HospitalInspections.org

Based on document review, the chief executive officer failed to assure that two (2) surgical technologists (ST#1 and ST#2) of 8 personnel files reviewed were either privileged/credentialed and evaluated by the medical staff or received performance evaluations as employees of the hospital.

Findings:

1. Personnel files ST#1 and ST#2 lacked any documentation of an annual performance evaluation or review through a clinical privileging process.

2. On 4-21-10 at 1:30 pm, upon interview, employee #A6 indicated personnel ST#1 and ST#2 accompany certain surgeons and perform duties as scrub techs. The employee also indicated those 2 personnel are not credentialed by the medical staff, since the medical staff doesn ' t want them to be credentialed, and the personnel are paid directly by the hospital, yet the hospital does not officially consider them " hospital personnel " .

3. As a consequence of not being credentialed and not being hospital personnel, per se, there is no review of their activities by either the medical staff through the credentialing process or through the personnel evaluation process.

Based on document review, the facility failed to ensure the inclusion of 6 of 36 services in its Quality Assessment and Improvement Program (QAPI).

Findings:

1. Review of the facility's QAPI indicated it did not document monitoring of, a standard for and reporting of, 6 of 36 services furnished in the hospital. These included contracted bioengineering, contracted blood bank, discharge planning, neonatal nursery, contracted transcription and contracted housekeeping.

2. On 4-21-10 at 3:45 pm, employee #A3 was requested to provide documentation of the above services and none was provided prior to exit.

Based on document review and interview, the facility failed to ensure that a registered nurse supervise and evaluate the nursing care for each newborn patient by following established newborn policy/procedure for 3 of 3 newborn medical records (MR) reviewed (1, 2 and 20).

Findings include:

1. Review of policy/procedure Newborn Stabilization indicated the following:
"Ongoing Care: - Normal Care Newborn
9. Complete and document physical assessment & vital signs (VS) every 1 hour x 4, every 6 hours until 24 hours of age, then every 12 hours."
This policy/procedure was last reviewed/revised on 09/2008.

2. Review of the following MRs indicated the following;
patient #1's MR indicated the patient was born on 04-20-10 at 0312 hours and physical assessments were documented at 04-20-10 at 0330 hours and 0648 hours.
patient #2's MR indicated the patient was born on 04-18-10 at 2146 hours and physical assessments were documented at 04-18-10 at 2200 hours and on 04-19-10 at 0206 hours and 0805 hours.
patient #20's MR indicated the patient was born on 11-28-09 at 1149 hours and physical assessments were documented at 11-28-09 at 1200 hours, 1300 hours, 1500 hours and 2025 hours.

3. On 04-20-10 at 1145 hours staff #45 confirmed that there was no documentation of hourly physical assessments x 4 in patient #1, 2 and 20's MRs.

Based on review of policies and procedures, blood transfusion records, and staff interview, blood transfusions failed to be administered in accordance with medical staff policies and procedures in 3 of 8 records reviewed.

Findings included:

1. Review of policies and procedures on 4-19-10 between 3:30 PM and 4:30 PM revealed a policy/procedure titled: "Blood Products Administration", last revised on "09/09" which read: "...Check VS 15 min after infusion begins..." and "If any signs of transfusion reaction...notify the physician immediately...if the physician determines that a transfusion reaction is occurring, notify the blood bank and the nursing supervisor and complete the following steps...obtain a Transfusion Reaction Form from the blood bank..."

2. Review of blood transfusion records on 4-19-10 between 1:35 PM and 2:50 PM and on 4-20-10 between 3:30 PM and 4:45 PM indicated the following:
a. Patient L1 had a blood transfusion initiated on 1-15-10 at "19:21". The 15-minute vital signs were taken at "20:03", 42 minutes after the transfusion was started.
b. Patient L3 had a blood transfusion initiated on 2-6-10 at "11:00". The 15-minute vital signs were taken at "11:30", 30 minutes after the transfusion was started.
c. Patient L3 had a blood transfusion initiated on 3-13-10 at "1505" and stopped at "1802" due to a possible transfusion reaction. The patient's physician was notified at "1802" of an increase in the patient's temperature. The physician determined the patient's rise in temperature was not due to a transfusion reaction, but to the patient's disease process. At "1900", the physician gave a telephone order to give a second unit of blood "...30 min with (sic) Tylenol..." At the same time, nursing staff notified the blood bank of a possible transfusion reaction and a "Transfusion Reaction Investigation Report" was initiated, without the physician's order. The physician was again notified at "1925" of another increase in temperature, and again at "1953" when the patient developed a rash. Nursing notes at "1953" indicated the blood transfusion bag and tubing was sent to the lab at that time. There was no indication in the patient's record that a blood transfusion reaction investigation was ordered by the physician, per policies and procedures.

3. In interview on 4-19-10 between 1:35 PM and 2:50 PM and on 4-20-10 between 3:30 PM and 4:45 PM, Staff Members #L1 and L2 acknowledged the above findings.

Based on review of policies and procedures, patient nutritional records, and staff interview, nutritional needs of patients failed to be met in accordance with the orders of the practitioner(s) responsible for the patients' care for 3 of 3 patient records reviewed.

Findings included:

1. Review of policies and procedures on 4-21-10 between 2:15 PM and 3:45 PM revealed the following:
a. A policy/procedure titled: "Medical Nutrition Therapy (MNT) Order Writing Privileges by Registered Dietitians", last reviewed "4/30/08" which indicated registered dietitians were allowed to write dietary orders in the following instances:
1. "If physician desires, he/she will enter/write order for "RD to order oral diet consistency, calorie or protein level, and supplements" in the physician orders section of the medical record."
2. "If physician desires, he/she will enter/write order for "RD to order tube feeding" in the physician orders section of the medical record."
3. "If the physician desires, he/she will enter/write order for "RD to order macronutrient regimen for parenteral nutrition" in the physician orders section of the medical record."
4. To downgrade diet texture
5. To "Adjust a calorie level"
6. To "Adjust appropriate protein levels for Renal or Hepatic Diets."
7. To "Initiate, change, or stop oral nutritional supplements within the diet order, based on the RD's nutrition assessment or patient request."
b. A policy/procedure titled: "Diets and Nutrition", last revised "10/31/00" which read: "Diet As Tolerated (DAT) is an unacceptable diet order."

2. Review of patient records on 4-21-10 between 2:15 PM and 3:45 PM indicated the following:
a. Patient #L11 was admitted on 4-6-10. On 4-18-10 at "1416", the patient's physician wrote a diet order which read: "Diet As Tolerated", which is an unacceptable diet order according to approved policies/procedures.
b. Patient #L12 was admitted on 4-18-10. On 4-21-10 at "1236", a registered dietitian, who was not a practitioner responsible for the patient's care, ordered a health shake "BID at lunch and dinner" and changed the patient's diet to a "cardiac bland diet".
c. Patient #L13 was admitted on 4-18-10. On 4-19-10 at "1027", a registered dietitian, who was not a practitioner responsible for the patient's care, ordered a no sodium health shake "BID".

3. In interview on 4-21-10 between 2:15 PM ad 3:45 PM, Staff Members #L8 and #L9 acknowledged the above findings.

The Goshen General Hospital (GGH) comprised of the main hospital campus in Goshen was not found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code (LSC), Chapters 19, Existing Health Care Occupancies for 1964 through 2000 buildings; Chapter 18, New Health Care Occupancies for The Cancer Center expansion built in 2006; with Chapters 38, New Business Occupancies for the GGH Centers for Rehabilitation Outpatient Facilities in Nappanee and Middlebury; and Chapter 39, Existing Business Occupancies for the GGH Centers for Rehabilitation Outpatient Facilities in Goshen (The Retreat).

The main hospital is a four story, sprinklered building with a partial basement and a construction Type of II (222) construction. The original hospital building (1964) and subsequent additions were completed in 1993. The Cancer Center was added to the building in 2000 and expanded in 2006. The facility has a fire alarm system with smoke detection in the corridors, spaces open to the corridors and patient sleeping rooms. This facility has a capacity of 124 and had a census of 73 at the time of this survey.

The Retreat facility in Goshen is a single story, partially sprinklered building with a construction Type of V (111) construction. The facility has a fire alarm system with smoke detection in the conference side of the building.

The GGH Center for Rehabilitation, Nappanee is located in a single story facility with a partial basement, fully sprinklered building of Type V (111) construction. The facility has a fire alarm system with smoke detection in the common use areas.

The GGH Center for Rehabilitation, Middlebury is located in a single story facility with a basement, nonsprinklered building of Type V (111) construction. The facility has a fire alarm system with smoke detection in the common use areas.

Based on Life Safety code survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure continuity of exterior egress lighting for 1 of 14 exits at the main hospital and failed to ensure continuity of exterior egress lighting for 1 of 4 exits at the Rehabilitation Center in Nappanee (see K 045), failed to ensure fire drills were conducted at various times and under various conditions for each shift for 4 of 4 quarters at the main hospital (see K 050), failed to ensure 1 of 4 fire alarm control panels located in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire (see K 051), failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 3 of 52 weeks for 1 of 3 generator sets (see K 144), failed to ensure flexible cords such as extension cords were not used as a substitute for fixed wiring in 1 of 1 hospital laboratories (see K 147), failed to provide a complete written policy containing procedures to be followed to protect 73 of 73 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period (see K 154), failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period to protect 73 of 73 patients (see K 155) and failed to ensure 16 of 16 alcohol hand sanitizing dispensers in the PCU patient rooms and in the area of the Emergency Room (ER) were not installed over or adjacent to ignition sources (see K 211).

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, record review and interview, the facility failed to ensure continuity of exterior egress lighting for 1 of 14 exits, failed to ensure fire drills were conducted at various times and under various conditions for each shift for 4 of 4 quarters at the main hospital), failed to ensure 1 of 4 fire alarm control panels located in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire, failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 3 of 52 weeks for 1 of 3 generator sets, failed to ensure flexible cords such as extension cords were not used as a substitute for fixed wiring in 1 of 1 hospital laboratories, failed to provide a complete written policy containing procedures to be followed to protect 73 of 73 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period, failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period to protect 73 of 73 patients and failed to ensure 16 of 16 alcohol hand sanitizing dispensers in the PCU patient rooms and in the area of the Emergency Room (ER) were not installed over or adjacent to ignition sources.

Findings:

1. During a tour of the main hospital with the maintenance supervisor and plant manager on 04/20/10 at 2:50 p.m., it was observed that the exit discharge for the "old" doctor's exit at the hospital was equipped with one light fixture with a single bulb. During a tour of the Rehabilitation Center at Nappanee with the maintenance supervisor on 04/21/10 at 12:15 p.m., the exit discharge for side exit was equipped with one light fixture with a single bulb. Observations on 04/20/10 at 3:20 p.m. with the maintenance supervisor and plant manager indicated the fire alarm control panel for the main hospital was located in the the mechanical room and was not electronically supervised by a smoke detector. Observation during a tour of the main hospital lab with the maintenance supervisor and plant manager on 04/20/10 at 2:55 p.m. indicated an extension cord was plugged into a specimen refrigerator which was plugged into the wall. Observations of the hospital on 04/20/10 between 2:15 p.m. and 4:10 p.m. with the maintenance supervisor and plant manager indicated the hand sanitizing dispensers in each of the patient's rooms on the third floor PCU and within the ER had the dispensers mounted six inches, or less, from the light switches and an electric door opener.

2. Review of the hospital's Fire Drill records on 04/20/10 at 11:25 a.m. with the maintenance supervisor and plant manager indicated the hospital had no evidence or documentation that personnel participated in routine fire drills. Review of the generator logs with the maintenance supervisor and plant manager on 04/19/10 at 2:35 p.m. indicated the main hospital exceeded the seven day requirement for the weeks of 01/06/10 to 01/15/10, 01/20/10 to 01/28/10 and 02/16/10 to 02/24/10. The Rehabilitation Center at Nappanee did not document or maintain records of generator battery inspections every seven days. Review of the hospital's policy and procedure book with the maintenance supervisor and plant manager on 04/20/10 at 3:45 p.m. indicated the fire watch procedure for an out of service automatic sprinkler system and automatic alarm system was not complete. The policy and procedure lacked the requirement to train and designate staff assigned to complete fire watch rounds and to document each round every 15 minutes. The procedure also lacked the required telephone numbers for the Indiana State Department of Health and the local fire department.

3. In interview at the time of record review and observations, the maintenance supervisor and plant manager stated they would correct the exterior lighting for the "old" doctor's exit and the exterior lighting for the exit at Nappanee. They were not aware the facility had no evidence of hospital personnel participating in fire drills. They indicated documentation may be generated by the Human Resources Department. The maintenance supervisor stated he did not understand the seven day inspection requirement and was not aware he was required to maintain the generator documentation. The maintenance supervisor agreed that the extension cord on the specimen refrigerator should not have been used and will be hard wired. The maintenance supervisor and plant manager stated they had no other policy or procedure documentation regarding the fire watch procedure available to review. The maintenance supervisor and plant manager stated they were not aware of the requirement regarding the alcohol based hand sanitizers..

Based on document review and observation, the facility failed to ensure preventive maintenance (PM) on 6 of 18 pieces of equipment and failed to conduct operational checks for 1 of 1 defibrillators according to the manufacturer's recommendations and failed to ensure safety in 5 instances.

Findings:

1. Review of documentation of preventive maintenance for pieces of equipment indicated there was no PM for the nurse emergency call (code) system, dietary ovens, housekeeping floor scrubber, speech and hearing audiometer, parallel bars and stair steps used in rehabilitation therapy. Employee #A1 was requested to provide documentation of the equipment and none was provided prior to exit.

2. Review of the CodeMaster XL+/XL defibrillator/monitor handbook indicated every shift the facility is to perform various checks, including but not limited to checking for adequate thermal paper in the recorder and checking ECG [electrocardiographic] leads, electrodes and adequate electrolyte paste or defibrillator electrodes.

3. Review of a document entitled ANCILLARY DEPARTMENT CRASH CART CHECKLIST, Month of April, 2010, Unit Nuc Med, indicated there were no checks for thermal paper, leads, electrodes and paste.

4. Review of a hospital policy entitled Cylinder/Equipment Handling, indicated free-standing cylinders must be chained or otherwise anchored to a wall or support frame.

5. On 4-19-10 at 2:00 pm in the presence of employee #A1, it was observed in the Positive Emitting Tomography waiting area of the main hospital that there was 1 fire extinguisher on the counter unsecured by chain or support frame.

6. On 4-19-10 at 3:45 pm in the presence of employee #A1, it was observed at the outside emergency generator at the main hospital that there was 1 fire extinguisher on the floor unsecured by chain or support frame.

7. On 4-20-10 at 9:15 am in the presence of employee #A1, it was observed in the Emergency Department basement of the main hospital that there were 13 fire extinguishers on a shelf unsecured by chain or support frame.

8. On 4-20-10 at 9:45 am in the presence of employee #A3, it was observed in the main hospital maintenance shop that there were 2 fire extinguishers on the floor unsecured by chain or support frame.

9. On 4-19-10 at 4:40 pm in the presence of employee #A1, it was observed in the boiler room of the main hospital that there were caustic chemicals used for water testing that included starch acid/sulfite and HP-3 Hardness Indicator Powder. It was also observed there was no eye wash in the immediate vicinity.

Based on document review, the facility failed to ensure compliance with their agreement with the Indiana Organ Procurement Organization (IOPO) for one (1) of 220 deaths.

Findings:

1. Review of the contract between the hospital and the IOPO, dated 2-15-07, indicated the Hospital shall provide Timely Referral to IOPO as soon as possible of every individual whose death is imminent or who has died (including calling prior to or at the time of Brain Death is declared), in the Hospital.

2. Review of a report entitled Goshen General Hospital Donation 2009 Statistics and Benchmarks, indicated for the entire year, the Total # Hospital Deaths was 220 and the Total # Deaths Reported was 219.