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Based on observation, interview and document review, the facility failed to meet NFPA 101, 2012 edition existing code by failing to ensure a four feet width path of egress was maintained in the laboratory, by failing to ensure paths of egress were marked when not readily apparent, by failing to ensure that all smoke barriers were able to resist the passage of smoke, by failing to ensure that doors with self closing and latching hardware that opened on a corridor self closed and latched, by failing to ensure that all Heating Ventilation and Air Conditioning equipment in accordance with the LSC, 2012 Edition 19.5.2.1, by failing to ensure fire drills complied with 19.7.1, NFPA 101, 2012 edition, by failing to ensure the piped in medical gas system received timely repairs, by failing to conduct a wet location operating room assessment for one surgical offsite facility, by failing to conduct initial testing of hospital grade electrical receptacles in patient care areas and where deep sedation was in use, and by failing to ensure routine medical gas storage areas were equipped with the required signage. The cumulative effects of these systemic practices resulted in the facility's ability to ensure the safety of the patients. (A 709) The facility's census was 112 patients.

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 receiving services at the facility. The facility had a census of 112 patients.

Findings include:

K211 Facility failed to ensure path of egress in the laboratory was maintained at four feet of width.

K293 Facility failed to ensure paths of egress were marked when not readily apparent.

K362 Facility failed to ensure that all smoke barriers were able to resist the passage of smoke.

K363 Facility failed to ensure that doors with self closing and latching hardware that opened on a corridor self closed and latched.

K521 Facility failed to ensure that all heating ventilation and air conditioning equipment was in accordance with the LSC, 2012 Edition 19.5.2.1.

K712 Facility failed to ensure fire drills complied with 19.7.1, NFPA 101, 2012 edition.

K907 Facility failed to ensure the piped in medical gas system received timely repairs.

K913 Facility failed to conduct a wet location operating room assessment for one surgical offsite facility.

K914 Facility failed to conduct initial testing of hospital grade electrical receptacles in patient care areas and where deep sedation was in use.

K923 Facility failed to ensure routine medical gas storage areas were equipped with the required signage.

Based on observations, staff interviews and policy review, the facility failed to ensure staff followed policy for the disinfection of equipment, the changing of IV (intravenous) tubing and the use of gloves. This affected two of three patient care observations, Patients' #13 and #14. The facility failed to ensure one nurse (Staff B) performed hand hygiene and changed gloves between administering medications to two different patients (Patient #4 and #5) of six medication administration observations conducted.

Findings include:

1. The facility's Bloodborne Pathogens Exposure Control Plan (revision 8, approved 11/30/18) was reviewed and revealed on page 12, "gloves are worn when contact with blood and other potentially infectious material, mucous membranes, and non-intact skin is reasonably anticipated."

On 03/19/19 at 10:13 AM Patient #13 was observed to have an IV infusion of 20 mEq KCl (potassium chloride) running. Observation of the IV tubing with Staff F revealed the IV tubing was hung on 03/12/19 at 7:00 PM and was to be replaced on 03/16/19 at 7:00 PM.

At 03/19/19 at 10:18 AM Staff F was observed administering a subcutaneous injection of Lovenox (anticoagulant medication) to Patient #13 without wearing gloves.

Staff C, Staff F, and Staff H were made aware of and confirmed these findings on 03/19/19 at 10:22 AM.

2. Facility policy titled "Medical Devices and Equipment, Low-Level Disinfection of Non-Critical " (revision 4, approved 10/11/18) was reviewed and revealed on page 2, "equipment or devices that are used from patient to patient, such as blood pressure machines and glucometers, are disinfected after each patient use and between each patient with an approved hospital disinfectant."

On 03/19/19 at 11:02 AM Staff G was observed performing a blood glucose check on Patient #14. Following the check, Staff G returned the glucometer to the docking station without cleaning it prior to doing so.

Staff C confirmed this findings on 03/19/19 at 11:15 AM.

3. On 03/20/19 at approximately 9:11 AM, observations were conducted of Staff B administering medications to two patients (Patient #4 and #5). Staff B administered an intravenous medication to Patient #4 at 9:11 AM and then administered a topical patch, a subcutaneous medication and oral medications to Patient #5 at 9:15 AM. Staff B did not perform hand hygiene or change gloves between the medication administrations of Patient #4 and Patient #5.

On 03/20/19 at 9:30 AM, the findings were shared with Staff A and Staff B and confirmed.

The facility's Standard Precautions policy (Approval Date 10/11/18, Revision:8) stated "hand hygiene is the single most effective deterrent to the spread of infection. Hands are washed or degermed between patient treatments, contacts, after gloves are removed, after touching inanimate objects likely to be contaminated by blood or saliva from other patients and before leaving the patient's room.

Based on medical record review and staff interviews, the facility failed to ensure there was an adequate number of respiratory therapists to meet the needs of the patients. This affected six of seven patients whose orders for respiratory treatments on 03/18/19 were reviewed, Patients' #19, #42, #43, #44, #45 and #46.

Findings include:

1. During observation of the administration of Duoneb (respiratory medication) to Patient #19 on 03/20/19 at 9:40 AM, review of the MAR (medication administration record) revealed a comment from 03/19/19 at 8:55 PM that revealed the patient didn't receive Duoneb because staff was "busy in ER."

2. Review of five (5) additional medical records with Staff A on 03/20/19 at 1:50 PM revealed the following related to administration of Duoneb on 03/18/19:

Patient #42 no 8:46 PM dose because RRT was "too busy in ER"
Patient # 43 no 2:00 PM dose because RRT (registered respiratory therapist) was "busy in ER"
Patient # #44 no 5:30 PM dose because RRT was "busy in ER"
Patient # #45 no 2:00 PM or 6:00 PM dose because RRT was "busy in ER"
Patient #46 no 8:48 PM dose because RRT was "busy in ER."

Staff A confirmed these findings at the time of review.

3. Staff D and Staff E were then interviewed on 03/20/19 at 2:39 PM regarding the above concerns. Both staff confirmed it was not acceptable for patients not to receive their RT treatments as ordered. Both staff stated the RRT in question should have contacted the other RRT who was working at that time if he/she was "swamped" in the ER and needed help.

Based on medical record review, policy review and staff interviews, the facility failed to ensure the respiratory treatments were administered for four of four patients (Patients' #10, # 41, #42 and #43) reviewed.

Findings include:

1. Facility policy Medication Standard Administration Times & Guidelines (revision 6, approved 08/18) was reviewed. Per page one (1) of the policy, "medications are administered according to the hospital's standard administration times or as ordered by the physician."

2. Review of the MAR (medication administration record) for Patient #41 revealed on 03/19/19 and 03/20/19 the RRT (registered respiratory therapist) administered Perforomist but not the scheduled Duoneb,noting "Perforomist given instead.". The same occurred on 03/20/19 at 6:56 AM. The RRT administered Perforomist but not the scheduled Duoneb, noting "Perforomist given."

3.Review of the MAR for Patient #42 revealed on 03/19/19 at 6:11 AM the RRT administered Perforomist but not the scheduled Duoneb, noting ""Perforomist given."

4. Review of the MAR for Patient #43 revealed on 03/19/19/19 at 6:25 PM the RRT administered Perforomist but not the scheduled Duoneb, noting "Perforomist given."

Staff A confirmed the above findings but stated respiratory therapy would need to answer any related questions.

Staff D and Staff E were interviewed on 03/20/19 at 2:39 PM regarding the above findings. At that time Staff D stated both medications should be administered as ordered and per pharmacy it was acceptable to do so. Staff D stated some RRT's refuse to administer both medications based on historical practice.

5. Patient #10 was admitted to the facility on 03/17/19 with a chief complaint of shortness of breath. The medical record for Patient #10 contained orders on 03/17/19 at 6:00 PM for Duoneb 1 ampule nebulizer every four hours while awake and Perforomist 20 mcg nebulizer two times a day. The Medication Administration Report review revealed Patient #10 did not receive the ordered Duoneb on 03/18/19 at 7:04 AM and 6:54 PM, 03/19/19 at 6:00 AM, 10:00 AM and 6:00 PM, and on 3/20/19 at 6:38 AM. On 03/18/19 at 7:04 AM and 03/20/19 at 6:38 AM Duoneb holds contained a comment which stated "Perforomist given".

The findings were shared with Staff I on 03/21/19 at 4:10 PM and confirmed.