical ventilation ducts in the building were protected.

K69 - The facility failed to ensure that the required placards were placed near each portable fire extinguisher in cooking areas.

K72 - The facility failed to ensure that means of egress were free of obstructions or impediments.

K77 - The facility failed to ensure that piped oxygen was only used for patient care applications.

K130 - The facility failed to ensure that where extinguishment or control of fire is effectively accomplished by a type of automatic sprinkler system that is installed, inspected and maintained in accordance with standards.

K145 - The facility was not provided with a Type I Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems.

K147 - The facility failed to ensure that electrical wiring was installed and maintained in good repair.

K211 - The facility failed to ensure that alcohol based hand dispensers were not installed directly over an ignition source.
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Based on observations and staff interview, the facility failed to ensure that: a) all ceiling tiles, light fixtures and ventilation ducts in the building were maintained in good repair and/or a clean condition, b) all hand wash sinks used by staff were trimmed with wrist blades that were at least four (4) inches long, and c) that walls that enclose designated Airborne Infection Isolation Rooms were sealed to prevent air from infiltrating the environment from the outside or from other spaces.

Findings:

a) On 09/29/14 at 10:05AM a heavy build up of dust was noted around and inside a ceiling exhaust ventilation duct opening in the T-Wing Nurses' Station Crash Cart / Oxygen Tank Storage Alcove on the 1st Floor of the "1955" Building.

On 09/29/14 at 2:00PM a heavy build up of dust was noted around a ceiling exhaust ventilation duct opening in the 1st Floor Hyperbaric Chamber Treatment Room.

On 09/30/14 at 9:52AM two (2) stained ceiling tiles were found in a C-Wing Storage Room on the 1st Floor of the "1955" Building.

On 09/30/14 at 10:54AM three (3) water stained ceiling tiles were found in a Basement Linen Storage Room (the former Training Room) in the "1955" Building.

On 10/01/14 at 9:25AM a plastic cover on a light fixture in the Basement Level accessory staircase that serves the basement Physical On-Call Room was found to be cracked / in disrepair.

On 10/01/14 at 9:32AM a stained ceiling tile was noted in the Formaldehyde Storage Room in the Basement of the "1955" Building.

As per concurrent interviews with the facility's Director of Engineering, the findings were confirmed.

b) On 09/29/14 at 11:30AM the wrist blades on a hand wash sink in the 1st Floor Critical Care Unit in the "1977" Building were found to only be approximately two and one-half (2½) inches long.

On 09/30/14 at 9:58AM the control valves on a hand wash sink in the 1st Floor EEG Room were noted to be conventional twist-operation valves rather than at least four (4) inch long wrist blades as required.

On 10/01/14 at 2:15PM the wrist blades on a hand wash sink in the 2nd Floor A-Wing PACU (Post Anesthesia Care Unit) / Recovery Room in the "2001" Building were found to only be approximately two and one-half (2½) inches long.

As per concurrent interviews with the facility's Director of Engineering, the findings were confirmed.

c) On 10/01/14 at 2:55PM three (3) unsealed cable penetrations and one (1) partially sealed conduit penetration were noted in the enclosure walls of a designated Airborne Infection Isolation Room in the PACU / Recovery Room on the 2nd Floor of the A-Wing in the "2001" Building.