HospitalInspections.org

Based on interview, the governing board failed to assure the appointment and granting of privileges to physician residents and did not consider any recommendations from the medical staff.

Findings:

1. Upon interview, staff #A4, the Medical Director, indicated several Indiana University School of Medicine physician residents periodically practiced and delivered patient care at the hospital. Staff #A4 was requested to provide documentation of those physicians' credential files, recommendation by the medical staff and granting of privileges by the governing board. The staff member indicated there was no such documentation and none was provided prior to exit.

Based on document review and interview, the facility failed to ensure that in the resolution of grievances that the patient was provided written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. Review of the grievances made to the facility from 11-09 to 04-19 indicated lack of documentation of written responses to the individual making the grievance.

3. On 05-18-10 at 1400 hours, staff #43 confirmed that written responses are not sent to the individuals who file the grievance.

Based on document review and interview, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient for 2 of 5 open medical records (MR) reviewed (#1 & 2).

Findings include:

1. Review of policy/procedure Policy for Implementation of Nursing Care Plans for Patients Residing in State Owned or Operated Facilities indicates the following:
"C. Nursing care plans must be developed by an RN. Nursing care plans will be initiated using standardized Nursing Care Plans.
4. The RN initiates nursing care plans (or incorporates the nursing care plan into the treatment plan) during the same shift in which the need for nursing care plans is identified or within eight hours of the time the need is identified, whichever is sooner."
This policy/procedure was last reviewed/revised on 02-08-10.

2. Review of patient #1's MR on 05-17-10 at 1405 hours indicated the patient was admitted to a mental health inpatient unit on 05-13-10 and the patient's Nursing Care Plan lacked documentation of addressing the patient's mental health needs.

3. Review of patient #2's MR 05-17-10 at 1550 hours indicated the patient was admitted to a mental health inpatient unit on 04-07-10 and lacked documentation of a Nursing Care Plan.

4. On 05-17-10 at 1550 hours, staff #42 confirmed that patient #2's MR lacked documentation of a Nursing Care Plan.

Based on document review, the facility failed to ensure laboratory services were available either directly or through a contracted agreement with a certified laboratory.

Findings:

1. On 5-19-10 at 10:30 am, employee #A2 indicated lab services were contracted. #A2 was requested to provide documentation of a contract, memorandum of agreement, letter or any other document which would ensure services of a certified laboratory would be available at any time. No documentation was provided prior to exit.

At this Life Safety Code survey, Larue D. Carter Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This five-story facility with a basement was determined to be of Type II (222) construction and was fully sprinklered. The hospital was constructed primarily in the 1930's as several separate buildings and has been modified into one building. The most recent addition occurred in the mid 1990's. The building description is as follows:
Building 1 is a five-story building. The first floor is business/educational occupancy, the second, third and fourth floors are health care occupancy and the fifth floor is business occupancy. There is smoke detection located at cross corridor smoke barrier doors, elevator lobbies, machine rooms, waiting rooms open to the corridor; in corridors of the first, second, third, fourth and fifth floors and duct detectors in the penthouses.
Building 2 is a three-story building. The first floor is industrial/storage space and the second and third floors are business occupancy. There is smoke detection located at the smoke and fire barrier doors, elevator lobbies and machine rooms.
Building 8 is a five-story building. The basement is a storage occupancy; the first floor is business occupancy; the second, third and fourth floors are health care occupancy. There is smoke detection in the corridors of all five floors and duct detectors in the penthouses.
Building 11 is a three story building. The first floor is business occupancy, the second and third floors are assembly occupancy. There is smoke detection in the elevator lobbies and mechanical room.
Building 40 is a four-story building. The basement is a storage occupancy, first floor a business occupancy and the second, third and fourth floors are health care occupancies. There is smoke detection in the elevator lobbies and machine rooms, at the smoke and fire barrier doors, the corridors on all four floors and duct detectors in the penthouses.
The facility has a capacity of 159 beds and had a census of 154 at the time of this survey.

Based on Life Safety Code survey and deficiencies found (CMS 2567L), it was determined that the facility failed to ensure 1 of 1 doors to room 1-3007 in Building 1, a soiled linen room, closed and latched to prevent the passage of smoke (K 029), failed to ensure the means of egress through 1 of 14 exits were readily accessible for patients and staff (K 038), failed to ensure illumination for the exit discharge for 1 of 14 exits was provided (K 045), failed to ensure 1 of 1 fire alarm systems was continuously maintained in reliable operating condition (K 052), failed to electronically supervise 1 of 1 Post Indicator Valves (PIV) serving the hospital health care occupancy portion of the facility (K 061), failed to ensure 1 of 1 wet sprinkler systems was continuously maintained in reliable operating condition (K 062), failed to ensure all fire dampers in the hospital heating and ventilating system were tested and and provided necessary maintenance at least every six years (K 067) and failed to ensure the two generators were inspected weekly for 40 of 52 weeks (K 144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility did not maintain the condition of the physical plant to assure the safety and well-being of patients in 4 instances.

\Findings:

1. On 5-17-10 at 2:55 pm in the presence of employee #A2, it was observed in storage room 1-1064, in the Employee Health area, there were 2 small oxygen tanks on the floor unsecured by chain or holder. If they were knocked over and broke the head off the compressed cylinder, it could result in harm to people and/or property.

2. On 5-17-10 at 3:00 pm, employee #A2 was requested to provide documentation of preventive maintenance (PM) on a centrifuge (hospital asset #145519) located in a laboratory room. No documentation was provided prior to exit.

3. On 3-15-10 at 3:05 pm, employee #A2 was requested to provide documentation of PM on a patient scale located in room 1-1067. No documentation was provided prior to exit.

4. On 5-17-10 at 3:10 pm, employee #A2 was requested to provide documentation of PM on a refrigerator, dishwater, 2 grilling machines, a toaster stove, a turbo oven, a wok, a microwave, a toaster oven, an electric skillet and a sewing machine. All items were located in the Occupational Therapy area. Upon interview, hospital staff indicated these items were used by patients undergoing occupational therapy.

Based on observation, document review, and interview, the facility failed to ensure 1 of 1 doors to room 1-3007 in Building 1, a soiled linen room, closed and latched to prevent the passage of smoke, failed to ensure the means of egress through 1 of 14 exits were readily accessible for patients and staff), failed to ensure illumination for the exit discharge for 1 of 14 exits was provided, failed to ensure 1 of 1 fire alarm systems was continuously maintained in reliable operating condition, failed to electronically supervise 1 of 1 Post Indicator Valves (PIV) serving the hospital health care occupancy portion of the facility, failed to ensure 1 of 1 wet sprinkler systems was continuously maintained in reliable operating condition, failed to ensure all fire dampers in the hospital heating and ventilating system were tested and and provided necessary maintenance at least every six years and failed to ensure the two generators were inspected weekly for 40 of 52 weeks.

Findings:

1. Observation on 05/18/10 at 10:25 a.m. with the Maintenance Supervisor and Assistant Superintendent indicated the door to the personal laundry room (1-3007) storing soiled linen in two 35 gallon containers was not provided with a door closer and failed to close and latch into the frame.

2. The Maintenance Supervisor and Assistant Superintendent acknowledged at the time of observation that the door was not provided with a door closer.

3. Observation on 05/17/10 at 3:25 p.m. with the Maintenance Supervisor and Assistant Superintendent indicated a pair of exit doors leading to the exterior of the gymnasium were magnetically locked and had a key override pad adjacent to the doors. When the Maintenance Supervisor attempted to override the lock with the key all employees carry, the key turned, but the magnets did not release.

4. In interview at the time of observation, the Maintenance Supervisor and Assistant Superintendent acknowledged the magnets did not release.

5. Observation on 05/17/10 at 2:45 p.m. with the Maintenance Supervisor and Assistant Superintendent indicated the exit discharge for the Building 8, stairwell #1, first floor exit discharge lacked a light source.

6. In interview at the time of observation, the Maintenance Supervisor and Assistant Superintendent acknowledged lighting was not provided outside this stairwell exit.

7. Review of "Report of Inspection/Test" documentation from the facility's fire alarm contractor dated 08/29/2009 at 12:30 p.m. on 05/17/10 with the Maintenance Supervisor and Assistant Superintendent indicated the Annual Alarm Inspection/Test form indicated four devices were incorrectly addressed in the panel and indicated the facility would need to contact the manufacturers to correct the programming. Devices 5M2-19 and 5M2-20 were entered as 5M2-18, while 5M2-27 and 5M2-29 were entered as 5M2-2.

8. In interview at the time of record review, the Maintenance Supervisor and Assistant Superintendent indicated the devices have not been reprogrammed.

9. Observation with the Maintenance Supervisor on 05/18/10 at 11:00 a.m. indicated the PIV serving Buildings 1 and 2 (health care occupancy), including the fire pump, was not mechanically secured and lacked electronic supervision.

10. Review of "Report of Inspection/Test" documentation from the facility's sprinkler contractor (deficiency summary) dated 03/01/2010 at 12:45 p.m. on 05/17/10 with the Maintenance Supervisor and Assistant Superintendent indicated the following:
a) Gauges all need replaced. Interview with the Maintenance Supervisor at the time of review indicated there were 70 gauges.
b) The control valve with seal/color OS&Y 2-1/2 inch, 1-148, Building 1, fifth floor, stairway 2, 1-148 tamper failed.
c) The control valve with seal/color OS&Y 6 inch, fire pump 13-16, Building 2, Boiler room did not report to panel.
d) The control valve with seal/color OS&Y 4 inch, fire pump 13-16, Building 2, Boiler room did not report to panel.
e) The control valve with seal/color OS&Y 1-1/4 inch, jockey pump 13-16, Building 2, Boiler room did not report to panel.
f) The control valve with seal/color Butterfly 4 inch, fire pump, Building 2, Boiler room device was not wired up.
g) The control valve with seal/color Butterfly 3 inch, Building 8, Basement HVAC office, 5M1-35 tamper failed to report to panel.
h) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, third floor, west stairwell, 5M2-197 control valve packing has a leak.
i) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, first floor, west stairwell, 5M1-91 control valve is corroded and leaking.
j) The control valve with seal/color Butterfly 3 inch, Building 8, Stairwell across from Gym, 5M1-97 tamper switch failed.
k) The control valve with seal/color OS&Y 2-1/2 inch, Building 8, second floor, east stairwell, 5M1-107 control valve packing leaks.
l) The inspector's test valve, Building 1, third floor, stairway 3 has a leak on sideflow of ITV 1-1/4 inch thread.
m) Flow test, Building 1, fourth floor, stairway 1, 1-109 has no gauge on the riser.
n) The inspector's test valve, Building 1, fourth floor, stairway 1 has a leak on sideflow of ITV 1-1/4 inch thread.
o) Flow test, Building 2, first floor, o/s Rm. 2-1024, 3M1-171 alarm did not actuate.
p) The inspector's test valve, Building 2, first floor, o/s Rm. 2-1024, 3M1-171 flow switch did not go into alarm.
q) Flow test, Building 8, second floor, o/s Rm. 8-2020, 5M1-38 alarm did not actuate.
r) The inspector's test valve, Building 8, second floor, o/s Rm. 2-2020, 5M1-381 flow switch failed.
s) Flow test, Building 8, stairwell across from Gym, 5M1-97 had a leak in pipe. Could not flow water for main drain test.
t) The inspector's test valve, Building 8, stairwell across from Gym, 5M1-97 had a leak in pipe. Could not flow water for main drain test.
u) Antifreeze System, Positive Temperature reading. Needs to be in the negatives.
v) Valve supervisory switches failed to indicate movement as required by NFPA 25, 9-3.4.3
"Tamper failed for OSY 2 1/2 inch address 1-148 (Potter OSYSU-2). Tamper butterfly 3 inch, Building 8, basement HVAC office, 5M1-37 failed to report. Tamper for Building 2, Boiler Rm. sub, the Maintenance Supervisor a-basement main, 3M1-39 comes into panel as an alarm. Building 1, fifth floor, stair #2 tamper switch failed 1-97."

11. In interview during the time of record review, the Maintenance Supervisor and Assistant Superintendent indicated the items listed in the "Deficiency Summary" of the March 01, 2010 Semi-Annual Sprinkler report had not been corrected.

12. Review of "2009 Statement of Condition, Plan for Improvement" documentation with the Maintenance Supervisor and Assistant Superintendent on 05/18/10 at 11:15 a.m. indicated the facility has a "Plan for Improvement" to identify and test all fire dampers located in the hospital HVAC system.

13. In interview with the Maintenance Supervisor and Assistant Superintendent at the time of record review, it was confirmed that there was no documentation to indicate that previous testing or maintenance on the fire dampers had been conducted.

14. Review of "Larue Carter Memorial Hospital Weekly and Monthly Generator Test" documentation with the Maintenance Supervisor and Assistant Superintendent on 05/17/10 at 12:55 p.m. indicated an inspection of the generators occurred once a month, which was the monthly load test.

15. In interview at the time of record review, the Maintenance Supervisor and Assistant Superintendent acknowledged the generators were run under load once a month but not inspected weekly.

Based on observation, the hospital failed to ensure proper trash storage in 2 instances of disposal.

Findings:

1. On 5-17-10 at 2:30 pm in the presence of employee #A2, it was observed in the outside trash compactor area there were on the ground next to the compactor, 3 large pizza boxes, a dish towel and other miscellaneous trash, 1 box on the outside ledge of the compactor itself and a bag of trash under the compactor.

2. On 05/19/10 at 9:00 AM, it was observed that on the ground next to the trash receptacle at the North Entrance was several items of miscellaneous trash.

Based on observation and interview, the facility failed to assure an acceptable level of safety and quality in 7 instances.

Findings:

1. On 5-17-10 at 2:55 pm in the presence of employee #A2, it was observed in storage room 1-1064, in the Employee Health area, there were 2 small oxygen tanks on the floor unsecured by chain or holder.

2. On 5-17-10 at 3:00 pm, employee #A2 was requested to provide documentation of preventive maintenance (PM) on a centrifuge (hospital asset #145519) located in a laboratory room. No documentation was provided prior to exit.

3. On 5-17-10 at 3:40 pm in the presence of employee #A2, it was observed in the overhead lights in the occupational therapy room there were several lights containing numerous dead insects.

4. On 5-17-10 at 3:50 pm in the presence of employee #A2, it was observed in the overhead lights in the second floor corridor leading from patient care areas to the patient dining area, there were several lights containing numerous dead insects.

5. On 5-17-10 at 3:55 pm in the presence of employee #A2, it was observed in the overhead lights in the second floor kitchen, there were several lights containing numerous dead insects.

6. On 3-15-10 at 3:05 pm, employee #A2 was requested to provide documentation of PM on a patient scale located in room 1-1067. No documentation was provided prior to exit.

7. On 5-17-10 at 3:10 pm, employee #A2 was requested to provide documentation of PM on a refrigerator, dishwater, 2 grilling machines, a toaster stove, a turbo oven, a wok, a microwave, a toaster oven, an electric skillet and a sewing machine. All items were located in the Occupational Therapy area. Upon interview, hospital staff indicated these items were used by patients undergoing occupational therapy. No documentation was provided prior to exit.

Based on document review, the facility failed to assure food products were stored within an appropriate temperature range in 1 instance.

Findings:

1. Review of a document entitled REFRIGERATOR and FREEZER TEMPERATURE LOG, for May, 2010, for the walk-in cooler in the dietary area, indicated the acceptable temperature for a refrigerator is 36-42 degrees. Further review of the log indicated for the first 17 days of May, the temperature was higher than the upper limit 10 times (58%). Staff was asked if this was brought to the attention of anyone who could resolve this problem and staff indicated it was not.

Based on observation and interview, the infection control officer failed to ensure the control of infection-oriented situations in 2 instances.

Findings:

1. On 5-17-10 at 2:10 pm in the presence of employee #A2, it was observed in the linen storage area, patient care linen was stored on open shelves. The shelves had no means of covering the linen and protecting it from dust, dirt and contamination.

2. On 5-17-10 at 2:40 pm in the presence of employee #A2, it was observed in a walk-in cooler in the dietary area, there was a large amount of a darkish-brown dried substance on the floor.

3. Upon interview, hospital staff indicated some meat had been stored in that area and blood from it had fallen onto the floor. The presence of this dried blood could have contaminated food stored in the cooler.