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Tag No.: C0220
Based on observations and testing during the survey conducted from 1/26/15 through 1/28/15, the volume of deficiencies issued to the Hospital for non compliance with the 2000 Edition of the Life Safety Code relating to the physical plant and physical environment, it is determined the hospital failed to ensure the safety of patients, staff and the public. Therefore, the condition is not met. C220, C225, C231, K038, K062, K067 and K147.
Tag No.: C0225
Based on observations and staff interview, during the survey conducted from January 26 - 28, 2015 the hospital failed to maintain the condition of the physical plant in a manner to ensure the safety and well-being of patients.
Findings include:
1. On 01/26/15 at approximately 2:46 p.m., ceiling tile in the fourth floor corridor was observed stained.
2. On 01/26/15 at approximately 2:59 p.m., a cluster of communication wires was observed hanging from the ceiling thru a missing ceiling tile at the nurse station.
3. On 01/26/15 at approximately 3:12 p.m., ceiling tile was observed missing outside the pharmacy.
4. On 01/27/15 at approximately 9:35 a.m., ceiling tile in the lab was observed stained.
5. On 01/27/15 at approximately 9:36 a.m., ventilation vents located in the ceiling of the lab was observed covered with a disposable bed pad to prevent air flow.
6. On 01/27/15 at approximately 9:37 a.m., the file room located in the lab area was observed with a electric space heater in operation.
7. On 01/27/15 at approximately 9:38 a.m., the storage room located in the lab area was observed with cardboard boxes stored on the floor.
8. On 01/27/15 at approximately 9:40 a.m., the over head emergency shower in the lab was found not functional.
9. On 01/27/15 at approximately 9:50 a.m., x-ray room number 3 was observed with cardboard boxes stored on the floor.
10. On 01/27/15 at approximately 9:51 a.m., the radiology department break room was observed missing a light bulb cover/guard.
11. On 01/27/15 at approximately 1:40 p.m., the operating room closet between OR #1 and OR#2 was observed missing a light bulb cover/guard.
12. On 01/27/15 at approximately 1:41 p.m., OR #1 and OR #2 was observed with an opening in the ceiling around a temperature sensor wiring.
13. On 01/27/15 at approximately 1:44 p.m., the floor tile in OR #2 was observed separating and would not allow proper cleaning.
14. On 01/27/15 at approximately 1:45 p.m., operating room sterile storage room was observed with stained ceiling tile.
15. On 01/27/15 at approximately 1:47 p.m., the operating room dirty cleaning room was observed with the laminate separating from the sink cabinet and would not allow proper cleaning.
16. These findings were discussed with the hospital maintenance director on 01/28/15 at approximately 10:00 a.m. and agreed that the aforementioned issues needed addressed.
Tag No.: C0231
Based on the volume of deficiencies issued to the Hospital for non compliance with the 2000 Edition of the Life Safety Code, it was determined the Hospital failed to ensure the safety of patients, staff, and the public.
Findings include:
1. Reference deficiencies cited at: K038, K062, K067 and K147.
Tag No.: C0278
Based on reviews of documents, observations and interviews with staff, it was determined the hospital failed to ensure the Infection Control Committee functioned in accordance with hospital policy and acceptable standards of care. This has the potential for the hospital to miss opportunities for improvements in the provision of care to all patients. Findings include:
1. Review of hospital policy "Infection Control Committee Meetings", last revised 6/2013, reveals the policy states "The Infection Control Committee will meet at least bi-monthly, and more frequently if indicated as determined by surveillance data."
Review of the Infection Control Committee meeting minutes for the 2014 year revealed there were a total of three (3) meeting minutes documented for the meetings held in February, May and August 2014. The Infection Control Nurse was interviewed on 1/27/2015 at 1:15 p.m. and she concurred there were only three (3) meetings held during the year.
2. Review of hospital policy "Infection Control Committee Meetings", last revised 6/2013, reveals the policy states "The Infection Control Committee will meet at least bi-monthly, and more frequently if indicated as determined by surveillance data...Reports of meetings will be submitted to the Medical Staff for their review and approval."
Review of the Medical Staff meeting minutes for the 2014 year revealed the Medical Staff met each month for a total of twelve (12) meetings during 2014. The only Infection Control Committee activity reported was during the 6/24/2014 Medical Staff meeting when it was documented "The (Infection Control) Committee is looking into Nurse Driven Foley Protocol." This issue was not discussed again during the monthly Medical Staff meetings in 2014, nor were any other activities or reports discussed. This was discussed with the Infection Control Nurse on 1/28/2015 at 10:45 a.m. and she concurred the Infection Control Committee failed to report to the Medical Staff as policy directs.
3. During a tour of the Emergency Department (ED) on 1/27/2015 starting at 10:00 a.m., it was observed there was an open multi-dose vial of Lidocaine. The vial had 1/15/2015 hand written on the label. The staff RN who was present during the tour stated the multi-dose vials are discarded 30 days after being opened. Review of the Infection Control Committee meeting minutes for the meeting held in August 2014 (no date listed) revealed it was documented "It was brought to the attention of the Infection Control Nurse that multi-dose vials are to be discarded 28 days after opening. The nurses will be reminded of this in the monthly acute care staff meeting by (the Nurse Manager)." The meeting minutes and the observation and interview with the ED staff were discussed with the Infection Control Nurse on 1/28/2015 at 10:45 a.m. and she concurred the information regarding the expiration of the multi-dose vials has not been completely dispersed to the hospital staff by the Infection Control Committee.