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Tag No.: C0221
2010 Guidelines for the Design and Construction of Health Care Facilities 2.3 Specific Requirements for Small Primary Care Hospitals 2.3-3.4.2 Surgical facilities for the small primary care hospital shall meet the criteria established for 3.7-3, 3.7-5, 3.7-7, and 3.7-8 in Part 3.
3.7-3.3 Ambulatory Operating Rooms, 3.7-3.3.1.2 Operating room definitions
Class A: Provides for minor surgical procedures performed under topical and local infiltration blocks with or without oral or intramuscular preoperative sedation. (Excluded are procedures that make use of spinal, epidural axillary, and stellate ganglion blocks; regional blocks (e.g., interscalene) and supraclavicular, infraclavicular, and intravenous regional anesthesia.) These procedures are also appropriately performed in Class B and C facilities.
Class B: Provides for minor or major surgical procedures performed in conjunction with oral, parenteral, or intravenous sedation or under analgesic or dissociative drugs. These procedures are also appropriately performed in Class C facilities.
3.7-3.3.3.1 Space requirements. Class B operating rooms shall have a minimum clear floor area of 250 square feet (23.23 square meters) with a minimum clear dimension of 15 feet (4.57 meters).
Based on record review it was determined that the facility failed to provided the proper square footage for the use of intravenous sedation.
Findings include:
During review of the surgical records provided by the facility it shows that intravenous sedation (propofol) was being used for endoscopy procedures in procedure room (C). On review of the facility's blue prints, procedure room (C) is 205 square feet, failing to meet the square footage needed for the use
of intravenous sedation.
Tag No.: C0222
Based on observation and interview the facility failed to have a preventive maintenance program for patient care equipment to be maintained in safe operating condition, along with the overall environment to be maintained in the surgical suite.
Findings include:
During tour of the surgical suite on 8/15/12 it was observed and shown to Staff F (Registered Nurse Manager of Surgical Services) that several pieces of equipment had rips or chips in them preventing them from being able to be cleaned and sanitized. The equipment is as follows:
1) Padded black stirrup edges had breeches
2) Arm pad had breech on surface
3) Multiple gel positioning pads had rips
4) Multiple IV pole casters and bases were rusted
Also during tour for the surgical suite it was observed and shown to Staff F that on the floor located in the semi restricted hall where the old autoclave was located tiles were separated and cracked and failed to be monolithic.
Also it was observed that the ceiling tiles located were the old autoclave was located had several holes in the ceiling that failed to be fixed after the piping had been removed.
2010 Guidelines for the Design and Construction of Health Care Facilities 2.3 Specific Requirements for Small Primary Care Hospitals 2.3-3.4.2 Surgical facilities for the small primary care hospital shall meet the criteria established for 3.7-3, 3.7-5, 3.7-7, and 3.7-8 in Part 3.
3.7-7.2.2.1 Corridor width (2) The semi-restricted corridor shall have a minimum width of 8 feet (2.44 meters) in areas used to transport patients or gurneys between preoperative, procedure and post-anesthesia recovery areas.
Also observed on 8/15/12 were several medical storage carts in the semi-restricted hallway blocking the hallway width to 3', this observation was shown to Staff F at time of finding.
21706
During tour of the emergency dept. on 8/15/12 it was identified that the control solutions for the blood glucose meters had been opened and in use but had not been dated to identify when they had been opened or when they, by manufacturers instruction, would expire. Inspection of the glucometer in use on the hospital based ambulance service identified the same issue. During tour of the off-site hospital based office practices on 8/16/12 it was identified in the pediatrics location that the control solutions for the blood glucose monitors had been opened, dated and in use but by manufacturers instruction had expired in June 2012.
Tag No.: C0279
Based on observation and interview the facility failed to provide acceptable hygiene practices within the kitchen dish room.
Findings include:
During the initial tour of the facility's kitchen it was observed that Staff A (Kitchen aid) entered the kitchen with a cart of dirty dishes which was from the patent's units from breakfast. Staff A was wearing a pair of gloves, Staff A entered into the dish room with the same pair of gloves failing to change them and started removing clean dishes from the dish machine room.
Staff B (Director of Dietary Services) was told about the observation who also noted it at the same time and stopped Staff A from removing the clean dishes from the dish machine. Staff B had Staff A change their gloves before removing more clean items from the dish machine.
Tag No.: C0292
Based on record review the facility failed to ensure that the prescribing practitioner countersigned all telephone orders as soon as possible after being written. (Patient identifier #24.)
Findings include:
Review of the medical record for Patient #24 on 8/15/12 identified physician orders taken as telephone orders on 8/11/12, 8/12/12 and 8/15/12. Review of the physician progress note section of the medical record identified that the physician had been in the record and had made several daily entries from 8/11/12 through the survey date of 8/15/12 but had not signed the telephone orders.
Tag No.: C0302
Based on record review and interview it was determined that the hospital failed to ensure that the patient medical record is complete and accurate. (Patient identifiers are #13, #14, #15, #18 and #20).
Findings include:
Review of the medical records for Patient #13, #14, #15, #18 and #20 on 8/16/12 revealed that no consent forms had been updated annually or completed for newly admitted patient. Interview with Staff E, RN, (Interim Director of Medical Services) confirmed the lack of consent forms.
Interview with Staff C, RN, JD,(Juris Doctor) (Director of Family Practices) at approximately 10:00 a.m., confirmed that no consent forms had been updated annually or completed at time of newly admitted patients.
Interview with Staff E, at approximately at 12:30 p.m. confirmed the lack of consent forms for Patient #13, #14, #15, #18 and #20 being updated or completed.
Review of the Medical Staff Rules & Regulations, dated 5/26/11, "Under section 7.: Medical Records
7.10 Medical Record Completion: ... The medical record shall be completed within a period of time that will in no event exceed 30 days following discharge. No medical record shall be filed until it is complete."
Interview with Staff D, (Corporate Compliance Officer/Director of Risk Management), on 8/16/12 at approximately 8:30 a.m. confirmed the actual delinquent records as of 8/14/12 were at 371, which was at 44%. The records were not complete and were missing verbal order signatures, discharge summary and consent forms were not completed. The process was to inform the physician on a monthly basis of the missing paperwork or signature via email.
Tag No.: C0304
Based on record review and interview the facility failed to maintain patient records to have properly executed consent forms on 5 of 8 patients in the medical practices. (Patient identifiers are #13, #14, #15, #18 and #20.)
Findings include:
Review of the medical records for Patient #13, #14, #15, #18 and #20 on 8/16/12 revealed that no consent forms had been updated annually or at time of a newly admitted patient.
Interview with Staff E, RN, (Interim Director of Medical Services) confirmed the lack of updated or completed consent forms for Patient #13, #14, #15, #18 and #20 on 8/16/12 at approximately 12:30 p.m.. .
Interview with Staff C, RN, JD,(Juris Doctor), Director of Family Practices at approximately 10:00 a.m. confirmed that no consent forms had been updated annually or completed at time of newly admitted patients.
Review of the Medical Staff Rules & Regulations, dated 5/26/11 revealed, "Under section 7.: Medical Records
7.10 Medical Record Completion: ... The medical record shall be completed within a period of time that will in no event exceed 30 days following discharge. No medical record shall be filed until it is complete."
Interview with Staff D, (Corporate Compliance Officer/Director of Risk Management), on 8/16/12 at approximately 8:30 a.m. confirmed the actual delinquent records as of 8/14/12 were at 371, which was at 44%. The records were not complete and were missing verbal order signatures, discharge summary and consent forms were not completed. The process was to inform the physician on a monthly basis of the missing paperwork or signature via email.