HospitalInspections.org

Based on observations as referenced in the Life Safety Report of Survey completed 11/22/2013, the hospital leadership failed to have an effective governing body responsible for the functions of the hospital.

The findings include:

The hospital leadership failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~Cross refer to 482.41 Physical Environment - Condition Tag A0700.

Based on review of hospital policy and procedures, observation during tours, and staff interviews, the hospital staff failed to ensure the patients' privacy for 27 of 27 patients on 1 of 13 acute inpatient units toured (3 South).

The findings include:

Review of the hospital's policy, "Patient Rights and Responsibilities" revised 06/2012, revealed, "...As a patient in this hospital, the patient has many rights that this hospital is committed to protecting and promoting. ...The following patient rights and responsibilities will contribute to more effective patient care and greater patient satisfaction: ... You have the right to personal privacy. ...".

Observation during tour of the medical-surgical patient care unit (3 South) on 11/20/2013 at 0930 revealed a flat screen computer monitor mounted on the wall at the nurses' station. The monitor screen was facing the hallway towards the visitor elevators. Observation revealed the computer monitor screen was in view of patients and visitors. Observation further revealed 27 patients' last name, first initial, diagnosis, physician and room number listed on the monitor screen and could be viewed while standing at the nurses' station.

Interview on 11/20/2013 at 0930 with administrative nursing staff revealed the information on the monitor screen was from the "bed board" for the patient care unit. Interview revealed, "yes, this is a violation of patient confidentiality. We hadn't thought about it".

Interview on 11/20/2013 at 0935 with administrative staff confirmed the information that could be viewed on the computer monitor screen by patients and visitors was a violation of the patients' privacy and confidentiality.

Based on hospital "Medical Staff Rules and Regulations" review, medical record reviews and staff interview, the hospital's hemodialysis nursing staff failed to ensure written physician orders were complete and acceptable before implementing the physician orders for 4 of 5 hemodialysis patients (#38, #39, #40, and #41) receiving hemodialysis treatments at the hospital.

The findings include:

Review on 11/20/2013 of the hospital's "Medical Staff Rules and Regulations" (dated 05/2013) revealed "Section 3 Orders for Treatment: 3.2 All orders must be written clearly, legibly and completely. Orders which are illegible or improperly written will not be carried out until rewritten or understood by the nurse. The use of "renew", "repeat", and "continue orders" is not acceptable."

1. Open medical record review on 11/20/2013 for patient #38 revealed the patient was admitted to the hospital on 11/16/2013. On 11/19/2013 at 1300, the patient had a written physician order documented as "Hemodialysis Tomorrow: Same orders as last treatment except give Heparin 2000 units bolus". The review revealed the physician order was written by the patient's nephrologist and chart checked by a registered nurse. The patient received hemodialysis treatment based on the "repeat and continue orders" on 11/20/2013. The review further revealed there was no rewritten or clarified orders for the patient related to the hemodialysis treatment for 11/20/2013.

Interview on 11/20/2013 at 1145 with the hospital's hemodialysis acute care coordinator revealed that all physician orders should be clearly written and not done as a blanket order (repeat or continue orders). The interview confirmed this order should not have been accepted as written and the patient should have had individualized physician orders.

2. Open medical record review on 11/20/2013 for patient #38 revealed the patient was admitted to the hospital on 11/16/2013. On 11/18/2013 (no time), the patient had a written physician telephone order by a registered nurse that did not include a hemodialysis blood flow rate. Review on 11/19/2013 revealed the patient received his hemodialysis treatment based on the order with a blood flow rate documented by the nursing staff as "400-450" range. The review revealed the hemodialysis nursing staff hemodialyzed the patient without a physician ordered blood flow rate.

Interview on 11/20/2013 at 1145 with the hospital's hemodialysis acute care coordinator revealed that nursing staff has not been obtaining hemodialysis patient blood flow rates from the physician. The interview also confirmed the blood flow rates need to be given by the physician as a standard of practice for hemodialysis treatment. The interview confirmed the finding.

3. Open medical record review on 11/20/2013 for patient #39 revealed the patient was admitted to the hospital on 11/13/2013. On 11/18/2013 (no time), the patient had a written physician telephone order by a registered nurse that did not include a hemodialysis blood flow rate. Review on 11/19/2013 revealed the patient received his hemodialysis treatment based on the order with a blood flow rate documented by the nursing staff as "400". The review revealed the hemodialysis nursing staff hemodialyzed the patient without a physician ordered blood flow rate.

Interview on 11/20/2013 at 1145 with the hospital's hemodialysis acute care coordinator revealed that nursing staff has not been obtaining hemodialysis patient blood flow rates from the physician. The interview also confirmed the blood flow rates need to be given by the physician as a standard of practice for hemodialysis treatment. The interview confirmed the finding.

4. Open medical record review on 11/20/2013 for patient #40 revealed the patient was admitted to the hospital on 11/13/2013. On 11/18/2013 (no time), the patient had a written physician telephone order by a registered nurse that did not include a hemodialysis dialysate (dialysate bath) order. Review on 11/19/2013 revealed the patient received his hemodialysis treatment based on the order with a dialysate bath of 3K (Potassium) 3 Calcium without a physician ordered dialysate bath.

Further review of the written physician orders revealed an order for 11/19/2013 (no time) did not include an order for a hemodialysis dialysate (dialysate bath). Review on 11/20/2013 revealed the patient received his hemodialysis treatment based on the order with a dialysate bath of 3K (Potassium) 3 Calcium without a physician ordered dialysate bath.

Interview on 11/20/2013 at 1145 with the hospital's hemodialysis acute care coordinator revealed that dialysate baths should be ordered by the physician. The interview also revealed the nursing staff should ensure they obtain the bath from the physician in the telephone orders. The interview confirmed the finding.

5. Open medical record review on 11/20/2013 for patient #41 revealed the patient was admitted to the hospital on 11/18/2013. On 11/20/2013 at 0945, the patient had a written physician telephone order by a registered nurse that did not include a hemodialysis blood flow rate or dialysate (dialysate bath). Review on 11/21/2013 revealed the patient received his hemodialysis treatment based on the order with a blood flow rate and dialysate bath selected by the nursing staff without a specific written physician order.

Interview on 11/20/2013 at 1145 with the hospital's hemodialysis acute care coordinator revealed that nursing staff has not been obtaining hemodialysis patient blood flow rates from the physician. The interview also confirmed the blood flow rates need to be given by the physician as a standard of practice for hemodialysis treatment. The interview also revealed this patient should have had a dialysate bath order for his 11/21/2013 hemodialysis treatment. The interview further revealed the bath is usually done on standing orders but needs to be obtained and completed accurately. The interview confirmed the finding.

Based on hospital policy and procedure review, medical record review and staff interview, the hospital staff failed to administer blood according to policy for 1 of 7 patients (Patient # 11) and failed to administer intravenous (IV) medications for 1 of 8 (Patient #22) medication passes.

The findings include:

1.) Review of hospital policy titled, " Blood and Blood Product Administration " with a revision date of 05/12 revealed, "PROCEDURE, I. Administration of Blood Products
19. Initiation of transfusion: (d) Set the infusion pump rate to infuse blood at 180 ml/hr (milliters/hour). (Note: The purpose of setting the rate at 180 ml/hr is to infuse 45ml of fluid in the first 15 minutes, 30 ml of saline and 15 ml of blood.) This administration during the first 15 minutes allows the nurse to assess the patient for hemolytic or allergic adverse reactions which usually occur within 15 minutes with as little as 10 ml of blood. 22. Administer blood unit at prescribed rate if no adverse effects occur. Most patients can tolerate a flow rate of one unit of packed cells in 1 ½ - 2 hrs. "

Review of open medical record of Patient #11 revealed an 83 year old presenting to the emergency room on 11/13/2013 at 1000 for weakness and abnormal electrocardiogram (EKG). Record review revealed patient's vital signs (VS) at 1004 were B/P (Blood Pressure) 116/57 (normal 90/60 - 120/80), pulse 110 (normal 60-110), and respirations 18 (normal 12-18). Record review revealed triage assessment at 1000, " General: Appears in no apparent distress. PMHx (Past medical history): atrial fibrillation (abnormal heart rhythm), myocardial infarction, CAD (coronary artery disease), coronary stents." Record review of physician documentation at 1152 revealed, "this is a well developed, well nourished patient who is awake, alert, and in no acute distress." Record review revealed vital signs taken between 1004 - 1258. Record review revealed the patient's systolic blood pressure (top number) was between 106 - 124. Record review revealed the patient's diastolic number (bottom number) was between 57 - 75. Record review revealed the patient's pulse was between 99 - 128. Record review revealed the patient's respirations were between 18 - 22. Record review revealed the patient began an infusion of 1 unit (325 ml) of RBC (red blood cells) at 1240 and completed infusing at 1255. Record review did not reveal documentation of why the patient received the infusion over 15 minutes.

Interview with nurse #1 on 11/20/2013 at 1530 revealed the ED (emergency department) RN (registered nurse) that administered the unit of RBC to Patient #11. Further interview revealed that blood is given to patients over about 3 hours. Further interview revealed Nurse #1 remembered Patient #11. Further interview revealed the nurse stating "the patient was very unstable with lots of blood coming from his belly after placement of a nasogastric tube (NGT) and he had a low B/P." Further interview revealed that Nurse #1 was directed by the ordering physician to give the blood as fast as possible. Further interview revealed that nurses are to document verbal orders in the medical record. Further interview revealed there was no documentation in the medical record "to give the blood as fast as possible."

2.) Review of hospital policy titled, "MEDICATION ADMINISISTRATION" revised 11/13 revealed, " Scheduled medications will be administered according to the following schedule ...Daily 0900. (9) Medications are absolutely not to be left with the patient.

Review of hospital policy titled,"CENTRAL VASCULAR ACCESS DEVICES (CVAD's)" revised 02/13 revealed (1) Flushing will be performed after blood draws, medication administration, and on a routine schedule when the CVAD is not in use ... (c) Saline only flushing: S-A-S
· Saline flush before each use to prevent drug interaction and assess patency
· Administer prescribed IV medications or fluid therapy
· Saline flush immediately after each prescribed infusion to maintain patency and prevent drug interaction

Review of open medical record of Patient # 22 revealed a 76 year old admitted to the hospital on 11/18/2013 for acute renal failure, CHF (congestive heart failure), and ascites (fluid in the abdomen). Further review revealed the patient received a triple lumen PICC (peripherally inserted central catheter), an intravenous (IV) line for medication and blood administration.

Observation of the Critical Care Unit (CCU) on 11/20/2013 at 1107 revealed Patient #22 receiving IV medications through an IV pump. Further observation revealed the patient had a syringe attached to one of the lumens of the PICC. Further observation revealed the syringe had 3ml of fluid in the syringe.

Interview with RN #2, the primary care nurse for Patient #22 on 11/20/2013 at 1110 revealed, "that (the syringe) was left there from this morning when I was pushing Protonix (a medication)." RN #2 exited the room without removing the syringe from the patient.

Interview with Adminstrative staff #1 on 11/20/2013 at 1115 revealed, "RN's know the correct way to administer medications."

Based on observations as referenced in the Life Safety Report of survey completed 11/22/2013, the hospital staff failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

2. The hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702

3. The hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709

4. The hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710

5. The hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure emergency lighting was provided at all exit discharges and fixtures were properly connected to the Essential Electrical System.

~Cross-refer to 482.41(b)(4) Physical Environment Standard Tag A-0711

6. The hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

~Cross-refer to 482.41(b)(9) Physical Environment Standard Tag A-0716

7. The hospital staff failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms.

~Cross-refer to 482.41(c)(4) Physical Environment Standard Tag A-0726

Based on observations as referenced in the Life Safety Report of Survey completed 11/22/2013, the hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

Building 01
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, sprinkler system maintenance is incomplete due to the following:

1. different types of pendent sprinklers located in the same compartment - located in administrative corridor near switchboard room, and information desk on first floor.

2. paint on heat sensitive element of sprinkler - located in IT closet beside medical records.

3. paint on heat sensitive element of sprinkler - located in storage room beside IT closet in medical records area.

4. paint on sprinkler near EMT entrance on first floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

B. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, HVAC systems are incomplete due to the following:

1. Combination fire and smoke damper did not close with activation of duct smoke detectors serving area - located behind access panel, beside elevator lobby at entrance #1, to Same Day Surgery.

2. Lack of air handler manual emergency stop switch for unit serving Medical Records - located on first floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

C. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there are no gauges installed on medical gas piping located in zone valve enclosure box - located in Adult Care section near room 364.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 077.

D. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the electrical systems are incomplete due to the following:

1. Lack of identification label on Life Safety panelboard - located in switchboard room on first floor.

2. Lack of complete labeling of all circuit breakers in electrical panel - emergency panel located in sixth floor electrical equipment room near south nurse's station.

3. Lack of label on snap switch identifying device to be shut-off - located behind nurse's station on sixth floor south wing.

4. Lack of cover on exposed incandescent light bulb located above storage space - janitor's closet near north tower elevators.

5. Lack of junction box covers on live electrical equipment - located in the Edgegard Units in the pharmacy on third floor.

6. Lack of documentation to demonstrate that all electrical circuit breakers are maintained and tested in accordance with the manufacturer's instructions.

7. Ground-fault circuit interrupters did not trip during test - located in bathrooms of rooms 415, and 238.

8. Lack of knockout cover for electrical junction box - located behind main sprinkler piping in boiler room near exterior ramp, and loading dock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 02
E. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is no solid and slip-resistant surface from exit discharge gate to publicway - enclosed exterior courtyard near first floor dining room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

F. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the electrical systems are incomplete due to the following:

1. panelboard circuit directory is not labeled to indicate devices served - circuit serving medication preparation room light could not be identified on third floor west wing.

2. lack of circuit directory for panelboard ELP2-2 - located in second floor north landing.

3. lack of connector fitting between conduit and electrical junction box - located above ceiling in corridor area near room 816 on second floor.

4. lack of cover on incandescent light located in clean room(TLC) - located on second floor.

5. GFCI receptacle is not functioning - located beside exit access door from enclosed exterior courtyard.

6. lack of documentation to demonstrate maintenance of electrical circuit breakers in accordance with manufacturer's specifications.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 04
G. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the facility is noncompliant with Business Occupancy requirements for the provider based facility due to the following:
a. the tamper switches for the sprinkler system backflow preventer is disabled and not maintained in operation condition.
b. there is no access to the sprinkler backflow preventer due to excessive vegetation.
c. the valve pit containing sprinkler valve contained standing water - pit did not appear to provide proper drainage to protect tamper switches from moisture damage.
d. there is paint on the heat sensitive element of sprinkler located in the south lobby.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

Building 05
H. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K76 of CMS-2786U
a. oxygen cylinders are not individually secured in storage area.
b. oxygen storage room is not equipped with venting for medical gas cylinders.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

Based on observations as referenced in the Life Safety Report of Survey completed 11/22/2013, the hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the essential electrical system is incomplete due to the following:

1. There are devices connected to the Life Safety Branch panelboard, as indicated by circuit directory, that are not permitted by Article 517 of the National Electrical Code - panelboard is located in the PBX room near the administrative corridor.

2. Light in medication preparation room is wired to the normal power distribution panelboard - light must be connected to the automatically switched critical branch of the emergency electrical system. Medication room is located on the sixth floor behind nurse's station.

3. Elevator sump pump, based on observation of circuit directory label, is connected to the Life Safety Branch panelboard 1LL - located on first floor. Sump pump is not permitted to be connected to the Life Safety Branch of the essential electrical system.

4. The emergency power system failed to restore power in not greater than ten seconds during loss of normal power to the Life Safety Branch automatic transfer switch.

5. The generator annunciator panel, located in the PBX room, did not indicate emergency power system supplying load during test of the emergency electrical system.

6. The low fuel indicator did not function on the generator annunciator panel during test of the fuel tank switch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0106.

Building 02
B. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the essential electrical system is incomplete due to the following:

1. The emergency power system failed to restore power in not greater than ten seconds during loss of normal power to the automatic transfer switch #4.

2. Lack of generator annunciator panel for emergency power system serving south campus hospital - panel must be located in a supervised area were signals can be heard and observed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0106.

Based on observations as referenced in the Life Safety report of survey completed 11/23/2013, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

The findings include:

Building 05
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K114/K115 of CMS-2786U
a. Occupancy separation and smoke barrier, respectively are incomplete, the one hour fire barrier doesn't separate other tenant spaces from the hospital based facility; and smoke barrier lacks smoke damper duct penetration, and self- closing device on storage room door in barrier.
b. there is unsealed holes in the one hour barrier located near the rear exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 011.

B. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K29 of CMS-2786U
a. the one hour rated enclosure walls for soiled linen and soiled utility room is incomplete. There was no fire damper in duct penetration of required one hour barrier. The area must be equipped with sprinkler(s) or provided with one hour fire resistive enclosure.
b. the adjacent tenant has a storage room within surgery center that is not equipped with one hour rated enclosure or sprinkler(s).
c. the storage room located on hall near operating rooms is not one hour enclosed or equipped with sprinkler(s).
d. the storage room located on the main hall is not equipped with one hour enclosure or equipped with sprinkler(s).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

C. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. The vertical mechanical shaft door at/near elevator lobby was not self-closing, one hour rated door.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

Based on observations as referenced in the Life Safety Report of survey completed 11/22/2013, the hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, doors protecting egress corridors are incomplete due to the following:

1. Lack of positive latching hardware on cross corridor doors to main Operating Suite.

2. Lack of positive latching hardware on double doors to recovery suite - located near suite doors to main operating suite.

3. Lack of positive latching hardware on door to kitchen - located near front elevator lobby.

4. Lack of positive latching hardware on double doors to kitchen, inactive leaf is not latched in the closed position. Doors could be pulled open due to lack of automatic latches on inactive leaf - located beside medical gas storage area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

B. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, fire door to elevator shaft is not self-closing and latching - located in mechanical room on second floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020

C. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there are unsealed penetrations in smoke barrier wall near EMT room - located on first floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025.

D. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, hazardous areas are incomplete due to the following:

1. Rehabilitation nursing supply storage room contains alcohol based hand sanitizers - room is not designed as a severe hazardous area storage room with forty-five minute rated fire door.(located on sixth floor)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

E. Based on observation, on November 19 - 22, 2013, at approximately 2:00pm onward, exit access is incomplete due to the following:

1. OT storage room is equipped with a manual deadbolt, in addition to the positive latching hardware, that creates greater than a single hand motion to exit the room. The additional hardware is mounted greater than forty-eight inches above the floor.(located on sixth floor)

Note: This door hardware arrangement consist throughout the facility on door openings in corridor walls.

2. Dictation room is equipped with a manual deadbolt, in addition to the positive latching hardware, that creates greater than a single hand motion to exit the room. The additional hardware is mounted greater than forty-eight inches above the floor.(located on the sixth floor)

3. Lack of guardrails protecting exit discharge boundary near loading dock - located near exit discharge adjacent to kitchen area.

4. The use of delayed egress special locking arrangement on cross corridor doors near room 304 - locks at this location create more than one delayed egress locking arrangement in the same egress path.

Note: The facility has no documentation supporting the use of categorical waiver permitted by CMS.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

F. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, exit and directional signs are incomplete due to the following:

1. Lack of exit directional sign at operating suite corridor near sterile processing entrance - located on second floor.

2. Lack of exit sign in corridor near EKG back entrance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

G. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, sprinkler coverage is incomplete due to the following:

1. Lack of sprinkler in walk-in cooler - located in main kitchen area on first floor.

2. Lack of sprinkler coverage for workroom behind IMCU nurse's station on first floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

H. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, sprinkler system valve supervision is incomplete due to the following:

1. There is no electrical supervision of valves located upstream of sprinkler system low air pressure, and alarm pressure switches - located in mechanical room near kitchen.

2. Use of unacceptable valve monitoring device for sprinkler system component located in boiler room on first floor - cord connected tamper switch device is not listed for use on NFPA approved systems.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

I. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, means of egress clearance is incomplete due to the following:

1. wall mounted charting station does not self-close - located on corridor wall beside room 504.

2. door to shower rooms does not open 180 degrees against corridor wall - located in Neon Unit, and across corridor from room 503. Doors protrude greater than seven inches into corridor width in fully opened position.

3. closet door protrudes greater than seven inches into corridor width in fully open position - located across corridor from room 239.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

J. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, medical gas cylinders are stored improperly due to the following:

1. Clean storage room in Labor/Delivery - oxygen cylinders are stored less than five feet from combustible supplies.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

Building 02
K. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is an unsealed conduit penetration in corridor wall above ceiling - beside elevator on second floor north.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 017.

L. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is a hole in the door to resident room 908.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

M. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, exit and directional signs are incomplete due to the following:

1. exit sign in inside stair directs occupants to nonconforming structure - located in stairway beside room 735.

2. lack of exit signs above exit access doors from exterior enclosed courtyard.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

N. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, HVAC systems are incomplete due to the following:

1. Lack of air handler manual emergency stop switch for units in second floor mechanical room; and third floor air handling unit. Switches must be located at a supervised location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

O. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is no baffle between the deep fryer and the range -located in first floor kitchen area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 069.

P. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, elevator operation is incomplete due to the following:

1. during test of corridor smoke detector near smoke barrier, it was observed that elevator returned to the level of exit discharge; however, the doors to elevator did not open.(elevator #1)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 160.

Building 03
Q. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the sprinkler system is noncompliant with Business Occupancy requirements due to the following:

1. K12 of CMS-2786U - there is no sprinkler coverage in the following areas:
a. nurse's medication room located in Infusion Center.
b. closet in surgical wait loss room 003.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 012.

R. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the fire alarm system is incomplete due to the following:

1. there is no remote annunciator for the facility fire alarm system within the infusion care or wound care center - facilities are located on the same floor within the Medical Office Building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

S. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is no emergency stop switch for air handler serving the infusion and wound care centers - switch must be located at a supervised area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Building 04
T. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the facility is noncompliant with Business Occupancy requirements for the provider based facility due to the following:

1. K29 of CMS-2786U
a. Hildebrand storage room door is not self-closing.
b. electrical equipment rooms are not one our enclosed or equipped with sprinklers.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

U. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the facility is noncompliant with Business Occupancy requirements for the provider based facility due to the following:

1. K47 of CMS-2786U
a. lack of adequate exit signage in the middle corridor, and corridor from mammography to lobby.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

V. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the fire alarm system is incomplete due to the following:

1. there is no remote annunciator for the facility fire alarm system within the surgery center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

W. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the facility is noncompliant with Business Occupancy requirements for the provider based facility due to the following:

1. K67 of CMS-2786U
a. Lack of air handler emergency stop switch for HVAC units.
b. Lack of duct smoke detector for HVAC units serving diagnostic center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Building 05
X. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K46 of CMS-2786U
a. single bulb fixtures are provided at exit discharges and facility could not verify connection to emergency power source.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Y. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the surgery center Life Safety Code requirements are noncompliant with Ambulatory Health Care requirements based upon the following:

1. K47 of CMS-2786U
a. there is inadequate exit signage in the pre-op leading to lobby, recovery room to lobby, and in the rear corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

Z. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the fire alarm system is incomplete due to the following:

1. there is no remote annunciator for the facility fire alarm system within the surgery center.

2. the main fire alarm control panel did not provide an audible and visual signal with loss of phone line connection within the surgery center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

Based on observations as referenced in the Life Safety Report of Survey completed 11/22/2013 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure emergency lighting was provided at all exit discharges and fixtures were properly connected to the Essential Electrical System.

The findings include:

Building 01
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, emergency lighting is incomplete due to the following:

1. Lack of emergency lighting connected to the Life Safety Branch of the essential electrical system - first floor medical records area, north exit vestibule and lobby.

2. Lack of unswitched emergency light circuit, connected to Life Safety Branch of essential electrical system, in corridor located on 8-West.(second floor)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Building 02
B. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, emergency lighting is incomplete due to the following:

1. lack of emergency lighting at exit discharge from exterior enclosed courtyard to publicway.

2. single bulb fixture at exit discharge serving first floor west.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Building 04
C. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the facility is noncompliant with Business Occupancy requirements for the provider based facility due to the following:

1. K46 of CMS-2786U
a. Lack of emergency exit discharge lighting at North and South entrance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Based on observations as referenced in the Life Safety Report of survey completed 11/22/2013, the hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

The findings include:

Building 02
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, there is an ABHR located above an electrical device located in the dining room near kitchen area.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K211.

Based on observations as referenced in the Life Safety Report of Survey completed 11/22/2013, the hospital staff failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms.

The findings include:

Building 05
A. Based on observation, on November 19 - 22, 2013, at approximately 2:00 PM onward, the relative humidity is 18% in OR #1; and 15% in OR #2.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 078.

Based on hospital policy and procedure reviews, medical record review, observation during tour, and staff interview, the hospital nursing staff failed to perform hand hygiene and to wear proper personal protective equipment (PPE) for 1 of 5 patients receiving dialysis (# 11).

The findings include:

Review of hospital policy "2013 Hospital Infection Control and Prevention Plan" revised 02/2013 revealed, "...2. b. Department-Specific Responsibilities: The Department Directors or their designees are responsible for monitoring employees and assuring compliance with infection control policies and procedures. Responsibilities include, but are not limited to: Ensure proper hand hygiene and compliance to isolation protocol. c. Healthcare Worker Responsibilities: All healthcare workers of the organization will: adhere to hand hygiene guidelines...".

Review of hospital policy "Hand Hygiene Policy" reviewed 05/2012 revealed, "...Indications for hand washing and hand antisepsis include: · Before and after direct contact with patients, blood/body fluids or equipment and environmental items touched by patients ·Prior to donning gloves and after removing gloves ...I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. ...G. All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by the policy."

Review of hospital policy "Personal Protective Equipment" FMS-CS-IC-II-155-080A, effective date 03/20/2013 revealed, "...Personal protective equipment such as a full face shield or mask and protective eyewear with full side shield, fluid-resistant gowns and gloves will be worn to protect and prevent employees from blood or other potentially infectious materials...when performing procedures during which spurting or spattering of blood might occur. ...Employees shall use personal protective equipment namely the combination of fluid-resistant gown, full face shield or mask and protective eyewear with full side shield, gloves, in accordance with the type of patient expected and anticipated exposure. ...Remove gloves and wash hands after each patient contact, and after exposure to blood and body fluids. ...Hand hygiene must always be performed after glove removal. Patient care activities that require the use of gloves, fluid resistant gown, and full face shield or mask and protective eyewear with full side shield: · In area at risk for blood splatter or spill ·Handling infectious waste ·Actual contact with blood, body fluids, mucous membranes, tissues ·Potential contact with blood, body fluids, mucous membranes, tissues."

Review of hospital policy "Bloodborne Pathogen Control Plan" effective 10/31/2013 revealed, "1. Standard Precautions shall be implemented when contact with any of the following are anticipated: a. Blood, human and some non-human primate b. All human ...tissues, secretions, and excretions ...2. Hand Hygiene a. Hands must be decontaminated promptly after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn b. Handwashing with named hospital approved antimicrobial soap and water for at least 15 seconds is required immediately or as soon as feasible after removal of gloves or other PPE ...c. Hands must be decontaminated between tasks and procedures on the same patient ... 1. Gloves a. Whenever contact with blood or other potentially infectious material is reasonably anticipated, PPE must be worn 2. Face Masks and Eye Protection a. Mask and Eye protection or a face shield must be worn to protect mucous membranes of the eyes, nose, and mouth during all procedures/tasks that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions 3. Protective Clothing a. Lab coats, gowns, scrubs, and surgical caps must be worn during a procedure if it can be reasonably anticipated that infectious materials might splash, splatter, or spray."

Open medical record review for patient #11 revealed an 83 year old admitted to the hospital via the emergency department on 11/13/2013 for weakness and abnormal electrocardiogram (EKG). Review revealed a final diagnosis of anemia, upper gastrointestinal bleeding and coagulopathy (condition where the blood has difficulty clotting). Further review revealed the patient had received a total of 7 blood products prior to 11/20/2013.

Observation during tour of the Critical Care Unit on 11/20/2013 at 1102 revealed an 8 bed unit. Further observation of room #281 revealed Patient #11 receiving bedside dialysis. Further observation revealed the nurse was without a face shield and a gown (PPE). Further observation revealed the nurse removed her gloves after touching the dialysis machine (contaminated). Further observation revealed the nurse did not perform hand hygiene before donning another pair of gloves and touching the patient.

Interview during tour with the dialysis nurse for room #281 revealed the nurse did not bring a face shield and gown to the unit. Further interview revealed the nurse forgot to perform hand hygiene prior to donning another pair of gloves. Interview confirmed the nurse failed to follow hospital policy.

Based on review of hospital policy and procedures, medical record reviews and staff interviews, the surgeon failed to complete an immediate operative report including procedure performed, findings, type of anesthesia and/or sign the immediate operative report in 2 of 2 outpatient surgical patients reviewed (# 46 and #47).

The findings include:

Review of the hospital's policy, "Operative Procedures within Medical Record", revised 08/2011, revealed, "...I. Documentation within the medical record. ...f. When a full operative report or other high-risk procedure report cannot be entered immediately into the patient's medical record after the operation or procedure, a progress note is entered in the medical record before the patient is transferred to the next level of care. This progress note includes the name(s) of the primary surgeon(s) and assistant(s), procedures performed and a description of each procedure finding, estimated blood loss, specimens removed, and postoperative diagnosis. ...".

1. Open medical record review on 11/21/2013 revealed a 61 year-old male admitted to the outpatient surgery center on 11/21/2013 for a left carpal tunnel release. Record review revealed the surgical procedure started at 0752, ended at 0804. Record review at 0945 on 11/21/2013 revealed no documentation by the surgeon (Physician A) of a post-operative report or progress note completed immediately after surgery.

Interview on 11/21/2013 at 0948 with administrative surgical staff revealed, "(Physician A) does not write an immediate post-op note. He dictates his notes and they are usually available within 20 minutes". Interview confirmed an immediate post-operative note was not available for Patient #46 at 0945 (41 minutes after surgery completed). Interview confirmed Physician A did not follow hospital policy.

2. Open medical record review on 11/21/2013 revealed a 59 year-old male admitted to the outpatient surgery center on 11/21/2013 for a left carpal tunnel release. Record review revealed the surgical procedure started at 0845, ended at 0859. Record review at 0950 on 11/21/2013 revealed no documentation by the surgeon (Physician A) of a post-operative report or progress note completed immediately after surgery.

Interview on 11/21/2013 at 0948 with administrative surgical staff revealed, "(Physician A) does not write an immediate post-op note. He dictates his notes and they are usually available within 20 minutes". Interview confirmed an immediate post-operative note was not available for Patient #47 at 0955 (56 minutes after surgery completed). Interview confirmed Physician A did not follow hospital policy.