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Based on observation, staff interview, and record review the facility failed to ensure patients had access to the state hot line number in the emergency department (A118 );
failed to ensure confidentiality and/or privacy of patients (A143); failed to ensure care was provided in a safe setting on the inpatient psychiatric units (A144); and failed to ensure physicians orders were written for the initiation of violent restraints (A168). The effect of these systemic practices resulted in the facility's inability to ensure the safety of all patients. The hospital active census was 314.

Based on observation, record review and staff interview it was determined the facility failed to post the Ohio Department of Health complaint hotline number signage in the emergency department. This affects all patients and visitors entering the emergency department. The hospital active census was 314.

Findings:

Review of the facility's policy titled "Patient Complaint and Grievance Process" Policy Number: 09.00 (Revised 2/16) states the hospital will provide patients, or their representative, a formal process to acknowledge, record, review and resolve complaints and grievances. Patients are informed that they may choose to file a complaint directly the Patient Rights and Responsibilities are displayed throughout the facility with information on how to report issues to the Patient Relations Department, Ohio Department of Health and The Joint Commission.

Tour of the Emergency Department was conducted on 02/26/19 at 11:00 AM. Observation of the patient waiting room revealed the Patient Rights and Responsibilities signage was posted behind the registration area on a wall not visible to those in the emergency department. Staff C stated the emergency department has made some recent changes and failed to move the sign to a visible area.

Based on observations, record review, and staff interview, the facility failed to ensure patients in the Neonatal Intensive Care Unit (NICU), Emergency Department (ED), and Neurosurgical Unit (12 D) were provided privacy. This affected all inpatients in the three departments. The active hospital census was 314.

Findings:

1. Observations were made on 02/25/19 at 3:00 PM on tour of the 12th floor, units C and D, of a flat screen monitor mounted on the wall at the end of the hall across from room #1267. The flat screen monitor had 12 sections, each with space for patient name, heart rhythm and pulse, and was mounted facing the hall in an area that was visible to anyone in the hall, including patients, family and visitors.

Another observation of the flat screen monitor on 02/26/19 at 12:14 PM revealed ten patient names, first and last name, fully visible in all capitals, printed on ten of the twelve spaces on the monitor with the pulse and heart rhythm.

Interview with Staff E on 02/25/19 at 3:00 PM revealed there were 18 beds with a census of 14 patients on the 12th floor unit and the telemetry (heart rhythm monitor) for the patients on this unit was viewed by a trained telemetry staff stationed on the 11th floor.

Interview with Staff E on 02/28/19 at 11:20 AM revealed the flat screen display of telemetry and names at the end of the hall was prominently in view for any person in the hall, including staff who may observe it.


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2. The Neonatal Intensive Care Unit (NICU) was toured on 02/26/19 at 11:00 AM. A flat screen monitor approximately 54 inches in size was mounted on the wall of each of the two nurseries, Nursery A and Nursery B, making up the NICU. In a large font, the first and last names of all mothers, sex of all babies, and bed space numbers were listed on the screens.

Staff K, NICU Manager, revealed the monitors were new. Staff K was asked if parents signed a consent prior to personal information being listed on monitors visible by all staff and visitors. Staff K was also asked if parents were verbally informed by staff that their personal information would be listed on monitors visible by all staff and visitors. Staff K answered "no" to both questions.

The facility's policy titled "Patient Rights and Responsibilities" Policy Number 4.00 reviewed/revised on 9/2016, was reviewed on 02/27/19 at 10:00 AM. The policy stated: "As a patient, you have the right to expect that all information and communication about your care is kept confidential."

Staff A was interviewed on 02/27/19 at 10:30 AM. He/She stated that personal information contained on the screens is "no different than signing in for a doctor's appointment." It was confirmed that staff in physician's offices typically black out the name of patients with a black marker once registration has occurred to protect the privacy of patients. It was confirmed that posting the full names, room numbers, sex of babies, and in the case of the Neurosurgical unit, heart rhythm (i.e. normal sinus rhythm) and heart rate were a violation of a patients right to privacy.


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3. Tour of the Emergency Department was conducted on 02/26/19 at 11:00 AM in which flat screen display monitors were observed in the hallways of Zones 2 and 3. The monitors displayed in both zones showed each patient's first and last name and was visible to anyone walking past the monitor.

Based on observation, record review and staff interview it was determined the facility failed to provide care in a safe setting on the adult behavioral and geriatric inpatient psychiatric units. This affected all patients on the inpatient psychiatric units. The active hospital census was 314; the inpatient psychiatric census was 24.

Findings:

Review of the Behavioral Health Council meeting minutes dated 04/03/2018 revealed capital funding of 7 million dollars was approved for renovations. There was notation of a problem on pod B that noted, " Due to CMS changes around ligature risks that require us to eliminate the risks. We have been asked to remove the medical beds on Pod B and have requested more platform beds. We are trying to separate the populations and to mitigate risk we will put medical patients on one pod. Pod B will be for more obtrusive and/or aggressive patients. Pod C will be used for the medical patients if not suicidal. We now have a well-defined plan on the patients we can take based on CMS and our environment."

Review of the Environmental Evaluation Summary ( Risk Assessment) for Behavioral Health Services last updated November 2018 notes the following:
- Hazard Severity: The hazard severity is an an assessment of the worst possible consequence, defined by degree on injury, occupational illness, or property damage which is likely to occur as a result of the identified safety concerns. Hazard severity categories shall be assigned by Roman numerals according to the following criteria.
- Category I - Catastrophic: May cause death of a patient, staff, or visitor
- Category II- Critical: May cause severe injury to patients, staff, or visitors, or major property damage
- Category III- Marginal: May cause minor injury to patients, staff, or visitors, or minor property damage
- Category IV-Negligible: probably would not affect personal safety or health, but is nevertheless in violation of OSHA, ODMH, or a consensus standard.
- Further, the level 4- Assessment of areas where patients spend a great deal of time alone with minimal or no Patient Bedrooms/ Patient Bathrooms POD A and Pod B. The risk identified that patients can barricade themselves in a room. The solution was to mount furniture to the floor, add door hinges for the door to swing in both directions, and seal platform beds to the floor during the 2019 renovation.

A tour was conducted on the adult and geriatric inpatient psychiatric units on 02/25/19 at 4:10 PM and confirmed the psychiatric unit (s) are currently under renovation with one unit being utilized with divided hallways to separate geriatric patients and acute adult patients.

The acute adult side has 17 platform beds, chairs, and bedside tables. The separate geriatric hallway has 10 geriatric hospital beds, chairs, and bedside tables. All furniture in the rooms are movable and could be used as a weapon to assault and/or barricade themselves, staff, patients, or visitors on the units. Phase two of the renovation isn't scheduled to be completed until May 2019 posing a safety risk to all individuals on the units.

Based on record review and staff interview it was determined the facility failed to ensure physicians orders were obtained per policy for patients placed in violent restraints for one (Patient #11) of 7 patients reviewed in violent restraints. f forty five medical records reviewed. The hospital active census was 314.

Findings:

Review of the facility's policy titled "Policy and Procedure for Restraint and/or Seclusion" Number: 17.00 ( Revised 06/2018) states to obtain an initial order from the Licensed Independent Physician (LIP) who is responsible for the care of the patient prior to the application of restraint or seclusion. A registered nurse (RN) may initiate emergency application of the restraint or seclusion to ensure the safety of the patient and others; however, a LIP order is required immediately after the restraint or seclusion has been applied.

Review of the medical record for Patient #11 revealed the patient presented to the emergency room with headaches. A CT scan revealed interval development of hydrocephalus with mass affect and edema suggesting a dysfunctional ventriculostomy shunt system. The patient was admitted for possible shunt repair per physician documentation.

Physician documentation on 12/25/18 at 10:49 PM noted he/she received a call from the RN due to the patient's aggressive behavior and spitting at staff. Per documentation the patient was placed in four point restraints on 12/25/18 at 10:45 PM and a physician's order was not written until 2:45 AM on 12/26/18.

This finding was confirmed with Staff E on 2/28/19 at 1:25 PM.

Based on record review and staff interview, the facility failed to ensure staff nurses followed physician orders related to administration of continuous oxygen, administration of pain medication, and performance of the Clinical Institute Withdrawal Assessment for Alcohol scale and failed to notify the physcian of a change in condition for one (Patient #29) of 45 medical records reviewed. The active hospital census was 314.

Findings:

Patient #29 presented to the facility's Emergency Department on 02/20/19 at 8:39 PM with complaints of fever and chills which caused the patient to have "a panic attack." The patient also complained of epigastric pain that the patient believed to be "gas." The patient was found to have sepsis secondary to a urinary tract infection and was admitted to 11 AB, a Telemetry unit, for treatment. At 11:42 PM on 02/20/19 the attending physician ordered Percocet (combination medication that contains an opioid narcotic pain reliever and a non-opioid pain reliever acetaminophen used to relieve moderate to severe pain) 1-2 tablets every 6 hours as needed for "moderate to severe" pain and 400 mg of Ibuprofen every 6 hours as needed for mild pain or as an adjunct to opioid analgesics.

The facility's policy titled "Pain Assessment and Management" (Policy Number 10.01), effective 12/2010 and last reviewed/revised 6/2018, revealed effective and appropriate care will be provided for all patients experiencing pain at initial assessment, throughout hospital stay, will set a realistic pain goal with the patient and provide pain management education. The policy further instructed staff to ask patients to rate their pain from zero being no pain up to 10 which is pain as bad as it can be. Terms such as "mild," "moderate" or "severe" are provided along the scale for guidance. The scale described a pain score of 1-3 as mild, 4-6 as moderate, and 7-10 as severe.

On 02/21/19 at 5:56 AM the medical record revealed that the patient complained of severe pain, rating it a 7 on a 0-10 scale. Although a 7 is considered severe pain, according to facility policy, for which a physician ordered Percocet to be administered, the Patient was medicated with Ibuprofen, 400 mg, at 5:56 AM, according to the Medication Administration Record (MAR), the patient was medicated with of Ibuprofen.

At 9:02 AM the patient complained of "chest discomfort" and "shortness of breath."
The medical lacked documentation a physician was notified of the complaints of the patient or that the patient was medicated with the ordered narcotic medication prescribed for severe pain. The pain was further described as "acute pain" radiating to the right shoulder. The medical record lacked documentation a physician was notified.

On 02/20/19 at 11:14 PM, the attending physician ordered continuous oxygen at 2 liters per nasal cannula. The medical record lacked documentation oxygen was administered during his/her hospitalization as ordered.

Further review of the medical record for Patient #29 revealed a nursing note on 02/22/19 that documented the patient reported concern that his/her alcoholic drinking had increased over the past 2 years, since the death of his/her spouse and expressed interest in getting treatment. A substance use screening was completed and a physician ordered alcohol withdrawal assessment tool on 02/22/19 at 10:54 AM. The physician ordered a Clinical Institute Withdrawal Assessment (CIWA) every 2 hours and as needed for subjective or objective evidence of alcohol withdrawal. Staff performed an assessment using the CIWA tool on 02/22/19 at 1:22 PM, 3:14 PM and 11:30 PM. The next assessment occurred 6 hours later, at 4:30 PM on 02/23/19 and lastly at 8:10 PM. Staff E was interviewed on 3/1/19 at 12:30 PM. It was confirmed that the CIWA scale was not performed as ordered.

The patient was discharged home at 2:23 PM on 02/24/19.

According to the medical record Patient #29 presented to the Emergency Department again, approximately 6 hours later, at 8:43 PM with complaints of severe chest pain. The History and Physical stated that the patient reported "the symptoms have been going on for 2 days." The patient was diagnosed with an acute myocardial infarction.

Staff E, Manager of Neurosurgical unit, was interviewed on 03/01/19 at 2:35 PM. and confirmed the findings.

Based on observations and staff interview the facility failed to ensure the protection of medical records from destruction by water in two sections at an off-site facility. This deficient practice had the potential to affect any patient at either center with a total of 31,638 annual census.

Findings:

Tour of an off-site facility with services for physical therapy, imaging and a sleep center was completed on 02/26/19 at 8:00 AM revealed medical records in paper folders on open shelving units in two of the three centers in the offsite location.

1. The tour conducted with Staff P in the imaging center revealed folders with medical records, identified as "dexa scan reports" in folders on an open shelf on the wall near a staff desk with overhead fire suppression water system sprinklers in the area. Staff P and others accompanying the tour walk-through confirmed the medical record folders were open to potential destruction by water from the sprinklers.

2. Tour in the physical therapy area, located on the same level, but across the hall from the imaging center revealed folders in an open shelving unit in a staff work area, which were identified as patient records dating back to 2012 that were open to the environment and potential water damage by the sprinklers in the area.

Based on medical record review, staff interview, and policy review it was determined the facility failed to ensure telephone and/or verbal orders were signed by the physician. This affected one (Patient #46) out of 45 medical records reviewed. The active hospital census was 314.

Findings:

Review of the facility's policy for "Physician Orders, Verbal, Telephone" Number: 29.00 ( Revised 03/2017) provides guidelines for the receiving of verbal, telephoned, faxed and physician computer entered orders of authorized, licensed practitioners, to be entered into the computer. Verbal, telephoned, or faxed orders should be used to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to enter it into the electronic medical record without delaying treatment.

Review of the medical record for Patient #46 revealed the patient had a history of schizophrenia and was non-compliant with antipsychotic medications. The patient presented to the emergency room agitated, paranoid, and with bizarre behaviors. The patient was admitted to the inpatient psychiatric unit where the patient had to be placed in a seclusion for the safety of self and others. Review of the orders noted the registered nurse received a verbal order for seclusion on 01/26/19 at 9:42 AM which lacked a signature by the ordering physician.

This finding was confirmed with Staff M on 03/01/19 at 2:32 PM.

Based on observations, record review, and staff interview, the facility failed to ensure staff followed the current facility policy related to labeling medications drawn up in a syringe be properly labeled. This had the potential to affect all 314 patients.

Findings:

The Labor and Delivery unit was toured on 02/26/19 at 10:30 AM. An epidural cart was noted in the hallway at the entrance of the unit. Staff , an anesthesiologist, unlocked the epidural cart. The first drawer of the cart was opened and a 10 mL syringe with a clear liquid was observed. There was no label identifying the contents of the syringe, initials identifying the staff member that drew the medication up, or when the medication was drawn up. Staff was asked the contents of the syringe and he/she immediately replied, "Epinephrine." The anesthesiologist was asked if he/she had drawn up the medication and he/she denied drawing up the medication. Staff was also asked how he/she could be certain of the contents of the syringe if he/she hadn't drawn up the medication. He/She had no response.

The facility's policy titled "Labeling Standards" (Policy Number: PHAR-14), with an effective date of October, 2013 and last reviewed/revised in June, 2018, was reviewed on 02/26/19 at 1:30 PM. According to the policy all medications prepared in the hospital must be correctly labeled with the following information: medication name; strength; amount (if not apparent from the container); expiration date when not used within 24 hours; expiration time when expiration occurs in less than 24 hours; preparation date and the diluent used for all compounded IV admixtures and parenteral nutrition formulas; certified pharmacy technician/pharmacist initials.

Staff R, staff anesthesiologist present during this observation, was interviewed during the tour. It was confirmed that the syringe should have been labeled with the medication name, date and time it was drawn up, and initials of person drawing up the medication.

Based on observations made during tour, facility policy review, and staff interview, the facility failed to ensure staff followed the current facility policy for securing prescription pads. This had the potential to affect staff, patients, and visitors in the event a prescription pad got in the wrong hands.

Findings include:

The 8 bed Obstetric Triage unit was toured on 2/26/19 at 10:00 AM. The medication room, located behind the nurse's station, was toured. A large Pyxis medication dispensing machine was noted in the corner of the medication room. A blank prescription pad was noted in an unlocked drawer. When asked if the prescription pad should be stored in an unlocked drawer accessible to staff, Labor and Delivery Assistant Nurse Manager, Staff L, stated: "No, that shouldn't be there." He/She revealed that the prescription pad should be locked in the Pyxis medication dispensing machine.

The facility policy titled Controlled Substance/Narcotic Key Control (Policy Number: PHAR-07), effective September, 1994 and last reviewed/revised February, 2018, was reviewed on 2/26/19 at 1:20 PM. It stated that accountability for controlled substances is mandated by law. When a Pyxis MedStation is available, all controlled substances and prescription pads are to be stored in an individual secure pocket in the Pyxis machine. The individual removing the prescription pad from the Pyxis cabinet creates a legal record of responsibility for it.

Staff Q, a Pharmacy manager, was interviewed on 2/27/19 at approximately 12:00 PM. It was confirmed that all prescription pads should be secured in a Pyxis medication dispensing machine.

Based on observation, interview and document review, the facility failed to either have interim life safety code procedures in place or when in place, not implemented in accordance with facility policy, to ensure the two hour barrier between it and other occupancies were free of penetrations and had doors that self closed and latched, to comply with 2012 National Fire Protection Association (NFPA) 101 - 2012 Edition, Sections 19.2.7, 7.7.1, 7.1.6, and with 7.7.3.4 to have its emergency lights comply with 39.2.9.1, NFPA 101, 2012 edition, to ensure paths of egress were marked in accordance with 7.10, NFPA 101, 2012 edition, to ensure construction protecting vertical openings was free of penetrations and the doors on vertical openings were rated and self closed, failed to ensure hazardous areas were protected with barriers free of penetrations and with doors that self closed, to comply with 21.3.4.2 and 9.6.2.3 of NFPA 101, 2012 edition, to ensure its fire alarm system complied with NFPA 72, 2010 edition, to ensure its sprinkler system complied with NFPA 13, 2010 edition and NFPA 25, 2011 edition, to ensure the proper identification of the locations of portable fire extinguishers, to ensure each waiting area complied with 19.3.6.1 (2), to ensure that doors with self closing and latching hardware that opened on a corridor self closed and latched, to have corridor doors comply with 19.3.6.4, NFPA 101, 2012 edition, to ensure smoke barriers were free of penetrations, to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors and where there were double doors, the doors did not have a large gap (greater than one-eighth inch) between leaves, to provide emergency lighting in accordance with NFPA 101 - 2012 Edition, Section 21.5.1.1, 9.1.3, 9.1.3.1, and NFPA 110 - 2010 Edition, Section 7.3, to inspect (and repair where necessary) the function of the smoke dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8.2 of 90A, 2012 edition and therefore 6.5.2 in NFPA 105, 2010 edition and failed to inspect (and repair where necessary) the function of the fire dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80, to have fire drills that complied with 19.7.1, NFPA 101, 2012 edition, to keep portable space heaters away from patient care areas, to comply with 5.1.5.16 and 5.1.5.16.1, NFPA 99, 2012 edition, to comply with 5.1.14, NFPA 99, 2012 edition, to comply with NFPA 70, 2011 edition, and NFPA 99, 2012 edition, to comply with National Fire Protection Association (NFPA) 99 - 2012 Edition, Section 10.2.3.6, 10.2.4, and 10.3 and with NFPA 70, 2011, section 400., and to comply with NFPA 99, 2012 edition, chapter 11. (A709). The active hospital census was 314.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients the facility. The active hospital census was 314.

Findings include:

K100 Failed to either have interim life safety code procedures in place or when in place, not implemented in accordance with facility policy.
K131 Failed to ensure the two hour barrier between it and other occupancies were free of penetrations and had doors that self closed and latched.
K271 Failed to ensure the egress was maintained to comply with 2012 National Fire Protection Association (NFPA) 101 - 2012 Edition, Sections 19.2.7, 7.7.1, 7.1.6, and with 7.7.3.4.
K291 Failed to have its emergency lights comply with 39.2.9.1, NFPA 101, 2012 edition.
K293 Failed to ensure paths of egress were marked in accordance with 7.10, NFPA 101, 2012 edition.
K311 Failed to ensure construction protecting vertical openings was free of penetrations and the doors on vertical openings were rated and self closed.
K321 Failed to ensure hazardous areas were protected with barriers free of penetrations and with doors that self closed.
K342 Failed to ensure the fire alarm initiation devices were installed to comply with 21.3.4.2 and 9.6.2.3 of NFPA 101, 2012 edition.
K345 Failed to ensure its fire alarm system complied with NFPA 72, 2010 edition.
K353 Failed to ensure its sprinkler system complied with NFPA 13, 2010 edition and NFPA 25, 2011 edition.
K355 Failed to ensure the proper identification of the locations of portable fire extinguishers.
K361 Failed to ensure each waiting area complied with 19.3.6.1 (2).
K363 Failed to ensure that doors with self closing and latching hardware that opened on a corridor self closed and latched.
K364 Failed to have corridor doors comply with 19.3.6.4, NFPA 101, 2012 edition.
K372 Failed to ensure smoke barriers were free of penetrations.
K374 Failed to ensure doors in smoke barriers with self closing and latching hardware closed and latched the doors and where there were double doors, the doors did not have a large gap (greater than one-eighth inch) between leaves.
K511 Failed to provide emergency lighting in accordance with NFPA 101 - 2012 Edition, Section 21.5.1.1, 9.1.3, 9.1.3.1, and NFPA 110 - 2010 Edition, Section 7.3.
K521 Failed to inspect (and repair where necessary) the function of the smoke dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8.2 of 90A, 2012 edition and therefore 6.5.2 in NFPA 105, 2010 edition and failed to inspect (and repair where necessary) the function of the fire dampers within the Heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition, and therefore 5.4.8 of 90A, 2012 edition and therefore 19.4.1.1 in NFPA 80.
K712 Failed to have fire drills that complied with 19.7.1, NFPA 101, 2012 edition.
K781 Failed to keep portable space heaters away from patient care areas.
K902 Failed to ensure gas and vacuum systems were maintained to comply with 5.1.5.16 and 5.1.5.16.1, NFPA 99, 2012 edition.
K907 Failed to ensure its medical gas specifically the vacuum and gas outlets and gas gauges/indicators were maintained to comply with 5.1.14, NFPA 99, 2012 edition.
K912 Failed to ensure proper installation of electrical outlets to comply with NFPA 70, 2011 edition, and NFPA 99, 2012 edition.
K920 Failed to ensure the use of multiple plug adaptors, extension cords, and power strips were be adhered to comply with National Fire Protection Association (NFPA) 99 - 2012 Edition, Section 10.2.3.6, 10.2.4, and 10.3 and with NFPA 70, 2011, section 400.
K923 Failed to ensure that all rooms that had medical gas storage were constructed as required and was identified with the required signage to comply with NFPA 99, 2012 edition, chapter 11.

Based on observations made during tour, facility policy review, and staff interview, the facility failed to ensure staff followed current facility policies related to maintaining a sanitary hospital environment, failed to ensure a urine sample was properly stored, and failed to ensure staff performed proper hand hygiene. This had the potential to affect all 314 patients in the facility.

Findings:


1. Observation was made on 02/26/19 at 1:55 PM of Staff D giving a Subcutaneous injection to Patient #45's left upper arm. Prior to the injection Staff D washed/his her hands and put on a clean pair of gloves. Staff D removed his/her dirty gloves after the injection was given and then went to the medication drawer, obtained a vial of Dilaudid and then went to type on computer keyboard. There was no observation made of Staff D using any kind of hand hygiene after removing the dirty gloves. Staff D then put on a pair of clean gloves and gave Patient #45's Dilaudid intravenous. Staff D then removed his/her dirty gloves and used hand gel.


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2. During tour of the medical/surgical intensive care unit (MSICU), a staff nurse that was performing patient care was observed walking out of the room while wearing gloves. He/She walked to the desk at the nurse's station, picked up a stethoscope and walked back to the room. The nurse did not remove the gloves and perform hand hygiene before leaving the room.

The facility's policy titled "Hand Hygiene" (Policy 5.01), effective 1/2012 and last reviewed 7/2017, was reviewed on 2/27/19 at 9:05 AM. According to the policy hand hygiene is considered the single most important procedure that can prevent the spread of microorganisms, and as such, is applicable throughout the entire organization. The policy instructs staff that hand hygiene should be performed upon entering and exiting a patient room, selecting either handwashing with soap and water or use of an alcohol hand rinse. The policy further stated staff should perform hand hygiene in accordance with the CDC Guidelines for Hand Hygiene in Healthcare Settings. Hand hygiene is required before medication administration and after removing gloves.

3. A tour was conducted in the emergency room on 02/26/19 at 11:00 AM where an observation was made of an unlabeled urine specimen in the decontamination room. Staff C immediately discarded the urine specimen and confirmed the specimen should be properly disposed of as per policy.

Review of the facility's policy titled "Urine Specimen Collection Policy" (070112) states the proper procedure for urine specimen collection is to label the evacuated tube or cup appropriately, deliver specimens to the laboratory as soon as possible and/or discard excess urine.

4. The 19-bed Medical Surgical Intensive Care Unit (MSICU) was toured on 02/25/19 at 3:00 PM. A portable monitor was noted on the counter behind the nurse's station. A brown residue was noted in the grooves of the monitor. Staff I, Manager of MSICU, present during the tour, applied gloves and obtained a damp disinfectant wipe. He/She wiped in the grooves around the perimeter of the monitor. The disinfectant wipe was examined after the monitor was wiped and the brown residue was noted on the damp wipe. The monitor areas that were wiped were noted to be free from the brown residue.

Staff I was interviewed during the tour. He/She revealed it was the responsibility of the unit nurses to clean the portable monitors after each use.

5. Room 7121, identified as clean and ready for patient use, was toured. A dark red substance resembling blood was noted on the buttons of the monitor attached to the wall next to the patient bed. The red substance was also noted on the surface of the hoyer lift. Donning gloves and obtaining a disinfectant wipe, Staff I wiped the surface of the monitor and the hoyer lift and the red substance was easily removed.

6. Dust was visible on the ledge above the patient bed in room 7122. Clumps of dust were noted to fall from the ledge as this surveyor wiped a gloved hand along the surface of the ledge.

7. Room 7127, also identified as clean, was toured. Dust was visible on top of the vacuum canister and on the ledge above the patient bed. Staff J, Environmental Services (EVS) Manager, joined the tour per request of Staff I. He/She wiped a hand along the surfaces where visible dust was noted. A large amount of dust was noted on his/her hand.

8. Dust on the ledge above the patient bed was also noted in room 7128. Again, as Staff J wiped his/her hand along the surface, clumps of dust were observed to fall to the floor. There was also dust noted on top of the monitor attached to the wall.

9. Room 7132 was also toured. An adhesive residue was observed on the counter. The residue was easily removed with a disinfectant wipe. Staff J stated it is the responsibility of EVS staff to wipe all counters with a germicidal solution when cleaning rooms.

10. The bathrooms of rooms 7134 and 7141 were toured. A thick layer of dust was noted in vents directly above the toilets in both bathrooms. Dust was noted on the outside and inside of the vents. Staff J revealed EVS staff are responsible for cleaning the outside of the vents however, in the event dust is observed inside the vent, staff are responsible for submitting a work order so that representatives from facilities can actually remove the vent for cleaning.

11. The facility policy titled High Profile Patient Room Cleaning (Procedure 7.01), issued on 10/1/17, was reviewed on 02/26/19 at 1:15 PM. According to the policy, staff are instructed to high dust, beginning at the entranceway and working around the room in a circle. High dust horizontal surfaces above shoulder height starting opposite the restroom. High dust surfaces in the restroom. The policy further stated staff should utilize a germicidal cleaner and a micro fiber clean cloth to sanitize all patient contact surfaces, including over bed table, bed rails, phone, nurse call button pad, chairs, low ledges, and counters. EVS staff are instructed to disinfect vertical surfaces including stains and spots from walls, light switches, door knobs and other vertical surfaces. An itemized list of objects EVS are responsible for cleaning was included in the policy. According to the list, EVS staff are responsible for cleaning monitors (not screen), oxygen meters, televisions, and computer keyboards.

These facts were confirmed with Staff I and Staff J on 02/26/19 at 4:30 PM.


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