HospitalInspections.org

Based upon document review, observation and interview, the facility failed to follow their policy/procedure ensuring that medical records (MR) were not accessible to unauthorized individuals for 1 of 5 off-site locations.

Findings:

1. The policy/procedure Medical Records (reviewed 5-12) indicated the following: " The MR shall be considered the property of the health care facility, which shall seek to safeguard it from unauthorized use, access, loss, or destruction ...Information in the MR will be kept confidential ... "

2. During an off-site tour of the satellite rehab therapy department on 1-07-13 at 1455 hours, MR were observed in two unsecured drawers in a patient registration area with two locking doors.

3. During an interview on 1-07-13 at 1455 hours, staff A14 indicated that housekeeping provided cleaning services in the area during the evening/night hours when therapy and office staff were not present and confirmed that the staff were not locking the cabinet drawers overnight when housekeeping services were provided and the MR were accessible to unauthorized staff.

Based on review of policies and procedures, blood transfusion records, and staff interview, medical records entries on blood transfusion administration records failed to be legible for 4 of 8 records reviewed.

Findings included:

1. Review of policy titled "Medical Records", last reviewed "10/11" on 1-8-13 between 2:45 PM and 3:00 PM, which read: "Entries must be legible."

2. Review of blood transfusion administration records on 1-8-13 between 11:30 AM and 2:45 PM revealed the time the unit of blood was issued was illegible for the following patients:

Patient Date
__________________
L1 10-12-12
L2 10-1-12
L3 10-26-12
L7 10-8-12

3. In interview on 1-8-13 between 11:30 AM and 2:45 PM, Staff Member #L2 acknowledged the above findings.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that a consent for admission and treatment was signed by 1 of 1 obstetric patient.
(pt. # 10)

Findings:
1. at 3:50 PM on 1/9/13, review of the policy and procedure "Consents - Adults, Minors, Emancipated Minors, Incompetent Patients, and Emergency Treatment", with a last date of review of 1/10, indicated:
a. under "I. Policy Statement", it reads: "Under Indiana law, a patient must consent to the Health Care provided to him/her. Parkview Noble Hospital complies with the requirement of Indiana law and with the standards of accrediting agencies relating to consent for treatment. Consent must be obtained for all hospital admissions."

2. at 4:35 PM on 1/8/13, while on tour of the obstetric nursing unit, the medical record for one patient admitted on 1/7/13 was reviewed and indicated a consent for admission and treatment was lacking in the patient's record

3. at 2:35 PM on 1/9/13, interview with staff member # 58, the nursing educator, indicated:
a. after thorough review of the medical record for pt. #10, a consent for admission and treatment could not be found, as required by facility policy

Parkview Noble Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

Parkview Noble Hospital is comprised of the main hospital in Kendallville, IN (Building 06), Ligonier Rehabilitation Services Building in Ligonier, IN (Building 02), Avilla Lab and Radiology Services in Avilla, IN (Building 03), Satellite Imaging Center in Angola, IN (Building 04) and Satellite Rehab Therapy in Kendallville, IN (Building 05).

Parkview Noble Hospital's main building, Building 06, a two story fully sprinklered building of Type I (332) construction with a basement and a fire alarm system with smoke detection in the corridors; patient rooms and spaces open to the corridors was surveyed with Chapter 18, New Health Care occupancies. Building 06 provides overnight care. Building 06 has a capacity of 31 and had a census of 29 at the time of this survey.

Ligonier Rehabilitation Services, Building 02, a one story fully sprinklered building of Type V (000) construction with a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 38, New Business Occupancies. Building 02 provides rehabilitative services during regular business hours.

Avilla Lab and Radiology Services, Building 03, a one story nonsprinklered building of Type V (000) construction without a fire alarm system was surveyed with Chapter 38, New Business Occupancies. Building 03 provides lab and radiology services during regular business hours.

Satellite Imaging Center, Building 04, a one story nonsprinklered building of Type V (000) construction with a fire alarm system was surveyed with Chapter 38, New Business Occupancies. Building 04 provides imaging services during regular business hours.

Satellite Rehab Therapy, Building 05, a one story nonsprinklered building of Type V (000) construction without a fire alarm system was surveyed with Chapter 38, New Business Occupancies. Building 05 provides rehabilitation therapy services during regular business hours.

Based on LSC survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 1 of 1 Radiology Suite electrical rooms (see K 056), failed to ensure oxygen stored in 1 of 2 sprinklered oxygen storage locations was separated from any portion of a facility wherein residents are housed, examined, or treated by a separation of a fire barrier of 1 hour fire resistive construction and is vented to the outside (see K 076) and facility failed to provide complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems in the main building, Building 06 (see K 144).
The facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire, failed to ensure emergency lighting was tested for 9 of 9 battery operated emergency lights and failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs (see K 130) at the Ligonier Rehabilitation Services, Building 02.
The facility failed to ensure emergency lighting was tested for 5 of 5 battery operated emergency lights, failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs, failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart and failed to ensure extension cords were not used as a substitute for fixed wiring (see K 130) at the Satellite Imaging Center, Building 04.
The facility failed to failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart, failed to ensure 2 of 2 battery powered emergency lights were tested and would function and failed to ensure 4 of 4 exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function (see K 130) at the Satellite Rehab Therapy, Building 05.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, record review and staff interview, the facility failed to ensure a complete automatic sprinkler system was provided for 2 of 2 elevator equipment rooms and 1 of 1 Radiology Suite electrical rooms, failed to ensure oxygen stored in 1 of 2 sprinklered oxygen storage locations was separated from any portion of a facility wherein residents are housed, examined, or treated by a separation of a fire barrier of 1 hour fire resistive construction and is vented to the outside and facility failed to provide complete documentation for testing 1 of 1 emergency generators providing power to the emergency lighting systems in the main building, Building 06.
The facility failed to ensure 1 of 1 fire alarm control panels, located in an area that was not continuously occupied, was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire, failed to ensure emergency lighting was tested for 9 of 9 battery operated emergency lights and failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs at the Ligonier Rehabilitation Services, Building 02.
The facility failed to ensure emergency lighting was tested for 5 of 5 battery operated emergency lights, failed to ensure exit signs connected to or provided with a battery operated emergency illumination source was tested for 2 of 2 battery operated exit signs, failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart and failed to ensure extension cords were not used as a substitute for fixed wiring at the Satellite Imaging Center, Building 04.
The facility failed to failed to ensure 1 of 1 portable fire extinguishers was given maintenance at periods not more than one year apart, failed to ensure 2 of 2 battery powered emergency lights were tested and would function and failed to ensure 4 of 4 exit signs connected to, or provided with, a battery operated emergency back up power source were tested and would function at the Satellite Rehab Therapy, Building 05.

Findings:

Building 06:
1. Observation with #0, #1 and #2 made on 01/08/13 from 2:02 p.m. to 2:20 p.m. indicated both basement elevator equipment rooms lacked sprinkler coverage.
2. In interview with #0, #1 and #2 on 01/08/13 from 2:02 p.m. to 2:20 p.m., it was confirmed both basement elevator equipment rooms lacked sprinkler coverage.
3. Observation with #0, #1, #2 and #3 made on 01/09/13 at 11:40 a.m. indicated the Radiology Suite electrical room lacked sprinkler coverage.
4. In interview with #0, #1, #2 and #3 on 01/09/13 at 11:40 a.m., it was confirmed the Radiology Suite electrical room lacked sprinkler coverage.
5. Observation with #0, #1, #2 and #4 made on 01/08/13 at 2:55 p.m. indicated a large stationary liquid oxygen unit was stored in the Cardiac Rehabilitation room and was not enclosed in a 1 hour construction with ventilation.
6. #0 indicated, at time of observation, was unaware the liquid oxygen unit was stored in the Cardiac Rehabilitation room.
7. Review of the generator log titled "Emergency Generator Log" with #1 on 01/08/13 at 12:34 p.m. indicated the emergency generator was tested monthly under load for at least 30 minutes; however, the monthly load test record lacked the time for the transfer of power from the main source to the generator.
8. Lack of time was acknowledged by #1 at the time of record review.

Building 02:
1. Observation on 01/08/130 at 2:00 p.m. with #4 indicated the fire alarm control panel located in the enclosed vestibule at the rear exit of the Ligonier Rehabilitation Services facility was not provided with automatic smoke detection.
2. In interview on 01/08/130 at 2:00 p.m. with #4, it was acknowledged the fire alarm control panel located in the enclosed vestibule at the rear exit of the Ligonier Rehabilitation Services facility was not provided with automatic smoke detection.
3. Observation made with #4 from 1:45 p.m. to 2:15 p.m. on 01/08/13 indicated the Ligonier Rehabilitation Services facility had nine battery operated emergency lights.
4. Interview at 4:30 p.m. on 01/08/13 with #1 confirmed there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.
5. Observation made with #4 from 1:45 p.m. to 2:15 p.m. on 01/08/13 indicated the Ligonier Rehabilitation Services facility had two exit signs with battery backup.
6. Interview at 4:30 p.m. on 01/08/13 with #1 confirmed there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.

Building 04:
1. Observation made with #4 from 11:45 a.m. to 12:30 p.m. on 01/08/13 indicated the Satellite Imaging Center had five battery operated emergency lights.
2. Interview at 4:30 p.m. on 01/08/13 with #1 confirmed there was no written record of a 90 minute annual test regarding the battery operated emergency lights available for review.
3. Observation made with #4 from 11:45 a.m. to 12:30 p.m. on 01/08/13 indicated the Satellite Imaging Center had two exit signs with battery backup.
4. Interview at 4:30 p.m. on 01/08/13 with #1 confirmed there was no written record of a 90 minute annual test regarding the exit signs with battery backup available for review.
5. Observation made with #4 from 11:45 a.m. to 12:30 p.m. on 01/08/13 indicated that the Satellite Imaging Center had one portable fire extinguisher manufactured in 2006 and lacked an annual maintenance tag.
6. In interview with #4 from 11:45 a.m. to 12:30 p.m. on 01/08/13, it was acknowledged that the Satellite Imaging Center had one portable fire extinguisher manufactured in 2006 and lacked an annual maintenance tag.
7. Based on observation made with #4 from 11:45 a.m. to 2:30 p.m. on 01/08/13 indicated a microwave oven was plugged into an extension cord in the employee break room and not directly into a wall outlet.
8. In interview with #4 at 11:45 a.m. to 2:30 p.m. on 01/08/13, it was acknowledged a microwave oven was plugged into an extension cord in the employee break room and not directly into a wall outlet.

Building 05:
1. Observation made with #4 from 2:30 p.m. to 3:00 p.m. on 01/08/13 indicated the Satellite Rehab Therapy building had one portable fire extinguisher and it lacked an annual maintenance tag.
2. In interview with #4 from 2:30 p.m. to 3:00 p.m. on 01/08/13, it was acknowledged the Satellite Rehab Therapy building had one portable fire extinguisher and it lacked an annual maintenance tag.
3. Observation made with #4 from 2:30 p.m. to 3:00 p.m. on 01/08/13 indicated the Satellite Rehab Therapy building had two battery operated emergency lights which failed to illuminate when tested.
4. In interview at 4:30 p.m. on 01/08/13 with #1, it was confirmed there was no written record of a 30 second monthly test or a 90 minute annual test regarding the battery operated emergency lights available for review.
5. Observation made with #4 from 2:30 p.m. to 3:00 p.m. on 01/08/13 indicated the Satellite Rehab Therapy building had two exit signs with battery backup. Two of the exit signs were not illuminated under normal power and all four failed to illuminate when the battery was tested.
6. In interview at 4:30 p.m. on 01/08/13 with #1, it was confirmed there was no written record of a 30 second monthly test or a 90 minute annual test regarding the exit signs with battery backup available for review.

Based on policy and procedure review, observation, and interview, the infection control practitioner failed to: 1. ensure that a sanitary environment was provided in three areas toured. [the crash cart in the hallway outside the Endoscopy suites, the crash cart in the CCU (critical care unit) and two wall surfaces in OR (operating room) suite #1]; 2. ensure the cleanliness of the patient refrigerator located on one medical/surgical nursing unit; 3. ensure that contracted housekeeping staff were oriented to the facility cleaning policies and practices and monitored for effective asepsis and cleaning processes in four of four off site locations.

Findings:
1. at 2:55 PM on 1/9/13, review of the "Infection Prevention & Control" policy titled: "Housekeeping Responsibilities - Unit Personnel", with a last approval date of 12/21/12 indicated:
a. the policy does not address cleaning of the crash cart

2. at 3:40 PM on 1/9/13, review of the policy and procedure "Crash Cart/Defibrillator/AED Checks" with a most recent review/revise date of 5/12 indicated:
a. the policy does not address cleaning of the crash cart

3. at 11:30 AM on 1/8/13, while on tour of the Endoscopy area of the facility in the company of staff member #56, the surgery manager, it was observed that the top of the hallway crash/code cart had accumulated dust present

4. at 11:35 AM on 1/8/13, interview with staff member #56 indicated it was assumed the crash cart was cleaned monthly when expiration dates are checked on the supplies within

5. at 4:25 PM on 1/8/13, while on tour of the CCU in the company of staff members #51, the Vice President of Patient Services, and #59, the manager of med/surg and CCU, it was observed that the top of the unit crash/code cart had accumulated dust present

6. at 4:30 PM on 1/8/13, interview with staff member #59 indicated cleaning of the crash cart itself is not a part of the monthly check log, but cleaning should occur routinely

7. at 11:40 AM on 1/8/13, while on tour of the surgical area in the company of staff member #56, the surgery manager, it was observed in OR suite #1 that two walls were chipped and gouged with some crevices being 1/4 to 1/2 inch deep

8. interview with staff member #56 at 11:45 AM on 1/8/13 indicated the chips in the walls of the operating room could create areas that would harbor bacteria and would make disinfection of the walls ineffective

9. at 2:55 PM on 1/9/13, review of the "Infection Prevention & Control" policy titled: "Housekeeping Responsibilities - Unit Personnel", with a last approval date of 12/21/12 indicated:
a. on page 3, it states in the section "Items to be cleaned"..."Food and Medication Refrigerators and freezer compartments, microwaves, coffeepots, and other small appliances" that the: "Frequency" of cleaning is: "Every month and as needed"

10. at 3:35 PM on 1/8/13, while on tour of the medical surgical nursing unit in the company of staff members #51, the Vice President of Patient Services, and #59, the medical/surgical unit manager, it was observed that the patient food refrigerator had debris on the freezer floor shelf, dried milk or other substance on one of the refrigerator shelves, and food debris under one of the vegetable drawers in the bottom of the refrigerator

11. interview with staff member #51 at 3:40 PM on 1/8/13 indicated:
a. it was unknown exactly which department, housekeeping, nursing, or dietary, was responsible for cleaning the patient food refrigerator
b. this staff member had confirmation by another nurse that they would take on the responsibility of monthly refrigerator cleaning, but to date no cleaning log has been created
c. it is unknown when the refrigerator was last cleaned or if it is part of a monthly cleaning routine

12. at 10:40 AM on 1/8/13, interview with staff member #61, the Infection Prevention Practitioner, indicated:
a. the four off sites have different contracted housekeeping services
b. no orientation of the contracted housekeeping staff to this facility's cleaning policies and processes has been provided by this staff member, or any other facility staff person, to the contracted cleaners
c. one agency provided their own policies and cleaning practices, but the infection control committee has not reviewed and approved those, to date
d. there has been no monitoring or observation of skills competencies, to indicate appropriate asepsis is occurring, by this staff member or any other facility staff member, of the off site contracted housekeeping staff
e. all of the above is "in process"