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Based on observation, staff interviews, and review of maintenance records between June 2 and June 3, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients in 11 of 11 smoke compartments.

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 39: egress corridor of the incorrect width;
K 46: emergency lighting is not provided for all egress pathways;
K 50: fire drills were not conducted at all required intervals;
K 51: fire alarm system without redundant transmission lines;
K 52: fire alarm system not fully tested per NFPA 72,
K 54: smoke detectors lacking sensitivity testing per NFPA 72;
K 62: sprinkler system was not properly maintained per NFPA 25;
K 67: dampers were not functionally tested within the last six (6) years;
K 69: commercial range hood was not tested nor cleaned per NFPA 96;
K 130: surgical spaces lacked battery backup lighting and required medical gas labeling was removed;
K 144: Level I emergency generator without a remote stop switch and without reliable annuciation to operating staff; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between June 2 and June 3, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients in 11 of 11 smoke compartments.

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 39: egress corridor of the incorrect width;
K 46: emergency lighting is not provided for all egress pathways;
K 50: fire drills were not conducted at all required intervals;
K 51: fire alarm system without redundant transmission lines;
K 52: fire alarm system not fully tested per NFPA 72,
K 54: smoke detectors lacking sensitivity testing per NFPA 72;
K 62: sprinkler system was not properly maintained per NFPA 25;
K 67: dampers were not functionally tested within the last six (6) years;
K 69: commercial range hood was not tested nor cleaned per NFPA 96;
K 130: surgical spaces lacked battery backup lighting and required medical gas labeling was removed;
K 144: Level I emergency generator without a remote stop switch and without reliable annuciation to operating staff; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review, observation and interview, the facility failed to ensure all medications are drawn up and administered in a safe manner to minimize the risks for cross contamination in 3 of 3 staff interviews (B, E, and M) and 1of 1 staff observations (RN D). This could potentially effect all patients receiving treatment at this facility.

Findings include:

Review on 6/3/14 beginning at 9:00 AM of facility policy entitled "IV Therapy" last revised 4/2010 states, between changes of components, the IV system should be maintained as a closed system as much as possible. All entries into the tubing for administration of medication will be made through ports that were disinfected before entry.

Observation on 6/2/14 beginning at 4:05 PM of RN D preparing to administer an IV infusion of ampicillin antibiotic revealed the following; RN D unscrewed the end of the previously used IV tubing from a blue connector port located on the IV tubing and attached it to the end of Pt 11's IV (intravenous) line, without first cleaning the end of the IV tubing.
Per interview on 6/3/14 beginning at 1:40 PM with RN M and RN B, nursing staff should be placing a cap on the end of the IV tubing when not in use. Per RN M and RN B, RN D should have wiped the end of the IV tubing with an alcohol wipe before connecting to the Pt 11's IV line.

Per review on 6/9/14 beginning at 8:00 AM of 2007 CDC (Centers for Disease Comtrol) guidelines titled "Safe Injection Practices to Prevent Transmission of Infections to Patients", multidose vials should not be drawn up or stored in the immediate patient treatment area.

Per interview with CRNA E on 6/3/14 beginning at 2:30 PM, CRNA E draws up multidose vials in the operating room for patients undergoing surgical procedures allowing for increased risk of potential cross contamination. Per interview with RN B on 6/3/14 beginning at 1:40 PM, multidose vials should not be drawn up in room with patient, multidose vials should be drawn up in separate area. RN B is the facility's Infection Control Officer and uses CDC guidelines for infection control program.

Based on observation, interview, and record review the hospital failed to ensure that patient supplies and medications are properly stored, the environment is kept clean, and that there is a system in place to prevent potential sources of contamination and infection in 6 of 10 areas (RT, Rehab, Clinic, ED,Nursing Unit, Central Supply) observed. This has the potential to affect all 2 patients served at the facility during this survey.


Findings include:

1. Supplies were observed in cabinets under sinks in the following areas;

-In the equipment cleaning room of Respiratory Therapy (RT) various supplies were stored under a sink including; 2 gallons of exymatic cleaning solution. This was observed on 06/02/14 at 2:14 PM during a tour with RT Supervisor I. I stated at the time of the tour that supplies should not be stored in this area.

-During a tour of the Physical Therapy (PT) Department with Rehab manager H on 06/02/14 at 3:00 PM it was observed that a cabinet under the sink was used for storage. Items stored there included; six containers of hydrogen peroxide wipes, 1 gallon of cavacide, and 5 litres of ultrasound gel. H stated at the time of the tour that this area should not be used for storage. During this same tour unsecured medications were found on a shelf in the PT office including; bacitracin ointment, Dexamethasone 0.4% solution and hydrocortizone 1% cream (which had expired 10/2008).

-During a tour of the off-site family practice clinic with Clinic manager N on 06/03/14 at 12:05 PM it was observed that a cabinet under the sink in the dirty utility room was used for storage of cleaning supplies and plastic bags.

-During a tour of the Emergency Department (ED) with ED manager C on 06/02/14 at 1:25 PM it was observed that a cabinet under the sink in the nursing station was used for storage of a money box, clipboard, vases and a measuring jug. In the ED dirty utility room the under sink cabinet contained enzymatic cleaner, a bucket, extension cord and a pitcher. In the ED clean utility room the following items were observed stored under the sink; Styrofoam transport containers and an insulated water jug. C stated at the time of the tour that this area should not be used for storage.







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(Physical Environment)

On tour of the nursing unit on 6/2/14 beginning at 11:00 AM, made the following observations:
-Supply room contained uncovered cart with patient gowns, towels, and blankets allowing for potential dust and debris contamination. Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled "Linen Handling and Storage" last revised 12/20012, clean linens on the patient care units should be stored in covered carts.
-Dirty utility room was unlocked and not labeled containing red biohazard containers and dirty linen. Per interview with RN D at the time of tour, dirty utility room is never locked. Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled "Hazardous Materials and Waste Management Plan" last revised 3/2012, all areas where biohazardous waste and materials are stored, used, or disposed of shall have appropriate signage and labeling. Per interview with RN B on 6/3/14 beginning at 1:40 PM, biohazardous and dirty linen storage room should be locked.
-Cabinet under sink in Nourishment Room contained dust and debris and brown residue.
-Housekeeping closet contained rust colored residue on floor near drain.
-Cabinet under sink in Steris Room contained pooling of bluish green water.

(Observations of Care)

Per observation on 6/2/14 beginning at 12:00 PM of RN D performing Pt 1's IV line insertion, with gloved hands RN D touched under bed rail to lower rail then proceeded to perform skin antisepsis, palpate vein, then insert needle into Pt 1's hand to place IV line, without first removing potentially contaminated gloves, performing hand hygiene, and donning clean gloves.
Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled "IV Therapy" last revised 1/2010, states staff must wash hands and don gloves prior to venipuncture.
Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled "Hand Hygiene" last revised 3/2011, staff should perform hand hygiene after removing gloves and before and after direct contact with objects likely to be contaminated.


Per observation on 6/2/14 beginning at 3:55 PM of RN D performing Pt 11's wound care to right knee, RN D did not disinfect Pt 11's bedside tray table prior to placing clean supplies on the table. RN D removed old dressing, removed one glove, then obtained new glove, donned new glove, then proceeded to open sterile supplies without first removing both gloves, performing hand hygiene, and donning a new pair of gloves, allowing for potential cross contamination.
Per review on 6/9/14 beginning at 8:00 AM of P & P titled "Hand Hygiene" last revised 3/2011, staff should perform hand hygiene after removing gloves and before and after direct contact with objects likely to be contaminated.

(Surgery)

Per interview with CST (central supply tech) F during tour on 6/2/14 beginning at 1:50 PM of OR (operating room) surgical tool and equipment disinfection/sterilization room, CST F does not measure the amount of water used to mix with enzymatic cleaner to ensure accurate disinfection of surgical tools and equipment. Per CST F, fills the sink with water to a specific area on the sink, not sure if this is a gallon of water. Per CST F manufactures directions are to mix 1/2 ounce of enzymatic cleaner with a gallon of water.
Per observation at time of tour, sink is not marked to identify the measurement of a gallon of water.
Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled, "Cleaning Reusable Items" last revised 7/2013, cleaning and disinfectant solutions shall be prepared according to directions concerning concentrate of packet or solution.

Based on record review and interview the hospital failed to ensure staff re-evaluated pain in 4 of 4 patients (#11, 12, 13 and 14) who were complaining of pain. This has the potential to affect all 2 patients receiving services at this facility at the time of the survey.

Findings include:

Hospital policy #21230 entitled: "Documentation Med/Surg Medical Record EHR (electronic health record)" dated 08/22/2013 states under "Implementation/Procedure" section "B"; "Pain assessments are also done with medication administration and one hour after med's administered."

According to the medical record (MR) pt. #11 was given vicodin for pain at the following times;
-6:15 PM on 05/23/14 and was not re-evaluated for pain until 10:12 PM
-11:34 AM on 05/24/14 and not re-evaluated until 3:29 PM.
-11:09 PM on 05/24/14 and not re-evaluated until 4:00 AM on 05/25/14.
-7:43 AM on 05/25/14 and not re-evaluated until 11:31 AM.
-12:36 PM on 05/28/14 and not re-evaluated until 4:26 PM.

According to the MR pt. #12 was given hydrocodone for pain at the following times;
-12:09 PM on 01/15/14 and was not re-evaluated until 3:13 PM.
-4:17 PM on 01/15/14 with no re-evaluation done until 8:43 PM.
-8:04 AM on 01/17/14 and not re-evaluated until 10:59 AM.
-7:32 AM on 01/19/14 and not re-evaluated until 11:45 AM.


According to the MR pt. #13 was given dilaudid for pain at the following times;
-12:34 PM on 01/18/14 and was not re-evaluated until 5:40 PM.
-8:15 PM on 01/18/14 with no re-evaluation done until 10:12 PM.


According to the MR pt. #14 was given hydrocodone for pain at the following times;
-8:02 PM on 04/16/14 and was not re-evaluated until 11:24 PM.
-6:04 AM on 04/17/14 with no initial evaluation and re-evaluation not done until 7:24 AM.

Findings were confirmed per interview with Assistant DON M on 06/03/14 at 1:30 PM. M stated pain re-evaluations should be done within 60 minutes with a numeric rating.

Based on record review and interview the hospital failed to ensure that nursing care plans developed for each patient are kept current to reflect progress toward goals. In 6 of 8 medical records reviewed (out of a total of 30) requiring a nursing care plan (#10,11,12,13,14 &16) documentation was incomplete. This deficiency potentially affects all 2 patients served at the facility during this survey.

Findings include:

1. Per MR (medical record) review on 06/02/14 and 06/03/14 the nursing care plans found in the MR of patients #10,11,12,13,14 and 16 did not contain nursing staff documentation reflecting progress towards goals.

Per interview, with Assistant DON M on 06/03/14 at 1:30 PM, the nursing care plans are developed from a computer system. Per M, she was able to print a list of nursing goals being "done", but there is no documentation of specific, individualized nursing interventions or progress as part of the nursing care plan. As a result, the nursing care plan in incomplete and not kept up-to-date.

Based on record review the facility failed to ensure that all physician progress notes are signed, timed, and dated in 4 of 4 patient operative notes reviewed (Pt 17, 18, 19, 20). This could potentially effect all patients receiving treatment at this facility.

Findings include:

Per review on 6/9/14 beginning at 8:00 AM of facility policy entitled, "Documentation in the Patient Hospital Record" last revised 10/2010, all entries must be dated, timed and signed.

Review of patient MR's on 6/3/14 beginning at 1:50 PM reveals the following:
Pt #17--physician operative note dated 4/14 does not include year and time of entry.
Pt #18--physician operative note dated 5/12 does not include year and time of entry.
Pt #19--physician operative note dated 4/9/14 does not include time of entry.
Pt #20--physician operative note dated 5/5 does not include year and time of entry, and signature of author.

Based on observation, record review, and interview the hospital failed to ensure records are protected from potential loss or damage. In 2 of 4 areas (Occupational Therapy and off-site storage) medical records were not secured or protected. This deficiency potentially affects all 2 patients served at the facility during this survey.

Findings include:

Hospital policy #0018 entitled; "Record Retention Guide-Hospital" last revised 08/22/11, states; "Organizational leadership and department managers shall be responsible for the retention of documents and files in a secure manner and/or environment safeguarding against loss, destruction or unauthorized access."


During a tour of the OT office with Rehab manager H on 06/02/14 at 3:00 PM it was observed that medical records were stored in an unlocked file cabinet in an unlocked room. According to H this area is cleaned by housekeeping staff after hours.


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Per observations during tour on 6/3/14 beginning at 9:00 AM of the off-site medical records storage building next door to the facility revealed the following;

Room #1--Boxes containing MR's on shelving unit; electrical wires hanging out of opened light fixtures; electrical outlets and wires hanging out of the wall; boxes touching ceiling; no drywall covering wall. Per interview with "J" (medical records manager) at the time of tour, the building does not have a functional sprinkler system in case of fire.
Room #2---16 boxes containing facility MR's directly on floor allowing for potential destruction from water and/or pests.
Room #3---11 box containing facility MR's directly on floor allowing for potential destruction from water and/or pests.
Room #4---13 boxes containing facility MR's directly on floor allowing for potential destruction from water and/or pests.

Based on record review and interview the facility failed to ensure the Post Anesthesia Evaluation includes all criteria in 2 of 4 surgical MR's reviewed (Pt 18 and 20) and 1 of 1 staff interviews (B). This could potentially effect all patients receiving treatment at this facility.

Findings Include:

Review of Pt 18's MR on 6/3/14 beginning at 2:55 PM shows the Anesthesia Progress Notes used for Post Anesthesia evaluation dated 5/12/14 at 11:10 AM does not contain documentation of cardiopulmonary status and level of consciousness.

Review of Pt 20's MR on 6/3/14 beginning at 3:45 PM shows the Anesthesia Progress Notes used for Post Anesthesia evaluation dated 5/5/14 at 11:25 AM does not contain documentation of cardiopulmonary status.

Review on 6/9/14 beginning at 8:00 AM of Anesthesia policy entitled, "Assessment Prior to Induction of Anesthesia-Sedation" last revised 12/2010; "Management of Anesthesia" last revised 12/2011; "Guidelines for Administration of Anesthesia" last revised 12/2011; "Discharge of patient from PACU Phase 1 and Phase 2" last revised 12/2011, reveals that none of the Anesthesia policies reviewed include guidelines for required criteria for Pre and post anesthesia evaluation.

Per interview with "B" on 6/3/14 beginning at 1:40 PM, facility does not have a Anesthesia policy that specifically addresses pre and post anesthesia evaluation documentation and assessment requirements.






29972

Based on record review and interview, the hospital failed to ensure that it had an effective quality assurance program that collected data for all services (medical records and organ procurement), and compiled aggregate data of adverse occurrences to identify high risk and/or problem-prone trends and patterns. This occurred in 3 of 3 quality assurance interviews conducted (Staff B, J and K ), and has the potential to affect the total patient population.

Findings include:


Per interview with Quality Director B on 06/02/14 at 3:00 PM the Organ Procurement department of the hospital is not involved in the QAPI (Quality Assurance Performance Improvement) program. B stated data is being tracked but there have been no initiatives for improvement.


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Per interview on 6/3/14 beginning at 10:00 AM with "B" (Quality director), the Medical Records department is not included in the facility wide QAPI program.

Per interview on 6/3/14 beginning at 8:30 AM with "J" (medical records manager) and "K" (lead coder), medical records department is not working on any quality improvement projects which are submitted to the facility wide QAPI program.