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Based on observation, staff interview, and pamphlet review; the facility failed to ensure patients were informed of the State Hotline phone number. This had the potential to affect all patients who present to the hospital or the emergency room for care. The census at the time of the survey was 21.

Findings include:

The emergency department was toured on 01/08/13 at 10:20 AM. The entire emergency department; including the waiting room, triage area, and registration area; lacked signage for patient rights and the State Hotline phone number and hours of operation. This was verified by Staff A at that time. Staff A stated the only location in the facility that the State Hotline phone number was posted was in the maternity unit.

On 10/09/13 at 10:45 AM, Staff E was interviewed. Staff E was assigned to the registration desk in the emergency department at the time of the interview. Staff E stated that after being triaged, all patients were seen by registration and provided with patient rights information and the consent forms were signed at that time. Staff E stated that he/she did not usually work in the emergency department and could not locate the patient rights documents at that time, but that they were the same pamphlets that the main registration office used.

Staff F and G were interviewed at 10:50 AM on 01/09/13 in the main registration area. Staff F stated that on admission to the hospital patients were given the Taking Part in Your Care booklet and the Patient Rights and Responsibilities pamphlet. Patients in the emergency room were given the Patient Rights and Responsibilities pamphlet on admission to the emergency room. The Taking Part in Your Care booklet and the Patient Rights and Responsibilities pamphlet were reviewed and it was noted that the State Hotline phone number was not included in either booklet. Staff G stated that he/she was not aware of any document that contained the State Hotline phone number.

Based on medical record review, policy review, and staff interview the facility failed to use restraints in accordance with the order of the physician. This affected two out of three (Patients #29 and #36) whose medical records were reviewed.
Findings include:
Review of medical record for Patient #36 completed on 01/09/13 revealed a diagnosis of acute pancreatitis and an admission date of 09/24/12. The medical record contained physician orders for restraint usage that had been written within the every 24 hours requirement. However, the physician orders lacked identification of what type of restraint was to be used.
Documentation of the restraint usage revealed bilateral wrist tough cuffs were applied.


The medical record for Patient 29 was reviewed on 01/09/13. The patient was restrained on 12/16/12 with bilateral soft wrist restraints from 8:30 AM through 4:30 PM for pulling out his/her peripheral intravenous access multiple times and removing his/her oxygen multiple times. The physician's order for restraint usage, dated 12/16/12, lacked identification of what type of restraint was to be used.

The Hospital's "Restraint Utilization" policy was reviewed on 01/09/13. The policy lacked direction on what information was required in a physician restraint usage order, except for the length of time the restraint order was valid.

Staff A and B were interviewed on 01/09/13 at 11:40 AM. Staff A and B verified the physicians' restraint usage orders lacked identification of the type of restraint to be used for Patients #29 and #36. Staff B verified there were no additional policies on restraint orders.



31007

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, specifically, to ensure; exit discharges provided a safe access to a paved common way, fire drills were held at varying times for each shift and relative humidity levels were maintained at or above 35% in all operating rooms.
Findings:
Please refer to A710 for the findings.

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association related to ensuring; exit discharges provided a safe access to a paved common way, fire drills were held at varying times for each shift, and relative humidity levels measurements were maintained at or above 35% in all operating rooms.
This had the potential to collectively affect all 21 patients present during the survey.
Findings:
Please refer to the following life safety code violations for the findings;
K-38 Exit discharges in three locations lacked a safe access to a paved public way.
K-50 Fire drills were not conducted at varying times on all three shifts.
K-78 Relative humidity in all three operating rooms were below the required 35%


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Based on observation and staff interview the hospital failed to ensure the professional staff complied with accepted standards of infection control in regard to the use of hand washing hygiene prior to medication administration. This affected one of five patients (Patient #7) who were observed while receiving medication from the professional staff. Upon entrance on 01/07/13, the census was 21 patients.

Findings included:

The medical record for Patient #7 was reviewed 01/07/13 at 3:00 PM. Patient #7 was admitted to the hospital on 12/30/12 with a diagnosis of congestive heart failure exacerbation. This patient was in contact isolation precautions due to a history of methicillin resistant staphylococcus aureus (MRSA). On 01/07/13 at 1:45 PM, an observation was made of Staff D administering medication to Patient #7. Staff C was also present for this observation. Staff D failed to cleanse his/her hands before obtaining the three vials of Lasix (diuretic) from the Pyxis machine (a locked medication dispensing machine). The ordered dose was 60 milligrams (mg), Staff D removed three 20 mg vials to equal the 60 mg dose. Staff D proceeded to draw the medication up into a syringe without cleansing his/her hands. Staff D donned a paper gown and gloves in preparation for entering Patient #7's isolation room without cleansing his/her hands. Staff D administered the medication intravenously then removed his/her gown and gloves, cleansed his/her hands and exited the room. This finding was verified by Staff A and Staff B on 01/07/13 at 4:00 PM.