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Based on record review and staff interview, the facility failed to ensure that clinical records were completed in a timely manner and that discharge summaries were included in the complete record for 2 (#s 7 and 15) of 28 patients. Findings include:

1. During the review of the Medical Records Department on 7/18/11, beginning at 10:30 a.m., the surveyor asked about the numbers of incomplete clinical records. Facility staff member N pointed to a rack of shelves and stated that all of the records on the shelves were incomplete and beyond 28 days after discharge. The surveyor requested a tally of the numbers of records that were incomplete more than 28 days and 60 days. Staff member N provided a note that indicated that there were 12 records incomplete after 28 days and 90 records incomplete beyond 60 days after discharge. Staff member N stated that many of the records were those of providers that had left the facility. She also stated that the Medical Records staff would take records to physician offices and to the operating room to obtain the signatures necessary to complete the records. This was verified by staff member O during an interview on 7/20/11 at 10:00 a.m.

During the end of the day meeting on 7/19/11 beginning at 4:45 p.m., with the facility administrative team, the number of incomplete records was discussed. Staff member K provided the survey team with a copy of page 15 of the facility Medical Staff Bylaws that included the facility requirements stipulating what comprised a completed clinical record. The bylaw item K.2 read in part; "The record must be completed promptly after discharge in accordance with state law, but no later than 28 days after discharge."


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2. Patient #7 was admitted to the hospital on 8/10/10. During review of patient #7's closed record on 7/20/11, the surveyor noted that the medical record lacked a discharge summary.

Patient #15 was admitted to the facility on 12/14/10. During review of patient #15's closed record on 7/20/11, the surveyor noted that the medical record lacked a discharge summary.

Based on record review, the facility staff failed to ensure that the clinical records of 2 (#s 7 and 15) of 28 sampled patient included a discharge summary. Findings include:

1. Patient #7 was admitted to the hospital on 8/10/10. During review of patient #7's closed record on 7/20/11, the surveyor noted that the medical record lacked a discharge summary.

2. Patient #15 was admitted to the facility on 12/14/10. During review of patient #15's closed record on 7/20/11, the surveyor noted that the medical record lacked a discharge summary.

Based on record review and observations during the survey completed on July 18 and 19, 2011, the facility failed to meet the Condition of Participation, Physical Environment, due to the nature and number of standards not met. These standards are listed as follow:

1. The condition of the overall hospital environment must be maintained in such a manner that the safety and well-being of all patients are assured. Refer to A-0701.

2. The hospital must ensure that the Life Safety from fire requirements are met. Refer to A-0709.

3. The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. Refer to A-0710.

4. The hospital must be in compliance with Chapter 19.2.9, Emergency Lighting. Refer to A-0711.

5. The hospital must maintain the requirements of State and local fire control agencies. Refer to A-0715.

Based on review of the Fire Life Safety survey conducted on July 18 and 19, 2011, the facility failed to keep the physical plant and the overall environment maintained in such a manner that the safety and well-being of patients was assured. Findings include:

The facility failed to ensure the safety of patients, staff and families for emergency situations by:
- not performing quarterly fire drills on every shift.
- not reacting to an alarm for the fire suppression system in the Magnetic Resonance Imaging (MRI) Data room which was in the alarm mode during the survey process.
- not actively repairing all fire doors that did not latch when monthly fire drills were performed, to maintain proper fire separations within buildings with communicating walls.
- not verifying that the hospital had developed and implemented a comprehensive plan to ensure that the safety and well being of patients was assured during emergency situations.

Refer to K011, K050, and K062 in the Life Safety Survey conducted on July 18 and 19, 2011 for the examples which will support these findings.

Based on review of the Fire Life Safety survey conducted on July 18 and 19, 2011, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code. Findings include:

The hospital failed to meet the minimum requirements of the 2000 Edition of the Life Safety Code. See Form CMS 2786 Statement of Deficiencies for the Fire Life Safety survey conducted on July 18 and 19, 2011, for further explanation.

Based on review of the Life Safety Code survey which was conducted on July 18 and 19, 2011, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code. Findings include:

As a result of the Life Safety Code survey on July 18 and 19, 2011, the facility failed to have in place preventive maintenance programs to ensure that:
- fire walls with non-confirming buildings had at least a two hour fire barrier. Refer to K11.
- building construction was intact at all connecting walls and ceilings. Refer to K12.
- corridors are constructed with at least 1/2 half hour fire resistive walls. Refer to K17.
- all corridor doors were not blocked open and latched properly. Refer to K18.
- stairways, vertical shafts and elevators were enclosed with at least one hour construction. Refer to K20.
- smoke barrier walls were intact. Refer to K25.
- smoke barrier doors were smoke tight. Refer to K27.
- doors on hazardous areas were self closing and walls in hazardous areas were sealed to resist smoke. Refer to K29.
- stairways used as exits had barriers to prevent one from going beyond the level of exit. Refer to K34.
- emergency lighting was checked monthly and annually. Refer to K46.
- fire drills were conducted once per quarter per shift. Refer to K50.
- sensitivity testing was conducted on all smoke detectors and proof retained in the record. Refer to K54.
- quarterly maintenance for the automatic sprinkler system was kept current, and sprinkler systems were monitored so as not to be in alarm mode. Refer to K62.
- all portable fire extinguishers were serviced annually. Refer to K64.
- combustion and ventilation air in boiler rooms was maintained at proper levels. Refer to K68.
- kitchen hood exhaust ducts were properly maintained, and fire suppression systems were properly maintained. Refer to K69.
- curtains in health care facilities were flame resistant or treated with a flame retardant chemical. Refer to K74.
electrical source was located above five feet elevation in all medical gas storerooms. Refer to K76.
- source valves for oxygen, nitrogen, nitrous oxide and medical air were properly labeled. Refer to K140, and
- extension cords, surge cords were monitored to prevent electrical problems. Refer to K147.

Refer to all K tag deficiencies in the Life Safety survey conducted on July 18, and 19, 2011 for further explanation.

Based on review of the Fire Life Safety survey conducted on July 18 and 19, 2011, the facility failed to maintain the requirement to be in compliance for battery pack emergency lighting. Findings include:

Beginning March 13, 2006, a hospital must be in compliance with Chapter 19.2.9, Emergency Lighting. Hospitals must replace 1-hour batteries with 1-1/2 hour batteries in emergency lighting systems that use batteries as power sources. The emergency pack batteries in the operating rooms had been replaced, but all other battery pack lighting (approximately 24 units) were not in compliance with the newer requirements for emergency lighting.

During an interview with staff member DD on July 18, 2011 at 11:30 a.m., he stated that he was not performing the required monthly and annual testing requirements for emergency light fixtures.

Refer to K046 in the Life Safety survey conducted on July 18 and 19, 2011, for further explanation.

Based on review of the Fire Life Safety survey conducted on July 18 and 19, 2011, the facility failed to implement suggestions made by the local fire control agencies. Findings include:

The local fire department had identified that a portable fire extinguisher had missed its annual service during their survey in 2011. This surveyor identified the same extinguisher during this survey and noted that it had not been serviced annually.

Refer to K064 in the Fire Life Safety survey conducted on July 18 and 19, 2011 for further explanation.

Based on observations and staff interviews, the facility failed to maintain patient care supplies in a manner to ensure an acceptable level of safety and quality. Findings include:

1. During the review of the second floor patient care area on 7/18/11 beginning at 12:45 p.m., the surveyor noted the following expired patient care supplies:
- 4 sterile individual Povidone-Iodine swabsticks with the manufacturer's expiration dates of 6/2008 (3) and 10/2010 (1).
- 1 BBL sterile Culture Swab Plus culture tube with the manufacturer's expiration date of 7/2009.

2. During the review of the first floor patient care area on 7/18/11 beginning at 1:15 p.m., the surveyor noted the following expired patient care supplies:
- 4 sterile 3 pack Isopropyl alcohol swabsticks with the manufacturer's expiration date of 3/2011.
- 1 16 gauge by 1.7 inch Insyte Autoguard intravenous catheter with the manufacturer's expiration date of 2/2010.
- 1 Blom-Singer Transesophageal Puncture Set with the manufacturer's expiration date of 6/2010.
- 2 Becton-Dickinson 1.8 milliliter blue top Vacutainer blood collection tubes with the manufacturer's expiration date of 3/2011.
- 1 Open tube K-Y individual lubricant with the manufacturer's expiration date of 3/2011.
- 8 sterile 3 pack Isopropyl alcohol swabsticks with the manufacturer's expiration date of 11/2010.
- 3 packages of 3-0 Nylon sterile suture on cutting needles with the manufacturer's expiration date of 4/2011.
- 1 sterile 2000 milliliter bag of Sterile Water for Irrigation with the manufacturer's expiration date of 4/2011.
- 25 sterile foil packets of white petrolatum with the manufacturer's expiration dates of 1/2008 (2) and 2/2011 (23).

3. During the review of the operating and recovery areas on 7/19/11 beginning at 1:15 p.m., the surveyor noted the following expired patient care supplies:
- 1 1000 milliliter bag of 5% Dextrose in .45 Normal Saline with the manufacturer's date of 11/2010.
- 2 24 gauge by .7 inch Insyte Autoguard intravenous catheters with the manufacturer's expiration dates of 8/2010 (1) and 4/2011 (1).

4. During the review of the first floor medication room on 7/20/11 beginning at 9:30 a.m., the surveyor observed the following outdated patient care supplies:
- 25 sterile 3 pack Isopropyl alcohol swabsticks with the manufacturer's expiration date of 11/2010.
- 1 Portex Arterial Blood Gas Kit with the manufacturer's expiration date of 3/2011.

During interviews with staff member E on 7/19/11 at 2:45 p.m., staff member J on 7/19/11 at approximately 4:00 p.m., and staff member G on 7/20/11 at 10:00 a.m., the staff members stated that the nurses on duty were responsible for checking expiration dates of supplies in their areas. Staff members G and E stated that they had personally reviewed the supplies in their areas on 7/18/11 and had missed the identified expired items.