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Based on observation, interview, record review, and policy review, the facility failed to ensure that the Infant Security System (ISS) was maintained and fully operational to prevent infant abduction from the Obstetric (OB) Unit (A-0144).

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights. The total facility census was 32. The OB infant census was one.

On 07/23/18, it was determined that the severity and cumulative effect of these practices had the potential to place all infants at risk for their health and safety, also known as Immediate Jeopardy (IJ). The facility provided an acceptable plan of correction and implemented corrective actions to remove the IJ on 07/24/18, to prevent further risk to infants that included the following:
- Immediately placed a security staff person or designee at the Obstetric (OB) stairwell door to continuously assess and prevent an infant abduction. Another security staff member or designee will relieve the staff member for meals and breaks.
-Educate 100% of the OB staff prior to their shift on the immediate action plan which included stairwell alarm failure, placement of security staff member or designee at the OB stairwell door until Infant Security Alarm is functioning properly, increase frequency in testing of the infant security alarms and the action plan if a failure occurs, and review of the infant safety alarm system.
- Any staff on leave will be educated prior to returning to work.
- Contacted the security alarm company to immediately send a technician to repair the stairwell door alarm
- Test the infant security alarms for 100% of the OB doors once every 12 hour shift for one week or until no failures of the alarm, then test weekly for four weeks and then resume monthly testing.
- If any test fails, we will revert to our ILS (Interim Life Safety) measures which will include immediately placing security guard or designee in area, immediately contact the security alarm company to evaluate and repair failed system, education with 100% of staff regarding failure and the measures listed above and return to or continue to testing of the system once every 12 hour shift until failure free for one week.

Based on interview, record review and policy review, the facility failed to follow the facility policy time frames for the provision of a response for two patient grievances (#39 and #40) of three patient grievances reviewed. This practice had the potential to affect all patients that filed a grievance, and cause the complainant to be unaware of the status of their grievance. The facility census was 32.

Findings included:

1. Review of the facility policy titled, "Opportunity for Improvement/Complaints and Grievances," dated 01/16/16, showed that:grievances should be resolved within seven days, and required a written response.

Review of the complaint/grievance log showed Patient #39's concern dated 04/02/18, was determined to be a grievance by the facility. A letter was sent to the patient on 04/24/18 (22 days later). The letter was not sent in a timely manner.

Review of the complaint/grievance log showed Patient #40's concern dated 04/21/18, was determined to be a complaint by the facility. The log showed an in-depth investigation (indicating that the complaint was a grievance), but there was no documentation that a written response was sent to the patient.

During an interview on 08/06/18, Staff PP, Patient Advocate, stated that a letter would be sent when all information was gathered and that could take an extended amount of time. She stated that the policy did not stipulate in what time frame a letter should be sent to the complainant.

Based on interview, record review and policy review, the facility failed to provide a written notice of resolution with actions taken for one discharged patient grievance (#39) of two discharged patients' grievances reviewed. This had the potential to affect all patients and/or patients' representatives who filed a grievance, by denying them information regarding the outcome of their grievance. The facility census was 32.

Findings included:

1. Review of the facility policy titled, "Opportunity for Improvement (OFI)/Complaints and Grievances," dated 01/12/16, showed:
- Unless a customer specifically requests only a written response, the individuals(s) responding on behalf of the hospital will make no less than two attempts to contact the customer via phone to discuss the details of the grievance, including findings and actions taken in response to the grievance.
- A grievance requires a written response with the general findings and results of the investigation into the grievance; and the date the grievance is considered closed by the hospital.
- If the individuals(s) responding on behalf of the hospital is unable to reach the customer after two attempts, the hospital will send a letter to the customer summarizing the attempts to contact him/her, and the findings and actions taken in response to the grievance.

Review of grievance logs showed Patient #39's concern on 04/02/18 was determined to be a grievance by the facility. The log's documentation showed that two phone calls were placed to the patient and three phone messages left for the patient. A letter sent to the patient on 04/24/18 (22 days later), asked her to call the facility for the results of their investigation. The letter did not inform the patient of the steps taken to investigate the grievance, the results of the grievance process and the date of completion, as required.

During an interview on 07/24/18 at 3:35 PM Staff A, Risk Manager, stated that since phone calls had not been successful, a letter was sent to the patient asking her to call the facility for further discussion of her grievance.

Based on observations, interview, record review and policy review, the facility failed to ensure that:
- Infants were safe from abduction in the Obstetrics (OB) Unit.
- Patients could be evacuated safely in case of emergency.
- Crash carts (mobile carts containing life saving medications, supplies and equipment) and defibrillators (life saving medical equipment) were checked daily.
The total facility census was 32, with one infant in the OB Unit and 15 patients on the Behavioral Health Unit (BHU).

Findings included:

1. Review of the facility policy titled, "Testing and Evaluation of the Infant and Pediatric Security System (ISS)," dated 01/01/17, showed a functional test and evaluation of the infant security system shall be conducted at a minimum monthly, or per manufacturer's recommendation, whichever is stricter, to ensure the system is properly functioning and connected to building security systems.

Review of the facility's undated procedure titled, "(Security System) Testing Procedures" showed that with the door in the open position, the door should alarm locally.

Review of ISS checks from January 2018 through June 2018 of the "G" stairwell door in the Obstetrics Unit showed no failures of the door to alarm when tested for infant abduction.

Observation on 07/23/18 at 3:20 PM, showed the "G" stairwell door in the Obstetrics Unit, when held open to test for alarm function, did not alarm. This could allow an infant abduction.

During an interview on 07/23/18 at 3:35 PM, Staff L, OB Registered Nurse (RN), stated that it could be possible for someone to get past staff with a baby, if no alarm sounded.

2. Review of the facility's policy titled, "Evacuation Plan," revised 12/21/17, showed the following:
- Patient relocation and evacuation is to be undertaken only when conditions of the environment cannot support care, treatment, and/or services.
- If patients cannot be moved via elevators within adjacent buildings, move them vertically using the secure and safe stairwells.
- Patients that cannot walk are transported down the stairwells on evacuation sleds.
- The Emergency Management team will review the use of evacuation equipment periodically.
- Drills will evaluate the appropriateness of the equipment and address the need for additional or different equipment.

Observation on 07/24/18 at 2:00 PM showed the following:
- The Medical/Surgical unit on the second floor had patient rooms on three separate hallways.
- The "70's" hallway had seven individual patient rooms, the "30's" hallway had six individual patient rooms and the "50's" hallway had seven individual patient rooms.
- Each hallway had a secure and safe stairwell for patient evacuation.
- Ten sleds were located in a clean utility room on the "50's" hallway.
- There were no sleds located on the "30's" hallway or the "70's" hallway.
- The nearest sled to transport patients if the "50's" hallway was not accessible during an evacuation, was in the Ambulatory Surgery Unit (ASU), which contained two sleds, and was 452 feet away from the clean utility room sled storage area on the second floor.

During an interview on 07/24/18 at 3:00 PM, Staff N, Director of Inpatient Services, stated that she had not thought of the possibility of the sleds being unattainable during a fire or disaster, and added that the sleds should be kept on all of the hallways.

This failure had the potential to place all patients on the second floor at risk for their safety if the sleds were not available for evacuation during a disaster.

3. Record review of the facility's policy titled, "Crash Cart and Defibrillator" revised 03/2017, showed that the cart was to ensure safe and properly operating equipment for patient care during emergency situations, and that all crash carts were to be checked, and documentation per checklist was to be completed every 24 hours.

Record review of the BHU checklist for crash cart and defibrillator showed the following:
- No daily check for 05/09/18, 05/15/18, 05/29/18 and 05/30/18;
- No daily check for 06/17/18 through 06/20/18; and
- No daily check for 07/07/18 and 07/13/18.

During an interview on 07/25/18 at 8:57 AM, Staff E, RN, BHU Director, stated that the crash cart was to be checked every day by the day shift charge nurse. She stated that she didn't review the checklists for completion as she trusted the charge nurse to check it daily.

The failure to ensure that the crash cart and defibrillator were operational placed all patients on the BHU at risk for a delay in their care, as the BHU was a locked unit, and there was not another crash cart nearby if an emergency occurred.


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