HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed 02/15/2012, the hospital's leadership failed to have an effective governing body to ensure a safe environment for patients, staff, and visitors.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

Based on policy review, medical record review and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by : (A) failing to implement skin breakdown prevention measures for 2 of 2 sampled patients at risk for skin breakdown (#41 and #42); (B) failing to ensure a patient's physician was notified a patient had refused a medication for three days for 1 of 1 patient records reviewed of patients on the blood thinner medication Heparin (#48); and (C) failing to ensure a complete physician's order for hemodialysis (HD) prior to initiating he HD treatment for 2 of 4 HD records reviewed (#48, #49).

The findings include:

A. The nursing staff failed to implement skin breakdown prevention measures for 2 of 2 sampled patients at risk for skin breakdown (#41 and #42).

Review of the hospital's policy, "Skincare", effective 12/2011, revealed, "...PURPOSE: To provide guidelines for skin assessment/reassessment on all patients. To identify the patient at risk for skin impairment and initiate nursing/clinical assessment and preventive interventions. POLICY: ...2) The licensed nurse will assess/reassess skin status of all patients and identify patients at risk for skin impairment and will initiate appropriate nursing assessment and care on admission and throughout hospitalization or continuum of care. 3)...The following criteria are used in identifying patients at risk for skin impairment when observing the patient directly...: a) mature adult (60 yrs. of age or older) b) previous skin disorders c) friction and shear risk with Braden Risk Assessment scale (assessment tool used for identifying patients at risk for development of skin breakdown)...e) edema, clotting disorder, diabetes, decreased circulation (arterial and/or venous)...g) physical immobilization...m) ...wound drainage...High Risk Skin Care Prevention Protocols...7) Patients' position should be changed every two hours when in bed and every one hour when in chair...".

Review of the hospital's document, "Braden Pressure Ulcer Risk Assessment", not dated, revealed patient's are scored in the area of sensory perception, moisture, activity, mobility, nutrition and friction and shear. Further review revealed "...Note: Patients with a a total score of 16 or less are considered to be at risk of developing pressure ulcers...".

1. Open medical record review of Patient #41 revealed a 68 year-old admitted 02/13/2012 with sepsis, pneumonia, urinary tract infection, acute renal failure and acute hypoxic respiratory failure. Further record review revealed Patient #41 was discharged from the hospital on 02/07/2012 after a left hemiarthroplasty was done for a fractured hip. Review of the initial nursing assessment completed 02/13/2012 at 1645 revealed Patient #41 had a left lateral leg blister with bloody, serosanguineous drainage, a left lower leg blister with bloody, serosanguineous drainage, a right arm skin tear and a left arm skin tear. Review of the Braden Risk Assessment completed on 02/13/2012 at 1645 revealed Patient #41 was at low risk for skin breakdown; at 2050 was a moderate risk for skin breakdown and on 02/14/2012 at 0745 was at moderate risk for skin breakdown. Review of the nurse's notes revealed Patient #41 was turned 02/14/2012 at 0049 (8 hours after admission) and 0642 (5 hours, 53 minutes later). Record review revealed no documentation that Patient #41 was turned every 2 hours.

Interview on 02/14/2012 at 1000 with the nurse manager of the unit revealed Patient #41 was incorrectly assessed for the risk of skin breakdown. Interview revealed, "existing skin breakdown puts her in the high risk category". Interview confirmed Patient #41 should be turned every 2 hours. Interview confirmed there was no documentation that Patient #41 was turned every 2 hours. Interview confirmed the nursing staff failed to follow policy for skincare.

2. Open medical record of Patient #42 revealed a 57 year-old admitted 02/07/2012 with hip pain after a fall at home, chronic hyponatremia, diabetes and deep venous thrombosis. Review of the initial nursing assessment completed 02/07/2012 at 2044 revealed no documentation of a Braden Risk Assessment. Record review revealed Patient #42 was assessed 02/08/2012 at 0824 and was assigned moderate risk for skin breakdown. Further review of the nursing assessment dated 02/08/2012 at 1607 revealed Patient #42 had a sacral pressure ulcer, a right ulcer pressure ulcer and a left lateral hip abrasion. Record review revealed no documentation that Patient #42 had been turned every 2 hours since admission (7 days).

Interview on 02/14/2012 at 1000 with the nurse manager of the unit revealed Patient #42 was incorrectly assessed for the risk of skin breakdown. Interview revealed, "existing skin breakdown puts her in the high risk category". Interview confirmed Patient #42 should be turned every 2 hours. Interview confirmed there was no documentation that Patient #42 was turned every 2 hours. Interview confirmed the nursing staff failed to follow policy for skincare.


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B. Review on 02/14/2012 of facility policy "Electronic Medication Administration" dated 01/2012 revealed "Policy:...8) A physician's order including...frequency of time is required for all medications administered..."

Open record review on 04/14/2012 for Patient #48 revealed a 61 year old admitted 02/06/2012 for left lower lobe infiltrate with end-stage renal disease. Review revealed a physician's order written 02/10/2012 "...2 - Heparin 5,000 SQ (subcutaneous) q (every) 12 (hours)." Review of the medication administration record (MAR) revealed documentation the patient refused every Heparin dose scheduled from the initial dose on 02/10/2012 at 1846 through 02/14/2012 at 0603 (eight doses refused). Review failed to reveal any documentation the physician was notified the patient was refusing the Heparin blood thinner medication.

Interview on 02/14/2012 at 1230 with the nephrologist physician for Patient #48 revealed the Heparin was ordered for the patient "since she (Patient #48) is at risk for deep vein thrombosis." Interview revealed the physician had not been notified "until this morning". Interview revealed the physician would have expected to be called before this morning that the patient was refusing the Heparin.

Interview with 7th floor administrative staff on 04/14/2012 at 1300 revealed nursing should call the physician with any refused medication. Interview revealed nursing staff failed to ensure the physician was notified an ordered medication was not administered to the frequency as ordered.

C. Review on 04/14/2012 of facility policy "Initiation of Hemodialysis Treatment" dated 02/2012 revealed "Initiation of Treatment...2) On the home screen, the goal, time, dialysate flow rate...is set...4) On the dialysate screen, the CONC(entrate)...are set per physician's order..."

Interview on 04/14/2012 at 1020 with the HD clinical coordinator during tour of the HD unit revealed the unit has different dialysate baths available some containing different potassium (K+) concentrations ranging from 0-3.0 and different calcium (Ca++) concentrations ranging from 0-3.0. Interview revealed the nursing staff can add to the standard concentrations or "spike" the dialysate bath jugs to customize the concentration as per the physician's order.

1. Open record review on 04/14/2012 for Patient #48 revealed a 61 year old admitted 02/06/2012 for left lower lobe infiltrate with end-stage renal disease. Review of the HD treatment sheet for 02/07/2012 revealed the patient received a dialysate bath 2 K+ and 2.5 Ca++ with a dialysate flow rate (DFR) of 500. Review revealed a physician's order for HD treatment dated 02/07/2012 revealed "Dialysis bath: 2.0". Review of the order failed to reveal what specific dialysis bath concentration the physician intended. Further review of the order written 02/07/2012 failed to reveal an ordered DFR. Review of the HD treatment sheet for 02/09/2012 revealed the patient received a dialysate bath 3 K+ and 2.5 Ca++ with a dialysate flow rate (DFR) of 500. Review revealed a physician's order for HD treatment dated 02/09/2012 revealed "Dialysis bath: 3.0K+". Review of the order failed to reveal an order for the calcium concentration the physician intended. Further review of the order written 02/09/2012 failed to reveal an ordered DFR. Review of the HD treatment sheet for 02/11/2012 revealed the patient received a dialysate bath 3 K+ and 2.5 Ca++ with a DFR of 500. Review revealed a physician's order for HD treatment dated 02/11/2012 revealed "Dialysis bath: 3.0K+". Review of the order failed to reveal an order for the calcium concentration the physician intended. Further review of the order written 02/11/2012 failed to reveal an ordered DFR.

2. Open record review on 04/14/2012 for Patient #49 revealed a 74 year old admitted 02/08/2012 for shortness of breath with end-stage renal disease. Review of the HD treatment sheet for 02/09/2012 revealed the patient received a dialysate bath 2.0 K+ and 2.5 Ca++ with a DFR of 500. Review revealed a physician's order for HD treatment dated 02/09/2012 revealed "Dialysis bath: 2.0". Review of the order failed to reveal what specific dialysis bath concentration the physician intended. Further review of the order written 02/09/2012 failed to reveal an ordered DFR. Review of the HD treatment sheet for 02/11/2012 revealed the patient received a dialysate bath 2.0 K+ and 2.5 Ca++ with a DFR of 500. Review revealed a physician's order for HD treatment dated 02/11/2012 revealed "Dialysis bath: 2.0K+". Review of the order failed to reveal an order for the calcium concentration the physician intended. Further review of the order written 02/11/2012 failed to reveal an ordered DFR.

Based on review of facility policies and procedures, medical records and staff interviews, nursing staff failed to ensure blood products were administered by the order of a physician for 2 of 2 hemodialysis (HD) patient records reviewed who received blood products (#35, #49).

Findings included:

Review on 02/14/2012 of facility policy "Blood, Modified Blood Product (Irradiated), Blood Components (Cryoprecipitate, Fresh Frozen Plasma, Platelets) Administration" dated 09/2011 revealed "Policy: 1) Blood...is initiated, regulated and discontinued by the Licensed Nurse as ordered by the physician..."

1. Closed record review on 02/14/2012 for Patient #35 revealed a 78 year old admitted 01/30/2012 for respiratory failure with end-stage renal disease. Review revealed on 02/01/2012 the patient received two units of blood product during the HD treatment, Unit #1 from 1029-1100 and Unit #2 from 1119-1152. Review failed to reveal a physician's order for the two units of blood administered.

Interview with HD administrative staff on 02/15/2012 at 0930 revealed a physician's order should be documented in the patient record prior to blood products being administered. Interview revealed the HD Registered Nurse who administered the blood to Patient #35 received a telephone order from the patient's physician and failed to document the order on the patient's record. Interview revealed the policy for telephone orders requires the nurse to document the telephone order in the record when received and "read back" the order to the physician. Interview revealed the RN failed to follow facility policy on receiving telephone orders and failed to ensure a physician's order for blood products was documented in the patient's record prior to the blood being administered. Interview failed to reveal any further documentation of a physician's order for the two units of blood administered to Patient #35 on 02/01/2012.

2. Open record review on 02/14/2012 for Patient #49 revealed a 74 year old admitted 02/08/2012 for shortness of breath with end-stage renal disease. Review revealed on 02/11/2012 the patient received one unit of blood product during the HD treatment from 1256-1343. Review failed to reveal a physician's order for the blood administered.

Interview with HD administrative staff on 02/15/2012 at 0930 revealed a physician's order should be documented in the patient record prior to blood products being administered. Interview revealed the HD Registered Nurse who administered the blood to Patient #49 received a telephone order from the patient's physician and failed to document the order on the patient's record. Interview revealed the policy for telephone orders requires the nurse to document the telephone order in the record when received and "read back" the order to the physician. Interview revealed the RN failed to follow facility policy on receiving telephone orders and failed to ensure a physician's order for blood products was documented in the patient's record prior to the blood being administered. Interview failed to reveal any further documentation of a physician's order for the blood administered to Patient #49 on 02/11/2012.

Based on observations as referenced in the Life Safety Report of Survey completed 02/15/2012, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

1. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~cross-refer to 482.41(a) Physical Environment: Maintenance of Physical Plant - Standard Tag A0701.

2. The hospital failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~cross-refer to 482.41(a)(1) Physical Environment: Emergency Power and Lighting - Standard Tag A0702.

3. The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.

4. The hospital failed to ensure that alcohol based hand rub dispensers were located away from an ignition source.

~cross-refer to 482.41(b)(9) Physical Environment: Alcohol-Based Hand Rub Dispensers - Standard Tag A0716.

Based on observations as referenced in the Life Safety Report of Survey completed 02/15/2012, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

Building 01
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is dust accumulation on sprinkler heat sensitive elements in the following areas:

a. First floor elevator lobby.

b. Seventh floor elevator lobby.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

2. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, medical gas cylinders are not secured or labeled properly in the following areas:

a. Medication preparation room on seventh floor - full and empty cylinders are not identified.

b. Bulk oxygen, near loading dock, cylinders are not individually secured.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

3. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the circuit directory is missing for electrical panel - located beside equipment panel QFPHB in mechanical, and electrical equipment room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Based on observations as referenced in the Life Safety Report of Survey completed 02/15/2012, the hospital failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, normal and emergency panels are not distinguished through color coding. Receptacles on emergency power are red, panels serving emergency receptacles have black labels.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

2. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there are no lights on the critical branch of the essential electrical system - main switchgear room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

3. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no signaling devices for a three hour fuel capacity remaining in the main fuel tanks for the essential electrical system. The devices must register signals on the annunciator panel for the essential electrical system.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

4. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no test switch for generator annunciator audible signaling device - Onan annunciator panel located in security room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

5. Based on observation, on February 15, 2012 at approximately 6:20 AM onward, the emergency power system required approximately thirteen seconds to transfer from normal to emergency power during loss of normal power to the ATS-LS-19.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

6. Based on observation, on February 15, 2012 at approximately 6:20 AM onward, the annunciator panel did not read emergency power supplying load with loss of power to ATS-LS-19.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

Building 03
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, exit discharge lighting is wired to the equipment branch of the essential electrical system. The lighting serves stair tower #2 of the heart center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Based on observations as referenced in the Life Safety Report of survey completed 02/15/2012, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the rated access door did not self-close and latch for mechanical chase near room 562 - access door is located on corridor wall.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

2. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, hazardous area in the following area is incomplete:

a. mechanical room 1-22B, inactive leaf of fire door is not self-closing and latching.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

3. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there are incomplete special locking arrangements in the following areas:

a. Fifth floor near room 544 - master release switch is mounted greater than forty-eight inches above the finished floor.

b. Cross corridor doors between ED & Radiology on second floor - there is no master release switch for electromagnetic locking arrangement.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

4. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is an incomplete access controlled egress lock for door near operating room #4. There is no switch not greater than five feet from the door - switch must state "Push to Exit."

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

5. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, exit access door from the third floor waiting area provides a clear opening less than forty-one and one half inches. The door serves greater than fifty occupants and does not open in the direction of egress.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

6. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the hardware for door to surgical admissions is greater than forty-eight inches above finish floor. The dead-bolt hardware creates greater than a single motion of the hand to exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

7. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the inactive door leaf contains manual flush-bolt hardware; and greater than a single hand motion to open, close, and latch doors to CT Scan #1. Doors are located on floor #2.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

8. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is a dead-end corridor at tunnel located between stair and elevators on the first floor. The present arrangement does not allow reentry through door between corridor and tunnel.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

9. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, exit signage is incomplete in the following areas:

a. Third floor waiting area - dimensions of exit sign do not comply with industry standard.

b. CT Scan #1 - exit sign directs occupants to a corridor less than eight feet minimum width.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

10. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there are no sprinklers in the following areas:

a. Front entrance vestibule located on second floor.

b. Alcoves near fifth floor nurse manager office - located on south wing.

c. Telephone equipment room - located on first floor near mechanical room 1-22B.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

11. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the tamper switch supervisory signal did not function with valve closed - valve 0152 in first floor mechanical room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

12. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no electrical supervision of small dry system valve located in fire pump room. There are no high and low pressure switch with supervision for the dry-pipe system located in fire pump room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

13. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no high and low pressure switch for dry-pipe sprinkler system located in mechanical room under ED - near EMS entrance to ED.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

14. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no high and low pressure switch for dry-pipe sprinkler system serving loading dock - valve is located in general storage room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

15. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is no emergency shutdown switch for air handler #3 in a supervised area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

16. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the laundry chute access door is not self-closing and latching - located in emergency department near discharge waiting area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 071.

17. Based on observation, on February 13, 2012 at approximately 7:30 AM onward, there are impediments in the exit discharge to the rear terrace located on the first floor. (stair exit passageway located near first floor elevator)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

18. Based on observation, on February 13, 2012 at approximately 7:30 AM onward, there are impediments to egress in the ICU. The ICU area is not defined within a suite meeting prescriptive requirements of the Life Safety Code.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

Building 03
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, electrical equipment rooms in the following areas are not equipped with sprinklers:

a. Fourth floor - room is not equipped with minimum two hour rated enclosure.

b. Fifth floor - room is not equipped with minimum two hour rated enclosure.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

2. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the laundry chute terminal room is not equipped with a minimum 1.5 hour door with listed hardware assembly. The door provided is rated for forty-five minutes.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 071.

Building 04
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, the dry-pipe sprinkler system alarm valve and pressure switch valves are not electrically supervised.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

Building 05
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, hazardous areas are incomplete in the following areas:

a. Soiled utility/soiled linen room - there is no sprinkler or one hour enclosure for room located in wound care center.

b. Storage room - room is equipped with a twenty-minute fire rated door; door to room is required to be a minimum forty-five minute rating.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

2. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there are no emergency shut-down switches for air handlers serving the wound care center, and the rehabilitation center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Based on observations as referenced in the Life Safety Report of survey completed 02/15/2012, the hospital failed to ensure that alcohol based hand rub dispensers were located away from an ignition source.

The findings include:

Building 01
1. Based on observation, on February 14, 2012 at approximately 7:30 AM onward, there is an alcohol based hand sanitizer located beside a light switch in the child birth suite.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0211.