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Based on observation, interview, and document review, the facility failed to ensure each door in a rated barrier self closed in accordance with 19.2.2.2.7, NFPA 101, 2012 edition (K223). The facility failed to test emergency lighting in accordance with 7.9 of NFPA 101, 2012 edition (K291). The facility failed to ensure paths of egress were marked in accordance with 7.10 NFPA 101, 2012 edition (K293). The facility failed to ensure its rated barriers protecting hazardous areas were free of penetrations (K321). The facility failed to test fire alarm system in accordance with NFPA 72, 2010 edition, 14.4.5 (K345). The facility failed to comply with table 5.1.1.2 and 5.2.4.1 and table 13.1.1.2 and 13.3.2.1.1. of NFPA 25, 2011 edition and 9.7.2.1, NFPA 101, 2012 edition (K353). The facility failed to ensure fire extinguisher signage complied with 6.1.3.3.2 of NFPA 10, 2010 edition (K355). The facility failed to ensure smoke barriers were free of penetrations (K372). The facility failed to maintain its medical gas system in accordance with 5.1.12.2.6.6 of NFPA 99, 2012 edition (K907). The facility failed to perform preventative maintenance to its generator in accordance with NFPA 110, 2010 edition (K918). The facility failed to assess patient care related electrical equipment in accordance with 10.3 of NFPA 99, 2012 edition (K921).

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 had the potential to affect all patients receiving services from the facility. The facility had a census of five patients at the time of survey.

Findings include:

-K223 Failed to ensure each door in a rated barrier self closed in accordance with 19.2.2.2.7, NFPA 101, 2012 edition.

-K291 Failed test emergency lighting in accordance with 7.9 of NFPA 101, 2012 edition.

-K293 Failed to ensure paths of egress were marked in accordance with 7.10 NFPA 101, 2012 edition.

-K321 Failed to ensure its rated barriers protecting hazardous areas were free of penetrations.

-K345 Failed to test fire alarm system in accordance with NFPA 72, 2010 edition, 14.4.5.

-K353 Failed to comply with table 5.1.1.2 and 5.2.4.1 and table 13.1.1.2 and 13.3.2.1.1. of NFPA 25, 2011 edition and 9.7.2.1, NFPA 101, 2012 edition.

-K355 Failed to ensure fire extinguisher signage complied with 6.1.3.3.2 of NFPA 10, 2010 edition.

-K372 Failed to ensure smoke barriers were free of penetrations.

-K907 Failed to maintain its medical gas system in accordance with 5.1.12.2.6.6 of NFPA 99, 2012 edition.

-K918 Failed to perform preventative maintenance to its generator in accordance with NFPA 110, 2010 edition.

-K921 Failed to assess patient care related electrical equipment in accordance with 10.3 of NFPA 99, 2012 edition.

Based on record review, interview, observation, and policy review, the facility failed to ensure care was provided in accordance with the patient's needs for one of one patients reviewed with a pressure sore that had a moisture barrier applied (Patient #2). The sample size was 30. The patient census was five.

Findings include:

Review of the policy and procedure titled Wound and Skin Care, origination date 08/1986, effective 02/2018, last approved 02/2018 included for nursing to continually aim to maintain skin integrity, tone, turgor and circulation to prevent skin breakdown, injury, and infection. The Braden Scale will be utilized as the tool for predicting the risk of skin breakdown/pressure ulcer development. A patient with a Braden Scale score of less than 18 is considered at risk. Patients with the following characteristics are also considered to be at risk included if the patient is bedridden, incontinent, elderly, and immobile. The definitions of staging on page two of five included for a Stage I non-blanchable erythema of intact skin, erythema (redness) not resolving within thirty minutes of pressure relief. Stage 1 wound care on page three of five included after cleansing apply a barrier cream.

Review of the medical record for Patient #2 revealed the patient was admitted to the in-patient unit on 10/28/18 with a diagnosis of pneumonia. Secondary diagnoses included stroke, hypertension, diabetes and coronary artery disease. Review of the skin assessment dated 10/28/18 included the patient was 72 years old with redness to the coccyx area. Review of the medication list included Calmoseptine (zinc oxide) topical was ordered on 10/28/18 as needed for soiling, moisture, incontinence, Stage I and Stage II pressure ulcers. Review of the plan of care revealed Patient #2 was identified at high risk for skin break down with a Braden Scale score of less than 12. Interventions included reposition/turn patient every two hours if unable to turn self and keep skin clean, dry and moisturized. The medical record lacked any documented evidence of Calmoseptine being applied to the coccyx area since the admission date.

Observation was made of Patient #2's coccyx area on 10/30/18 at 09:50 AM with Staff A and Staff H. Staff H was providing care for Patient #2. Observation was made of Patient #2's coccyx area and it was noted to be reddened. The patient had on an incontinent brief. Staff H stated he/she had just changed the patient's brief.

Interview with Staff H on 10/30/18 at 10:30 AM revealed the staff was respositioning the patient every two hours. Staff H also stated "I do not think the patient has an order for Calmoseptine."

The findings were cofirmed with Staff A in an interview on 10/30/18 at 10:30 AM.

Based on record review and staff interview, the facility failed to ensure physician orders were co-signed within 48 hours according to the policy and procedure and the Medical Staff Bylaws review for two of 30 patient records reviewed (Patient #1 and #4), and the facility failed to ensure medical records were completed after patient discharge as defined in the Medical Staff Bylaws. The patient census was five.

Findings include:

Review of the policy and procedure titled Medical Staff Rules and Regulations revealed on page 10 of 26 that all telephone and verbal orders, with the exception of restraint orders, must be cosigned, dated and timed within 48 hours of giving such order by the ordering physician/practioner.

1. Review of the medical record for Patient #1 revealed he/she was admitted to swing bed status on 10/25/18 at 11:55AM. The physician orders written on 10/25/18 were not co-signed by the ordering physician until 10/30/18.

This finding was confirmed in an interview with Staff A on 10/30/18 at 9:36 AM.

2. Review of the medical record for Patient #4 revealed he/she was admitted to the facility on 10/24/18 at 0655. Physician orders were placed on 10/25/18 by Staff F. The physician orders written on 10/25/18 were not co-signed by the ordering physician until 10/30/18.

This finding was confirmed in an interview with Staff A on 10/30/18 at 11:30 AM.


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3. Review of the facility's Medical Staff Bylaws Policy Staff ID:4989425 on 10/31/18 revealed: "Completion Time Frame. The admitting practitioner shall complete the medical record at the time of the patient's discharge, including progress notes, final diagnosis and discharge summary...; Delinquency. A practitioner will be considered delinquent in completion of his/her medical records if the records are not completed, written or dictated within the period specified in these rules".

Review of the Medical Record Statistics on 10/31/18 revealed the facility's October 2018 medical record delinquency number was 20. An interview with Staff B on 11/01/18 at 10:00 AM confirmed the facility had 20 delinquent medical records according to the most recent statistics.