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500 BURLINGTON ROAD

JACKSON, OH 45640

No Description Available

Tag No.: C0220

Based on observations, review of fire plan policies, generator logs, relative humidity logs, and staff interviews, this Condition of Participation of Physical Plant and Environment is not met related to the results of the life safety from fire survey regarding the facility's failure to ensure the doors of four of eight patient sleeping rooms in the critical care unit were equipped with latching hardware in order to resist the passage of smoke, one of one set of latching fire doors latched when released from the automatic hold open device, one of ten exits was marked by an approved, readily visible sign, the door to one of one soiled utility rooms, located in the critical care in-patient unit, resisted the passage of smoke, one of ten exits lacked a hard or paved continuous surface from the exit discharge to the common way, five of ten exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness, the facility's failure to conduct fire drills once a shift per quarter, failed to conduct them at various times, lacked documentation of staff who participated in the drills, and did not ensure all patient care areas participated in fire drills, failed to ensure relative humidity was maintained at equal to or greater than 35% in three of three operating rooms, failed to ensure the facility's documented acceptable parameters for humidity in the operating room met the requirement of 35% or greater, lacked weekly generator checks, and lacked evidence the fire watch plan included the frequency of, and the person responsible for conducting the fire watch rounds, in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.
The facility had a capacity of 25 and a census of 21 during this visit. .

Finding include:


The facility failed to ensure the doors of four of eight patient sleeping rooms in the critical care unit were equipped with latching hardware in order to resist the passage of smoke. Refer to C221.

The facility failed to ensure one of one set of latching fire doors, located in the administrative wing, latched when released from the automatic hold open device. Refer to C221.

The facility failed to ensure one of ten exits was marked by an approved, readily visible sign. The way to reach this exit was not readily apparent to visitors and staff. Refer to C221.

The facility failed to ensure the door to one of one soiled utility rooms, located in the critical care in-patient unit, resisted the passage of smoke. Refer to C221.

The facility failed to ensure one of nine exits lacked a hard or paved continuous surface from the exit discharge to the common way. Refer to C221.

The facility failed to ensure five of five exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness. Refer to C221.


The facility failed to conduct fire drills on the second quarter third shift, did not ensure fire drills were held at unexpected times and days, and did not ensure the operating room and in-patient care units participated consistently in fire drills. Refer to C231.

The facility failed to ensure relative humidity was maintained at equal to or greater than 35% in three of three operating rooms, failed to ensure the facility's documented acceptable parameters for humidity in the operating room met the requirement of 35% or greater. Refer to C231.

The facility lacked documented evidence of weekly generator checks between 07/07/10 through 03/01/11. Refer to C231.

The facility lacked evidence the fire watch plan included the frequency of, and the person responsible for conducting the fire watch rounds, in accordance with the code at 9.7.6.1, in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. refer to C231.

No Description Available

Tag No.: C0221

Based on observations and staff interviews, the facility failed to ensure the doors of four of eight patient sleeping rooms in the critical care unit were equipped with latching hardware in order to resist the passage of smoke, one of one set of latching fire doors latched when released from the automatic hold open device, one of ten exits was marked by an approved, readily visible sign, the door to one of one soiled utility rooms, located in the critical care in-patient unit, resisted the passage of smoke, one of nine exits lacked a hard or paved continuous surface from the exit discharge to the common way, five of five exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness (without lighting). The facility had a capacity of 25 and a census of 21 during this visit.

Findings include:

The facility failed to ensure the doors of four of eight patient sleeping rooms in the critical care unit were equipped with latching hardware in order to resist the passage of smoke. Refer to K18.

The facility failed to ensure one of one set of latching fire doors, located in the administrative wing, latched when released from the automatic hold open device. Refer to K21.

The facility failed to ensure one of ten exits was marked by an approved, readily visible sign. The way to reach this exit was not readily apparent to visitors and staff. Refer to K22.

The facility failed to ensure the door to one of one soiled utility rooms, located in the critical care in-patient unit, resisted the passage of smoke. Refer to K29.

The facility failed to ensure one of nine exits lacked a hard or paved continuous surface from the exit discharge to the common way. Refer to K38.

The facility failed to ensure five of five exit discharges were illuminated so that failure of any single lighting fixture (bulb) will not leave the area in darkness. Refer to K45.

No Description Available

Tag No.: C0231

Based on observations and staff interviews, the facility failed to ensure the provisions of the Life Safety Code of the National Fire Protection Association, NFPA 101, 2000 edition of the Life Safety Code, were met regarding the facility's failure to conduct fire drills once a shift per quarter, failed to conduct them at various times, lacked documentation of staff who participated in the drills, and did not ensure all patient care areas participated in fire drills, failed to ensure relative humidity was maintained at equal to or greater than 35% in three of three operating rooms, failed to ensure the facility's documented acceptable parameters for humidity in the operating room met the requirement of 35% or greater, lacked weekly generator checks, and lacked evidence the fire watch plan included the frequency of, and the person responsible for conducting the fire watch rounds, in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period.
The facility had a capacity of 25 and a census of 21 during this visit.

Findings include:

The facility failed to conduct fire drills on the second quarter third shift, did not ensure fire drills were held at unexpected times and days, and did not ensure the operating room and in-patient care units participated consistently in fire drills. Refer to K50.

The facility failed to ensure relative humidity was maintained at equal to or greater than 35% in three of three operating rooms, failed to ensure the facility's documented acceptable parameters for humidity in the operating room met the requirement of 35% or greater. Refer to K78.

The facility lacked documented evidence of weekly generator checks between 07/07/10 through 03/01/11. Refer to K144.

The facility lacked evidence the fire watch plan included the frequency of, and the person responsible for conducting the fire watch rounds, in accordance with the code at 9.7.6.1, in the event the required automatic sprinkler system is out of service for more than 4 hours in a 24 hour period. refer to K154.

No Description Available

Tag No.: C0274

Based on review of the facility's complaint logs, policy review, medical record review, and staff interview, the facility failed to have uniform policies for emergency medical services. This affected one of 67 patients seen in the emergency department on 11/25/10. (Patient # 20) In addition, the facility failed to conduct a complete investigation of a complaint regarding Patient #20 in November 2010. The emergency department sees 1900 patients per month.

Findings include:

Review of the facility's complaint log on 3/17/11 revealed a patient presented to the emergency department on 11/25/10 who was complaining of nausea and vomiting and abdominal pain occurring no more that 10 minutes after vomiting. This patient had a history of seven pregnancies with two live births in the past and on 11/25/10 was 8 months pregnant. The patient arrived to the Emergency Department on 11/25/10 at 9:27 PM. The patient was evaluated by the triage nurse at 9:27 PM and was determined to be category IV (requiring minimal assessment and treatment). The history did not include information explaining the outcome of the five other previous pregnancies. The triage evaluation did not include evidence fetal heart tones were obtained. This facility has no maternity department.

Review of the facility's policies on 3/17/11 revealed the policy titled TRIAGE OF PATIENTS with a last review date of January 2011. This policy identified four patient classification category definitions of triage. Category I was defined as emergent with life threatening illness or injury. Category II was defined as urgent and potentially life threatening, Category III was defined as requiring moderate assessment and diagnostic and treatment measures and are to be evaluated within one hour and Category IV was defined as requiring minimal assessment and treatment. This policy did not address pregnant patients. This TRIAGE OF PATIENTS policy refers to an additional facility policy, POLICY NUMBER 135.47 B that identified five categories for determining priority of care. POLICY NUMBER 135.47 B identified this policy was last reviewed in January, 2011. The five categories listed in POLICY NUMBER 135.47 B defined the triage assignment categories differently from the categories' definitions included in the TRIAGE OF PATIENTS policy. On 3/17/11 at 1:30 PM Staff K confirmed the facility's policies had conflicting category definitions and directions for staff to follow for Emergency Department triage.

Review of the facility policy titled OB/GYN PATIENTS on 3/17/11 revealed:
A: all OB/GYN patients will be seen in the Emergency Department by the Emergency Department physician
B: transfer arrangements will be made as soon as patient is stable to another facility where OB/GYN is available,
C: In the event that the patient is in active labor with delivery soon, the Emergency Department physician will deliver; stabilize both mother and child and transfer to another facility ASAP.

Review of patient #20's medical record revealed at 1:15 AM on 11/26/10 patient #20 left the emergency department without being seen by the Emergency Department physician.
Patient #20's medical record revealed a complaint of excessive wait time in the Emergency Department on 11/25/10 was filed with the hospital by patient #20's mother on 11/26/10. The hospital's complaint investigation did not have correct information regarding why the wait time was 3 hours and 45 minutes. The complaint investigation lacked evidence of a resolution of the complaint, information concerning the complainant's response to a phone call made by the hospital to the complainant regarding the complaint or if further investigation was required as outlined by the facility's policy for 4.04-COMPLAINT/MANAGEMENT-AND-RESOLUTION. This finding was confirmed by Staff P on 3/17/11 at 11:30 AM.

No Description Available

Tag No.: C0301

Based on observation, staff interview, and review of medical records policy on discharge summary, it was determined the hospital failed to ensure 95 of 95 outpatient therapy records, observed in a box in the treatment area of the outpatient therapy department, had been completed within 30 days of discharge. The patient census was 21.

Findings include:

On 03/15/11 between 10:00 A.M. and 10:45 A.M. observations were made in the outpatient therapy department with Staff B and Staff C. A large, cardboard box containing patient medical records was observed stored in the treatment area. Interview with Staff C on 03/15/11 at 2:00 P.M. revealed the box of patient medical records were discharged patients' medical records that were incomplete. Staff C stated these patient medical records contained discharge summaries that had not been signed and returned by the physician. Staff C confirmed on 03/15/11 at 2:00 P.M. the oldest delinquent record had a discharge date of January 2010. Staff C stated that outpatient therapy records are faxed to the physician to sign and the physician is supposed to sign and return the completed patient record within 30 days. Staff C stated one of the problems getting the patient records completed within the 30 days required is due to the fact some of the physicians are not on the hospital staff.

On 03/15/11 at 10:40 A.M. an interview was conducted with Medical Records Staff , who revealed outpatient records are not monitored. Staff T confirmed no policy for the monitoring of the outpatient therapy departments discharged patients' medical records has been developed.

On 03/17/11 at 9:30 A.M. Staff A verified there were 95 outpatient medical records stored in the outpatient therapy department that were not completed within the 30 day discharge requirement.

Review of the policy titled Discharge Summary 2.4 (b) on 03/15/11 revealed medical records shall be completed in a timely fashion, but in no event exceeding 30 days from discharge.