HospitalInspections.org

Based on review of 5 of 5 clinical records, interview with facility staff and data collected by the facility, the hospital failed to have verbal orders authenticated within 48 hours.

Findings include:

Per hospital policy verbal/telephone orders must be signed within 48 hours.

Per review on 06/22/2010 at 11:00 AM, patient (pt.) #1's clinical record contained verbal orders written on 06/18 and 06/19/2010 which had not been signed, dated or timed.

Per review on 06/22/2010 at 11:00 AM, patient (pt.) #2's clinical record contained verbal orders written on 06/16 and 06/17/2010 which had not been signed, dated or timed.

Per review on 06/22/2010 at 11:00 AM, patient (pt.) #3's clinical record contained 2 verbal orders written on 06/18/2010 which had not been signed, dated or timed.

Per review on 06/22/2010 at 11:00 AM, patient (pt.) #4's clinical record contained a telephone order written on 06/15/2010 and a verbal order written on 06/18/2010 which had not been signed, dated or timed.

Per review on 06/22/2010 at 11:00 AM, patient (pt.) #5's clinical record contained 2 verbal orders written on 06/19/2010 which had not been signed, dated or timed.

These findings were confirmed per interview with Quality Manager A at 11:15 AM on 06/22/2010.

Based on observation and interview, the facility failed to (i) maintain exhaust grilles clean in the Sterile Processing Room; (ii) maintain negative pressure in one soiled utility room in patient sleeping/use area; and (iii) install air filter of 90% or more filtration efficiency in one patient treatment area in accordance with the recommendations in CDC and the American Institute of Architects (AIA) guidelines. This had a potential of affecting indeterminable number of patients.

Findings include

During a tour of the facility with Staff C (facility management supervisor), Staff D (security supervisor), and Staff E (environmental safety officer) between 2/9 and 2/12/2010, Surveyor 12316 observed spaces in the following locations that did not either have properly maintained exhaust system, or adequate negative pressure, or HVAC units with proper filtration efficiency.

1. 1st Floor: On 2/9/2010 at 3:12 pm, the Sterile Processing Room in the Surgery Department had three exhaust grilles dirty, and an accumulation of lint with possible dirt was observed along the small gap around the thru-the-wall Washer Unit in the Sterile Processing Room;
2. 3rd Floor: On 2/11/2010 at 1:45 pm, the Soiled Utility room on the 3rd Floor 1963/69 building did not have negative pressure in relation to the corridor as recommended by CDC and AIA guidelines. The airflow was not in the right direction i.e. from adjacent corridors into the Soiled Utility room; and
3. 2nd Floor: On 2/11/2010 at 2:30 pm, the ceiling plenum return air from the Nuclear Medicine and Pulmonary Suite in the 1948 building was not properly treated with a primary air filter of at least 90% filtration efficiency by the HVAC units serving these spaces before recirculation as recommended by AIA guidelines.

The above deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The above deficiency was acknowledged by the facility management supervisor, security supervisor, and environmental safety officer at the time of discovery, and confirmed with the facility management manager, Staff A (quality manager) and Staff F (compliance coordinator) at the exit conference on 2/12/2010 at 4:15 pm.

During the verification visit between 6/22 - 6/23/2010, Surveyor 12316 determined that the facility has made a satisfactory progress toward correcting the deficiency.