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Based on observation and interview, the facility failed to ensure consumers entering the emergency department area, namely that of the waiting area, were advised of their rights under Emergency Medical Treatment and Active Labor Act. This has the potential to affect all individuals who come to the emergency department for treatment. Based on medical record review, policy and clinical record review, the facility failed to show evidence that all patients had been notified of their rights to privacy. This affected eleven of twenty sampled inpatients whose medical records were reviewed. Patient numbers (12, 13, 15, 32, 33, 34, 35, 36 , 37, 38 and 39.) The facility failed to protect the patient's personal information for 21 of 21 patients on the medical surgical unit. Patient numbers (7, 11, 13, 15, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65 and 67.) The facility census was 63.

Findings include:

Review of patient's #12, 13, 15, 32, 33, 34, 35, 36, 37, 38 and 39's medical records on 7/06/10, 7/07/10 and 7/8/10 revealed there was no documented evidence on the patient's "Condition of admission" form that the patient had been notified of the details of the facility's "Notice of Privacy Acts". Interview of staff F on 7/09/10 at 10:45 AM revealed the patient's are to initial on the form that they have been notified that the patient's medical information may be released. The Notice of Privacy section on the condition of admission form revealed that by initialing the information they have been notified or can be provided with the facility's Privacy Acts which describe what is included in medical information.

Observation on 7/6/10 at 2:00 PM the facility had all patient's last name (numbers 7, 11, 13, 15, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65 and 67) posted on a large white board on both halls. Review of the facility's policy Obtaining and Complying with Patient Authorizations Directive 009 dated 2/10 Page
1 revealed personal health information includes patient names.


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Findings:

On 07/08/10 at 9:40 A.M., the surveyor and Staff G toured the emergency department. While observing the waiting area, the surveyor was unable to locate notice of the patients' rights under the Emergency Medical Treatment and Active Labor Act. The surveyor also did not observe notice of patients' rights under the Emergency Medical Treatment and Active Labor Act at or near the patient registration area.

During the 07/08/10 at 9:40 A.M. tour, Staff G confirmed the sign was not posted, but had been. She said she wasn't sure when it had been taken down.

During the afternoon of 07/08/10 in an interview, Staff H confirmed that the sign had been taken down. He said that there wasn't a clear policy on who was responsible for ensuring its being posted.

Based on observation and policy review, the facility failed to ensure the safety and privacy for Patient #4, #5, #6, #7, #8, #9, #10, #13, #14, #15, #32, #35, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #68, #69, #70, #71, #72, and #73.

Review of the Hospital's Privacy Directive 009 on 7/7/10 that had been reviewed by the facility on 2/10/10 revealed that personal information that is considered personal health information includes names of patients and is not to be shared without patient authorization. Interview of staff A on 7/7/10 revealed there is no documentation that reveals the patient's had been informed of or given consent for the posting of their names in the hallway.


On 07/07/10 at 9:20 AM it was noted that 27 of the 27 patients admitted on the telemetry and Intensive care unit had their names listed on the two white boards located in the hallway on both sides of the nurses' station. This affected Patient #4, 5, 6, 7, 8, 9, 10, 32, 35, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 68, 69, 70, 71, 72 and 73. This was confirmed with Staff C at 9:25 AM.













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Based on observation and interview, the facility failed to secure the room in which mammography radiological images are kept. The room contained over 1000 files, and affects all patients for whom those files contained their medical information.

Findings:

On 07/08/10 at 11:15 A.M., the surveyor toured the area in which radiology keeps hard copies of mammography imagery. The surveyor approached the door to find it unlocked and unlockable, with only a C-shape handle bolted to it. The surveyor entered the room to find it containing at least 1000 files of radiological images. The surveyor did not observe at any point in the system of hallways leading to said door a locked door leading to the room.

On 07/08/10 at 11:15 A.M. Staff C confirmed the door was unlocked.

Based on review of the medical record and policies and procedures and interviews conducted with family and staff it was determined that the facility failed to ensure that a patient at risk for skin breakdown was turned as policy dictates. This was noted in 1 out of 5 telemetry records reviewed, Patient #6. The current census for the unit is 24 patients. The hospital census is 63.

Findings include:
Patient #6 was admitted on 06/29/10 for a blood clot in the lung. Further testing revealed a cancerous mass in the colon that had spread to the liver. An interview was conducted with Patient #6 ' s family members on 07/07/10 at 10:05 AM. Family discussed concerns regarding Patient #6 ' s care. They stated that prior to Patient #6 ' s placement on comfort care he/she was never repositioned while in bed. The medical record was reviewed for Patient #6 on 07/07/10. There was no documented evidence that Patient #6 was turned and repositioned prior to being placed on comfort care which occurred on 07/04/10. This was confirmed with Staff C on 07/07/10 at 1:35 PM who stated that the policy had not been followed. Staff C stated that Patient #6 scored under a level 3 on the Braden Scale (a tool used to measure the risk for impaired skin integrity) which meant that he/she should have been turned every two hours.

Based on interview and record review, the facility failed to ensure Patient #19 and Patient #20 received intravenous fluids under the order of a physician. The sample of emergency room patients taken was 10 total.

Findings:

The clinical record review for Patient #19 was completed on 07/09/10. The clinical record review revealed Patient #19 was brought to the emergency department on 04/07/10 at 4:06 A.M. by local emergency medical services for intoxication and status-post assault at a local bar. The clinical record review revealed the patient was in the department until 04/07/10 at 8:06 A.M. The clinical record review revealed in that time the patient received 1 liter of intravenous fluid. The clinical record review did not contain a physician's order for the amount and type of intravenous fluid.

On 07/09/10 at 10:45 A.M. in an interview, Staff C confirmed the clinical record for Patient
#19 did not contain a physician's order for the amount and type of intravenous fluid.

The clinical record review for Patient #20 was completed on 07/09/10. The clinical record review revealed Patient #20 was brought to the emergency department on 07/04/10 at 4:34 P.M. by emergency medical services for taking an unknown amount of an unknown type of pills. The clinical record review revealed an emergency medical services run report dated 07/04/10 that stated the patient was alert but lethargic.

The clinical record review revealed the patient had three liters of intravenous fluid from arrival on 07/04/10 at 4:34 P.M. to10:55 P.M. The clinical record review did not contain a physician's order for the type and amount of intravenous fluid the patient was to receive.

On 07/09/10 at 10:45 A.M. in an interview, Staff C confirmed the clinical record did not contain a physician's order for the amount and type of intravenous fluid.

Based upon the observations during the life safety code tour of the hospital on 07/06/10 to 07/09/10 and interview with staff, the hospital failed to meet the requirements of the 2000 Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to the Life Safety Code Survey Report Form for 2000 Existing for Building one of three.


Deficiencies were issued at:

K76 The facility failed to ensure that electrical fixtures in one of one medical gas storage rooms on the obstetrics unit were located equal to or greater than five feet above the floor.
K78 The facility failed to maintain relative humidity equal to or greater than 35 per cent in one of one delivery rooms during the months of January through April, 2010, and in five of five active operating rooms during the months of January through May, 2010.

K130 The facility failed to ensure that smoke detectors in various locations in the building were located where air flow would not prevent operation of the detectors.

Refer to the Life Safety Code Survey Report Form for 2000 new, business for building three of three.

K52 no evidence of inspection of fire alarm system

Based on observation and staff interview the facility failed to maintain supplies, food and equipment in a safe and sanitary manner, and the facility failed to ensure that grab bars that were located in the central showers were secure. This was present in 1 out of 2 central showers toured and had the potential to affect the safety of all 24 patients. The hospital census was 63.
Findings include:

Observation on 7/08/10 with staff A and staff B from 8:15 AM to 9:30 AM revealed the following:

The milk cooler's outer seal was torn and hanging from the door. The fan inside the cooler was soiled with dust. Under the dish machine, was a leaking pipe that had dripped onto the heavily soiled floor and had a thick buildup of dark substance. The insulation surrounding a pipe was torn with insulation product exposed. The cleaning supply cupboard was rusty and had chipped paint. A large fan in the dirty area was covered with black dust and the base was heavily rusted. Within a storage area there was open pancake mix that was not dated. A bag of macaroni was dated 6/7/10 was not sealed tightly and when picked up the macaroni spilled out. The large partially used containers of rosemary and oregano spices were not dated. An unlabeled food product in a large plastic container ( later identified by staff as baking soda ) was not dated. An unlabeled food product in a large plastic container of a food (later identified by staff as graham cracker crumbs) was not dated. A large mixer had rust on the sides and was covered by a large soiled cloth. There were 5 oven mitts on the top part of the mixer that were heavily soiled and stiff. The two tiered oven had red and pink substances on the sides of the oven and the door of the oven. There were gnats flying around the sealed bread bags. A tray of foods like mandarin oranges, meat salad, and a boiled egg that had expired use was sitting on the end of the tray line and was covered in gnats. There was rust on 2 small steam jacket kettles. There was a soiled hotel pan on the clean side of the pan rack. There were gnats flying above the tray line.

All of the findings were confirmed by staff B at 9:25 AM on 7/08/10.



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On 07/06/10 at 3:20 PM, a tour was conducted of the fourth floor. Of the two central showers one out of the two was noted to have 2 loose safety grab bars. The shower located in E446 had two grab bars. The grab bar on the right side was secured by all three screws, but was loose when it was pulled on. The grab bar located on the left side was only secured by 2 out of the 3 screws on each side and was completely loose on the bottom. This was confirmed with Staff C.