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Based on document review and interview, it could not be determined that the hospital used data collected to identify opportunities for improvement and take actions for changes that would lead to improvement for 3 of 3 below goal monitors reviewed for corrective actions (anesthesia services, obstetrics and outpatient therapy services) and it could not be determined that if actions were implemented, the hospital measured its success or tracked performance to ensure that improvements were sustained.

Findings include:

1. Review of the Performance Improvement Plan, approved 3/2018, indicated the following:
A. Performance Improvement Teams are formed to address interdepartmental (functional) or system-wide (cross-functional) issues as needed. The team is responsible for, but not limited to, the following: 4. Initiating small tests of change and spreading the identified improvements. 5. Taking action to ensure that improved processes are designed and act to hold the gain. 6. Evaluating the effectiveness of actions.
B. The Team leader is responsible for, but not limited to, the following: 5.. Documenting activities of the team including meeting minutes, team composition, team goals, and performance improvement activities..., 6. Implementing actions necessary for improving performance. 7. Evaluating the effectiveness of the team.
C. If the standard is not met, a PDCA (plan, do, check, act) action plan should be reported to the appropriate Quality Council Committee.

2. Review of Quality Assurance Performance Improvement (QAPI) dashboard documentation indicated the following:
A. An Anesthesia monitor for body temperature to be =/> 95.5 degrees Fahrenheit within 30 minutes prior to or 15 minutes after Anesthesia end time with a goal of 100%, indicated the department fell below their goal for 6 months as follows: 1/18 - 75%, 2/18 - 90%, 3/18 - 76%, 4/18 - 76%, 5/18 - 90% and 6/18 - 97%. The dashboard indicated this was "To be reported at Anesthesia department meeting (Jan/Feb results). Education to be provided."
B. An Obstetrics (OB) monitor for documented follow-up of response to PRN (as needed) medications for pain, indicated the department fell below their goal of 95% for 12 months as follows: 7/17 - 38%, 8/17 - 40%, 9/17 - 48%, 10/17 - 74%, 11/17 - 44%, 12/17 - 56%, 1/18 - 66%, 2/18 - 48%, 3/18 - 57%, 4/18 - 51%, 5/18 - 56% and 6/18 - 64%. The dashboard lacked documentation of actions taken or actions to be taken.
C. An Outpatient Therapies monitor for percentage of patients that completed the therapy program, indicated the department fell below their 90% goal 8 of 12 times as follows: 7/17 - 62%, 8/17 - 56%, 10/17 - 61%, 11/17 - 79%, 1/18 - 75.56%, 2/18 - 80.43%, 4/18 - 70.37% and 5/18 - 82.81%. The dashboard lacked documentation of actions taken or actions to be taken.

3. Review of departmental meetings and documentation indicated the following:
A. Anesthesia Department Meeting Minutes dated 1/31/18, 2/28/18, 4/25/18, 6/18 (no day documented) and 7/31/18, lacked documentation of actions taken or to be taken for improvement. The hospital lacked documentation of departmental education related to the monitor having been provided.
B. Documents provided from the OB department indicated that an "Ongoing Action Plan for Pain P.I. Improvement" was written. Departmental documentation lacked evidence of actions implemented for improvement.
C. Outpatient Therapies Meeting Minutes dated 2/13/18, 3/13/18, 4/10/18, 5/8/18, 6/12/18 and 7/17/18, lacked documentation of actions taken or to be taken for improvement. For the 4 of 12 months in which the department met or exceeded goal, the minutes lacked documentation of measures taken during those periods of success.

3. On 8/30/18 between approximately 2:15 p.m. and 3:00 p.m., A12, Quality Manager, verified that the Anesthesia, OB and Outpatient departments lacked documentation of actions taken for repeatedly low/below goal data measures and the outpatient department failed to ensure improvements were sustained.

Based on document review, observation and interview, the facility failed to ensure staff follow their policy/procedure for Storage of Medications for 1 (Behavioral Health Unit) of 17 areas toured:

Findings include:

1. Policy/procedure, Storage of Medications, revised/reapproved 1/2018 indicated: "All medications will be stored to maintain integrity, stability and effectiveness by use of proper conditions of sanitation, temperature, light, moisture, ventilation, segregation and security".

2. While on tour of the Behavioral Health Unit on 8/27/18 at approximately 1030 hours, accompanied by staff N1 and N3, food items were observed being stored in the medication refrigerator.

3. Staff N3 (Program Director) was interviewed on 8/27/18 at approximately 1030 hours and confirmed staff should not store food items in the medication refrigerator.

Based on document review and interview, the facility failed to ensure staff follow their policy/procedure for Transfer of a Patient in 2 of 5 closed medical records (MR) reviewed (patient 9 and 10).

Findings include:

1. Policy/procedure, Transfer of Patient, reviewed/revised 06/2018 indicated on page 3: "A completed transfer form, summary of care record, and medication reconciliation sheet, signed by the physician licensed independent practitioner must be sent with the patient".

2. Review of patient 9's MR lacked documentation of a completed Authorization of Transfer form for transfer of the patient to another facility on 4/20/18.

3. Review of patient 10's MR lacked documentation of a completed Authorization of Transfer form for transfer of the patient to another facility on 7/24/18.

4. Staff N2 (Quality/Risk/Regulatory/Infection Control Manager) was interviewed on 8/27/18 at approximately 1400 hours and confirmed patient 9 and 10's MR lacked documentation of a completed Authorization of Transfer form. Staff N2 confirmed staff should follow their policy/procedure for Transfer of a Patient.

Daviess Community Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies. The facility was inspected as one, partially sprinklered building. It consisted of the original three story building, a 1937 three story addition, a 1953 addition determined to be of Type ll (222) construction and a two story 1961 addition, a four story 1975 addition and a one story 1998 addition, each determined to be of Type I (443) construction. The buildings were sprinklered except: the first floor 1926, 1937 and 1971 buildings housing the maintenance, housekeeping service and supply areas, nuclear medicine, MRI, boiler room and 5 patient rooms in the ICU suite; Second floor administrative offices in the 1926 and 1937 buildings. The facility has a fire alarm system with system-based smoke alarms in corridors, patient rooms, waiting rooms and hazardous areas. The facility has the capacity for 80 patients and had a census of 74 patients.

Based on observation, record review, and interview, the facility to maintain the limited noncombustible rating in accordance with Table 19.1.6.1 (see tag K161), the facility failed to ensure 1 of 1 Surgery Waiting room smoke barrier door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system (see tag K223), the facility failed to maintain protection of 1 of 1 Condensation shaft (see tag K311), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 21.3.4.1 (see tag K341), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1 (see tag K341), the facility failed to ensure a 1 of 1 complete automatic sprinkler system was installed in accordance with 21.3.5.1 (see tag K351), the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 4 of 10 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier (see tag K372), the facility failed to ensure there were battery-powered lighting for 1 of 4 1st floor Operating Rooms using general anesthesia (see tag K911), the facility failed to ensure 1 of 1 multiplug and 4 of 4 flexible cords were not used as a substitute for fixed wiring according to 9.1.2 (see tag K920).

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 and interview, the facility to maintain the limited noncombustible rating in accordance with Table 19.1.6.1. This deficient practice could affect all occupants, the facility failed to ensure 1 of 1 Surgery Waiting room smoke barrier door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system. This deficient practice could affect staff and any occupants in the Waiting room, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 21.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff and at least 16 patients, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.3.1.2 requires the location and spacing requirements shall be based on six factors. (2) Ceiling height. (5) Compartment ventilation. NFPA 72 17.7.3.2.1 spot-type smoke detectors shall be located on the ceiling, or, if on a sidewall, between the ceiling and 12 inches down from the ceiling to the top of the detector. This deficient practice could affect staff only, the facility failed to ensure 1 of 1 multiplug and 4 of 4 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 4 patients.


Findings include:

1. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 2:35 p.m., there were exposed steel support beams in the Medical Vacuum room with multiple spots measuring a total of two square feet where the protective coating was removed. Based on an interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed that bare metal was exposed and provided the estimate square feet of exposed metal.

2. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:22 a.m., the Surgery Waiting room entrance smoke barrier door was propped open with a chair that prevent the door from self-closing. When the door was tested, the door self-closed, hit the frame, and left a three eights inch gap. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 moved the chair and provided the door gap from the frame.

3. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:08 a.m. and 10:31 a.m., the following was discovered:
a) a smoke detector was eighteen inches away from a ceiling vent near patient room 400
b) a smoke detector was twelve inches away from a ceiling vent near patient room 315
c) a smoke detector was twelve inches away from a ceiling vent near the Program Director's office
Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:59 a.m., the following was discovered:
d) a smoke detector was twenty inches away from a ceiling vent near 1st floor OR locker
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged each smoke detector was located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

4. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 11:02 a.m., the equipment room next to the Imaging Suite had a smoke detector two and a half feet from the drop ceiling. The drop ceiling was not smoke resistive because multiple gaps would allow smoke and heat to pass through. Based on interview at the time of observation, the Director of Maintenance and the Maintenance Technician #1 acknowledged each gap in the drop ceiling, provided the measurement from the smoke detector from the ceiling, and was unable to confirm if a smoke detector was above the drop ceiling.

5. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:43 a.m. and 2:20 p.m., the following was discovered:
a) a surge protector was powering a coffee pot and refrigerator in the Social Worker's office
b) a surge protector was powering a microwave, coffee pot, and a toaster in the OB Break room
c) a surge protector was powering a coffee pot in the Maintenance Shop

6. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 between 9:21 a.m. and 10:48 a.m., the following was discovered:
d) a multiplug adapter was powering monitoring equipment in Sleep Lab #2
e) a surge protector was powering a refrigerator and a microwave in the ICU Break room
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 confirmed the surge protector was powering each aforementioned high amperage device.

Based on observation and interview, the facility failed to ensure there were battery-powered lighting for 1 of 4 1st floor Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and one patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:15 a.m., 1st floor operating room #3 did not have battery operated emergency lighting. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 acknowledged staff's confirmation that anesthesia is used and confirmed no battery operated emergency light is installed in the 1st floor operating room #3.

Based on observation, record review, and interview, the facility failed to maintain protection of 1 of 1 Condensation shaft. This deficient practice could affect staff and any occupants near the Front Entrance, the facility failed to ensure a 1 of 1 complete automatic sprinkler system was installed in accordance with 21.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect all occupants, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 4 of 10 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and up to 20 patients.



Findings include:

1. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 9:09 a.m., the Condensation vertical opening shaft 1st floor door had a forty five instead of a ninety minute fire resistive tag. Based on record review at the time of observation, the Condensation shaft is two hour rated. Based on interview at the time of observation and record review, the Director of Facilities and the Maintenance Technician #1 confirmed the door was rated forty five minutes in a two hour rated fire barrier.

2. Based on observations with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:15 a.m. and 2:57 p.m., the following was discovered:
a) a sprinkler pipe was supporting a conduit via wire near the patient room 300 above the drop ceiling
b) a sprinkler pipe was supporting PVC pipe via wire in the Boiler room fire barrier above the drop ceiling
c) a sprinkler pipe was supporting a conduit via wire in the 1st floor B Elevator above the drop ceiling
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged and confirmed the sprinkler pipes were supporting non-system components.

3. Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 9:56 a.m. and 10:15 a.m., the following unsealed penetrations were discovered:
a) a half inch gap around wires in the 4th floor smoke barrier above the drop ceiling
b) a half inch gap around wires in the smoke barrier near patient room 300

4. Based on observations with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 between 9:05 a.m. and 10:42 a.m., the following unsealed penetrations were discovered:
a) a one inch by two inch gap and a one and one half inch by three inch gap was in the Health Information smoke barrier above the drop ceiling
b) a half inch gap around a wire in the Surgery Waiting smoke barrier above the drop ceiling

5. Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged each aforementioned condition and provided the measurements.