HospitalInspections.org

Based on record review and 2 of 2 staff interviews by surveyor #29972, the hospital failed to be prepared to handle medical emergencies related to children, failed to have policies and procedures for medical protocols established by medical staff to handle emergencies for children, and failed to have adequate staff trained to handle medical emergencies for children. The lack of policies and procedures for preparedness for medical emergencies could deny children safe and adequate initial treatment of an emergency medical condition.

Findings include:

Interview with Staff RN (D) by surveyor #29972 on 6/14/2011 at 9:45 am confirmed the facility provides alcohol detoxification treatment to children. Staff RN (U) has never received education in-services or training specific to children.

Interview with Nursing Director (E) by surveyor #29972 on 6/14/2011 at 10:45am confirmed there is no specialized training or competencies specific to children and there are no policies and procedures governing how to handle medical emergencies in children.

Based on review of the hospital Quality Assurance Program and 1 of 1 interviews with facility staff, the hospital failed to ensure that all the hospital departments and services, to include those services furnished under the contract or agreement, are a part of the hospital performance improvement program.
Findings include:
1. Per interview, with Nursing Service Manager (E) on 6/15/2011 at 10:10 AM by surveyor #29963, the performance improvement program does not evaluate all of the services offered at the hospital as part of the quality assurance program to include: Housekeeping, and Laundry.
2. Per review, of the hospital quality assurance program documentation on 6/15/2011 at 10:00 AM, by surveyor #29963, the quality assurance program does not include evidence of on going evaluation of the following services: Pharmacy, Housekeeping, Laundry, Therapy and Infection Control.

Based on observation, staff interview and review of maintenance records between 6/13-6/15/2011, the facility failed to construct, install, and maintain the building system due to (i) lack of astragals in 4 sets of smoke doors; and (ii) not maintaining access to one exit free of obstructions.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-27, K-72, K-130 and A-710 tags for detail.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

1. Failed to protect the life safety of patients from fire due to lack of astragals in 4 sets of smoke doors;

2. Failed to protect the life safety of patients from fire due to one means of egress to exit not maintained free of obstructions; and

3. Failed to protect the life safety of patients from fire due to three corridor doors not positively latching.


Refer to K-tags K-27, K-72 and K-130 for detail.

Based on 1 of 1 interview and review of Refrigerator Temperature documentation, the hospital failed to verify that food products are stored under the appropriate temperature to ensure food safety and quality.

Findings include:

Per review of refrigerator temperature documentation during tour on 6/13/11, refrigerator temperatures were not checked on 4 of 14 days listed.

Per interview during the tour on 6/13/11 with Food Supervisor (B), the refrigerator and freezer temperatures should be checked and documented daily.

Per review of Dietary Documentation Procedures on 6/14/2011 at 4:00pm, refrigerated temperatures are to be documented daily for refrigeration units in the main kitchen and the dietary support areas .