HospitalInspections.org

20866




29731

Based on direct observation, review of policies and procedures and interviews with staff and patients, it was determined the facility failed to ensure personal privacy and observe HIPPA requirements. This affected two patients (Patient#'s 30 and 31) in a full emergency department with a capacity of 54. The emergency department has an average daily census of 227 patients.

Findings include:

Observation of Patient #30 was made during an emergency department visit on 08/22/11 at approximately 3:15 PM. Patient #30 was observed in an open area without a screen/curtain or any other means of privacy. Bay-10A is an indentation in the hallway and used as a patient area. Patient #30 was triaged and admitted to the emergency department on 08/22/11 and was being treated for Cellulitis and painful swelling of the left arm. Placement of Patient #30 in the hallway allowed him/her access to view care administered to other patients in the area. Patient #30 was able to see and hear confidential information about other patients while staff cared for them. During an interview with Patient #30, he reported observation of what was being done for a patient within his area during his own treatments. Additionally, Patient #30 gave the surveyor the first name of the nearby patient and the patient's complaints. Patient #30 also told the surveyors what the physician told the nurse about the patient in room #14. Patient #30's account of events of the patient in room #14 was verified with the clinical record of the patient in room # 14. An interview with Staff A on 08/22/11 at approximately 3:45 PM confirmed the privacy barrier had been down for approximately three days.

Observation of Patient #31 was made during an emergency department visit on 08/22/11 at approximately 3:15 PM. Patient #31 was triaged and admitted to the emergency department on 08/22/11 and was being treated without privacy barriers at Bay-1A for Diskitis and spinal disc inflammation. Due to the lack of privacy, Patient #31 was able to be observed by other patients and family in the area while being treated with the insertion of an IV(intravenous) line. Patient #31 was also observed as being in a position in which he/she could observe and/or hear information regarding other patients' care. This patient was not interviewed during the observation as he/she was in distress. An interview with Staff A on 08/22/11 at approximately 3:45 PM confirmed the privacy barrier had been down for approximately three days.

The hospital's policy for patient's rights reviewed on 8/23/2011 revealed that patient privacy and confidentiality will be observed. Please refer to hospital policy A0143- Patient Rights: Personal Privacy.

Based on interview, review of hospital by-laws and clinical record review, it was determined the hospital failed to ensure all medical records were completed within 30 days following discharge. This affected 1 of 4 (Patient # 41) discharge records reviewed. The total sample size for the survey was 50 and the current census at the time of the survey was 260.

Findings include:

Review of the hospital by-laws was completed on 08/24/11 at 3:00 PM. These by- laws were documented as last approved on 04/28/11. The section of the by-laws related to medical records stated an expected time of medical record completion was 30 days from discharge.
Interview with Staff O (medical records manager ) on 08/24/11 at 3:00 PM revealed the number of medical records delinquent for incompletion greater than 30 days was 11 percent or 849 records. This was reported from the 3rd quarter report of the medical staff executive committee for the year 2011.
Review of the clinical record for patient #41 was completed on 08/24/11. The discharge date for this patient was 07/19/11. The medical record discharge summary was not dictated by the physician until 08/25/11 and lacked signature authentification by the physician.
These findings were confirmed during interview with Staff B on 08/25/11 at 10:30 AM.






20866

Based on facility tours and staff interviews, it was determined that the facility failed to ensure that the building met construction type and height requirements; failed to ensure that doors in corridor walls had no impediments to closing and latched into door frames; failed to ensure that doors in smoke barriers would close in the event of fire; failed to ensure that exits had a hard or paved surface to the common way; failed to ensure that exit corridors were maintained free of impediments to exit travel; and failed to ensure that suites of sleeping rooms did not exceed 5000 square feet (Building 1.)

The facility failed to provide the required exit discharge lighting and failed to provide one exit with a hard or paved surface to the common way (Building 3.)

The facility failed to ensure that the building met construction type and height requirements; failed to have a directional exit sign that clearly indicated the direction of egress travel; failed to maintain one-hour fire resistance of smoke barriers; failed to ensure that smoke barrier doors were arranged so that the doors would swing in opposite directions; failed to ensure that hazardous areas were both sprinklered and one-hour protected; failed to ensure that the sprinkler system was continuously maintained in reliable operating condition; and failed to perform monthly inspections of fire extinguishers (Building 5.)

Based on the cumulative effect of these systematic problems, it was determined that the Condition of Environment was not met.

Findings include:

Please refer to A710 for details.

Based on facility tours and staff interviews during the Life Safety Code survey, it was determined that the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association 2000 edition. The facility failed to ensure that the building met construction type and height requirements; failed to ensure that doors in corridor walls had no impediments to closing and latched into door frames; failed to ensure that doors in smoke barriers would close in the event of fire; failed to ensure that exits had a hard or paved surface to the common way; failed to ensure that exit corridors were maintained free of impediments to exit travel; and failed to ensure that suites of sleeping rooms did not exceed 5000 square feet (Building 1.)

The facility failed to ensure that the required exit discharge lighting was provided and failed to ensure that an exit had a hard or paved surface to the common way (Building 3.)

The facility failed to ensure that the building met construction type and height requirements; failed to have a directional exit sign that clearly indicated the direction of egress travel; failed to maintain one-hour fire resistance of smoke barriers; failed to ensure that smoke barrier doors were arranged so that the doors would swing in opposite directions; failed to ensure that hazardous areas were both sprinklered and one-hour protected; failed to ensure that the sprinkler system was continuously maintained in reliable operating condition; and failed to perform monthly inspections of fire extinguishers (Building 5.)

The facility capacity was 568 and the census was 260 at the time of the survey.

Findings include:

Building 1:

Refer to K12 for details regarding failure to ensure that the building met construction type and height requirements.
Refer to K18 for details regarding failure to ensure that doors in corridor walls had no impediments to closing and latched into door frames.
Refer to K27 for details regarding failure to ensure that doors in smoke barriers would close in the event of fire.
Refer to K38 for details regarding failure to ensure that exits had a hard or paved surface to the common way.
Refer to K72 for details regarding failure to ensure that exit corridors were maintained free of impediments to exit travel.
Refer to K130 for details regarding failure to ensure that suites of sleeping rooms did not exceed 5000 square feet.

Building 3:

Refer to K130 for details regarding failure to ensure that the required exit discharge lighting was provided and failure to ensure that an exit had a hard or paved surface to the common way.

Building 5:

Refer to K12 for details regarding failure to ensure that the building met construction type and height requirements.
Refer to K22 for details regarding failure to have a directional exit sign that clearly indicated the direction of egress travel.
Refer to K25 for details regarding failure to maintain one-hour fire resistance of smoke barriers.
Refer to K27 for details regarding failure to ensure that smoke barrier doors were arranged so that the doors would swing in opposite directions.
Refer to K29 for details regarding failure to ensure that hazardous areas were both sprinklered and one-hour protected.
Refer to K62 for details regarding failure to ensure that the sprinkler system was continuously maintained in reliable operating condition.
Refer to K64 for details regarding failure to perform monthly inspections of fire extinguishers.

Based on direct observation, staff interviews and review of policies and procedures related to infection control, it was determined the hospital failed to ensure all infection control requirements were met in accordance with the Centers for Disease Control and Prevention and regulations with Centers for Medicare and Medicaid. The hospital staff failed to ensure equipment and surfaces soiled with blood and body fluids are disposed of or cleaned in accordance with hospital policy. This affected Patient # 32 who was cared for in the emergency department. The hospital staff also failed to use proper technique during dressing changes for Patient # 42, and perform hand hygiene after the removal of gloves for Patient # 50. This could affect all patients receiving care at the hospital. The total sample size was 50 with a current hospital census of 260. Patient # 32 was cared for in the emergency department where the capacity is 54 with an average daily census of 227.

Findings include:

During the observational tour of the emergency room on 8/22/2011, the surveyors observed a nurse(staff N) at 3:45 PM at the door of room 14 with gloves on talking to a physician. The gloves were covered with a bloody substance. The nurse touched the door knob and door frame with the bloody gloved hands. Three minutes later the same nurse with soiled gloves on, carried a 2 gallon plastic container covered with a bloody substance out of room 14 and placed the soiled container on the shelf under the cart/stretcher in the hallway. Again, the nurse left the room and returned to the room with soiled gloves on. The surveyor questioned staff A (hospital chief nursing officer who accompanied surveyors on tour) regarding the contents of the container and why the container was placed directly on the cart. Staff A summoned staff L (emergency department charge nurse) and staff L put the container in a wash basin. The surveyor further questioned Staff A about the policy for transporting items containing blood and bloody substance. Staff A stated that the container should be put in a red bag for biohazard materials. At the direction of Staff A, Staff L placed the container in a red bag. At 4:00 PM, the patient was taken from room 14. A housekeeping staff ( staff P ) arrived to clean room 14. The surveyor observed staff P when she/he cleaned the room. Staff P was observed soiling her clothes with blood while reaching to clean the exam table. The room had blood spatters in several areas i.e.., the exam table, floor and wall. There was a vaginal speculum and 2 syringes covered with blood on the step of the exam table. The exam table contained 2 blood soaked chux/pads. There were 4 blood soaked pads on the floor, 2 blood soaked pads on the step of the exam table. Also blood was dripping down the sides of the exam table and a large amount of blood on the floor. Staff P stated that the nursing staff should remove medical equipment prior to housekeeping's arrival. The housekeeping supervisor arrived and verified that the nursing staff should remove the medical equipment. Staff P was observed wiping up the blood on the floor with wipes. The surveyor questioned the staff regarding the use of the blood spill kit. Staff P looked puzzled and staff Q (housekeeping supervisor) stated: "there is a spill kit somewhere around here". Staff Q returned with the spill kit about 5 minutes later, after staff P had already placed the blood soaked chux/pads and wipes into the regular trash. Staff P finished cleaning the room, bagged up the soiled trash and carried the bags to the regular trash area. At no time during this observation did the surveyors observe any staff clean the shelf under the cart. The facility failed to ensure proper cleaning and disinfection of the patient cart, exam table surfaces, the wall and the floor and failed to transport items contaminated with blood and/or bloody fluids in accordance with hospital policy.

Patient #32's (the patient cared for in emergency room 14) clinical record revealed the patient was a 29 year old who presented to the emergency room on 8/22/2011 after a missed abortion. The patient complained of abdominal cramping and vaginal bleeding. The bleeding was brisk on exam. She was infused with 2 units of blood. A physician with a specialty in gynecological care saw the patient in the emergency room and removed the retained tissues.

The hospital's policy on infectious waste disposal (IC-002) reviewed on 8/23/2011 revealed trash containing large amounts of blood and/or blood products should be placed in a red biohazard bag. The policy on protective apparel (IC-012) reviewed on 8/23/2011 revealed that protective apparel is to be worn when the potential for contamination of clothing exists.

In addition to the above observations in the emergency department, on 08/22/11 at 3:37PM, Staff L was observed leaving room #3 with gloves on and returning to a room to care for a patient.

The above findings were confirmed with staff A on 8/22/2011 at 5:30PM.







03284

The clinical record review for patient #42 was completed on 08/25/11. This patient was admitted to the Burn Unit on 07/31/11 with a primary diagnosis of bilateral leg burns. Staff D (staff nurse) was observed during removal of the patient's surgical dressings 08/24/11 at 9:30 AM by the surveyor, staff J (unit nursing director) and staff I (nursing administrative staff ). The patient was observed to have dressings covering second degree burns on both lower extremities. The patient had surgical dressings covering bilateral upper extremity donor skin graft sites. The physician orders for the dressing changes were dated 08/21/11 with removal of the surgical dressing and one time a day application of Nitro-furacin (antimicrobial) .2% with covering of dermanet (skin cover ) dressing and final application of gauze to cover. Staff D placed chux (protective ) pads under the lower extremities to contain the continuous oozing of blood during removal of the burn dressings. During the procedure, Staff D was observed to have a bracelet on the right wrist. This bracelet was observed to dangle loose from under the gloves and drag on the bloody chux. The hospital policy MHP-HR 1540.0 , Professional Policy related to jewelry/piercing/fingernails stated "all accessories must meet safety and infection control standards." The above finding was shared on interview with Staff C (quality assurance/administrative nursing), Staff J and Staff B on 08/25/11 at 9:30 AM at which time it was confirmed this did not meet infection control standards.



21893

On 08/23/11 at 10:40 AM, Staff H was observed to change a central line dressing on Patient 50. Patient 50 was in Contact Precautions per the sign posted outside the patient's room. Staff H donned protective gown and gloves and entered the patient's room. Staff H put on a face mask and removed the old central line dressing. Staff H removed the used gloves and put on a pair of sterile gloves without performing hand hygiene. Staff H cleansed the insertion site of the central line and applied a clear sterile dressing. Staff H removed his/her gloves, again without hand hygiene. Staff H, with bare hands, then removed the border off of the clear dressing, applied two strips of tape to the dressing, reached into his/her pocket under the protective gown, labeled the dressing with the marker, and returned the marker to his/her pocket. This information was verified with Staff H and G after exiting Patient 50's room.

The Maintenance and Care of Central Line Catheters policy was reviewed on 08/24/11. The policy contained step by step directions for changing central line dressings. Step 8 stated remove the old dressing. Step 9 stated dispose of gloves and old dressing. Step 10 stated Perform hand hygiene and apply sterile gloves.

The Standard and Transmission Based (Isolation) Precautions policy was reviewed on 08/24/11. The policy stated hand hygiene must be done before donning sterile gloves and after removing gloves. For patients in Contact Precautions, the policy stated to put gloves on when entering the patient room and to wear a gown when it is anticipated that clothing will have contact with the patient, environmental surfaces, or items in the patient's room.

The clinical record for Patient 50 was reviewed on 08/25/11. The clinical record revealed the patient had been placed in Contact Isolation upon admission to the facility on 08/20/11. The medical record further contained documentation the patient's sputum culture, collected on 08/20/11, contained Acinetobacter baumanii (a genus of gram negative bacteria that can cause serious infection). This was verified by Staff R at the time of record review.