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Based on observation, interview, and documentation review, the facility failed to ensure doors in occupancy separation self closed to latching position (K131). The facility failed to ensure suites were appropriately separated from the remainder of the building (K255). The facility failed to ensure surfaces to public ways were safe (K271). The facility failed to ensure exit signs were present and marking directions of the exits (K293). The facility failed to maintain vertical openings between floors (K311). The facility facility failed to ensure protection from hazardous areas (K321). The facility failed to ensure the cooking facility was closed to the corridor as per NFPA 101 (K324). The facility failed to ensure the time interval between alarm activation to when the monitoring company received the signal was documented at least monthly as per NFPA 25 (K345). The facility failed to ensure gauge readings were documented during weekly and monthly inspections (K353). The facility failed to ensure the opening to the corridor per room were not greater than 80 total square inches (K364). The facility failed to ensure the one hour fire rated smoke barrier was free of penetrations (K372). The facility failed to ensure staff were knowledgeable as to where the medical gas zone valves were located (K712). The facility failed to ensure that if the medical gas zone valve was shut off for one operating room it did not affect another operating room as per NFPA 99 (K900).

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 4.

Findings include:

Building 1 of 2 ( identified as 4 of 5)

1. Please see K131 for findings related to the facility failing to ensure doors in occupancy separation self closed to a latching position.

2. Please see K255 for findings related to the facility failing to ensure suites were appropriately separated from the remainder of the building.

3. Please see K293 for findings related to the facility failing to ensure the exit signs were present and marking directions of the exit.

4. Please see K311 for findings related to maintaining vertical openings between floors.

5. Please see K321 for findings related to the facility failing to ensure protection from hazardous areas.

6. Please see K324 for findings related to the facility failing to ensure a cooking facility was closed to the corridor.

7. Please see K345 for findings related to the facility failing to ensure the time interval between alarm activation to when the monitoring company received the signal.

8. Please see K353 for findings related to the facility failing to ensure gauge readings were documented during the weekly and monthly inspections.

9. Please see K364 for findings related to the facility failing to ensure openings to the corridor were greater than 80 square inches.

10. Please see K372 for findings related to the facility failing to ensure the one hour fire rated smoke barrier was free of penetrations.

11. Please see K712 for findings related to the facility failing to ensure staff were knowledgeable as to where the medical gas zone valves were for the PACU.

12. Please see K900 for findings related to the facility failing to ensure that if the medical gas zone valve was shut off for one endoscope room it would not affect the other endoscope room.

Building 2 of 2 (identified as 5 of 5)

1. Please see K271 for findings related to the facility failing to ensure surfaces leading to the public way was safe.

2. Please see K321 for findings related to the facility failing to ensure hazardous areas were protected with a one hour fire rated barrier, or that self closing doors closed to a latching position.

Based on dietary department observations, review of facility contracts, review of facility policy and procedures and staff interview, the facility failed to follow policies for the storage of hazardous chemicals, sanitation of food preparation surfaces, and the preparation of raw produce. This deficient practice negatively affected five of seven inpatients the facility provided meal service for.

Finding include:

Review of the facility's contract for dietary services signed by the facility and the contracting company on 08/10/17 directed at item 5.1.5 that all contracted staff, providing service under this agreement, must at all times comply with hospital policies and procedures.

Review of the facility's policy and procedure titled Food Production with a most recent update of 6/23/11 directed the morning cook to set up the three compartment sink and record the parts per million sanitizer in the log, prepare the cooks' sanitizer buckets and soap buckets for cooks' preparation areas, and to clean and sanitize work tables and then prepare breakfast items for patients and retail between 6:00 AM and 7:00 AM.

Environmental tour of the kitchen on 03/06/18 from 7:52 AM until 8:29 AM revealed the two counters near the salad preparation area and the food preparation area near the grill both contained 16 ounce spray bottles of quaternary ammonia cleaning products which both displayed the warning label of Danger, Do not drink and keep away from children. Interview with Staff J confirmed these hazardous cleaning agents were stored in food preparation areas.

Additionally, the environmental kitchen tour revealed the facility had failed to prepare the sanitation buckets used in the food preparation area of the kitchen. Staff J confirmed the patient breakfast service was already completed and ready to deliver to patient rooms. When Staff J was questioned at the time of observation, Staff J verbalized the buckets had not yet been prepared for the morning. Observation of the sanitation area which included the three compartment sink used for dishwashing revealed the third compartment (final sanitizing compartment) which was observed to have a water based solution it in it and pans from morning food preparation submerged in the solution. Staff J was asked to test the strength of the solution to ensure adequate sanitizing agent. The test strip registered below the required amount of sanitizing chemical. When questioned, Staff J verbalized the parts per million for adequate strength solution was to be 200 part per million. Staff J confirmed the solution in the sink failed to register in that range. Additional environmental observations included the bulk sugar storage bin was observed to have a plastic cup stored in the sugar. The vegetable preparation area also contained a set of three compartment sinks. The third compartment of this set of sinks was observed to have a water based solution and a vegetable sanitizing agent. Two tomatoes were observed to be soaking in this solution, Staff J was asked to test the solution for adequate concentration of the vegetable wash. Again this solution failed to register in the adequate agent range. Additionally, the manufacturer's printed directive by the FDA (Food and Drug Agency) Food Code gave two options for washing produce, either washing under running potable water or using the chemical wash. These deficient practices were all confirmed by Staff J at time of finding.

Based on medical record review and staff interview, the facility failed to ensure the Registered Nurse administered medications as ordered for three of 20 in-patient records reviewed (Patients #4, #5, and #25). A total of 26 medical records were reviewed.

Findings include:

1. Patient #4 had a physician's order for point of care glucose testing four times a day (before meals and at bedtime). On 03/06/18 at 11:47 AM Patient #4's BG (blood glucose) was recorded as 64. Per physician's order, Patient #4 should have received "one tube" of glucose 40% oral gel. There was no documented evidence Patient #4 received the ordered glucose and no documented evidence as to why not. Approximately 36 minutes later Patient #4's BG was recorded as 96. Per the same order, Patient #4's BG was to be re-checked in 15 minutes.

Staff I and H confirmed this finding at the time of review on 03/06/18 at 2:12 PM. .

2. Patient #5 had a physician's order for point of care glucose testing four times a day (before meals and at bedtime). On 03/06/18 at 11:39 AM Patient #5's BS was recorded as 144. Per physician's order, Patient #5 should have received one unit of Humalog insulin. There was no documented evidence Patient #5 received the ordered insulin and no documented evidence as to why not.

Staff I and H confirmed these findings at the time of review on 03/06/18 at 2:30 PM.


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3. On 03/08/18 at 11:30 AM a medical record review was conducted with Staff I for Patient #25. On 01/28/18 the physician ordered Humulog insulin per sliding scale at each of the three meals and nightly.

The medical record review revealed on 01/31/18 at 7:31 AM an elevated blood sugar of 215. Per the sliding scale, the patient should have received two units of Humulog insulin; however, the medical record was silent to administration of insulin per sliding scale at the breakfast meal. There was no documentation of food intake at the breakfast meal for Patient #25. An entry in the medical record at 9:05 AM on that same date,01/31/18, by a nursing school instructor revealed the patient's blood sugar was 259. The patient was administered three units per the physician's orders at that time.

Interview with Staff I at the time of the record review revealed the meal times were 8:00 AM, 12:00 PM and 5:00 PM.

Further interview with Staff I at 11:45 AM on 03/08/18 confirmed the lack of documentation in the patient's medical record of the breakfast meal intake on 01/31/18, or the administration of insulin until a recheck at 9:05 AM when the patient's blood glucose level was 259.

Further review of Patient #25's record revealed the patient's blood glucose level was 216 on 01/28/18 at 4:36 PM. Per the sliding scale, the patient should have received two units of insulin, but the record showed the insulin was not administered until 6:40 PM for the elevated blood sugar. Staff I confirmed the findings in an interview at the time of the record review.

Based on policy review, medical record review, and staff interview, the facility failed to ensure comprehensive care plans were developed for four of 20 in-patient medical records reviewed (Patients #22, #23, #12, and #25). A total of 26 medical records was reviewed.

Findings include:

Review of the policy titled "Interdisciplinary Plan of Care - Patient Care Plan" revealed the major patient problems, needs or issues with appropriate interventions and expected outcomes for each identified problem should be included in the Interdisciplinary Plan of Care.

1. Review of the medical record for Patient #22 revealed orders for coumadin (blood thinner) and sliding scale insulin administration. The care plan lacked documentation for diabetes or blood thinners. This was verified on 03/08/18 at 10:00 AM by Staff K.

2. Review of the medical record for Patient #23 revealed the patient was on cardiac monitoring with episodes of junctional rhythm and sick sinus syndrome. The plan of care lacked documentation for cardiac care or monitoring. This was verified on 03/08/18 at 11:30 AM by Staff K.


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3. Patient #12 was admitted to the facility on 02/25/18 with history of a gastrointestinal bleed. Hemoglobin and hematocrit laboratory tests (anemia and blood loss tests) dated 02/25/18 revealed a hemoglobin of 6.7 grams/deciliters (normal is 12.0 to 16.0 gm/dl) and a hermatocrit of 20.9% (normal ranges 36-46%). The physician's plan directed the patient to receive two units of packed red blood cells. Review of the nursing plan of care revealed it did not address or provide guidance to nurses for the management of blood loss.

This deficient practice was confirmed with Staff I on 03/07/18 at 11:16 AM.


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4. On 03/08/18 a medical record review was conducted for Patient #25. The patient was admitted on 01/28/18 for pneumonia and treated with intravenous antibiotics and fluids. The physician's progress note on 01/29/18 revealed the patient was a diabetic. The physician ordered insulin dosing based on sliding scale at each meal and at bedtime and an oral hypoglycemic medication daily. The patient's blood sugar levels were elevated throughout the hospital stay to 259.

A review of the care plan with Staff I revealed the care plan was silent to insulin administration, blood glucose monitoring and diagnosis of diabetes.