HospitalInspections.org

Based on observation and interview, the hospital failed to maintain adequate facilities for services provided.

Findings:

1. At 12:30 on April 13, 2015, surveyors toured all Obstetrical services areas of the hospital to include the newborn nursery and the Neonatal Intensive Care Unit (NICU).

2. Surveyors observed the newborn nursery.

~ The newborn nursery was located on the 7th floor of the hopital. The newborn nursery was located in 2 rooms (room 744 & room 745). Administrative staff told surveyors room 744 and room 745 were medical surgical patient rooms that had been re-purposed into the newborn nursery. Administrative staff told surveyors room 745 was the newborn nursery procedure room and room 744 was now the newborn nursery.
~Administrative staff told surveyors Obstetrical services and the newborn nursery was moved to the 7th floor in 2013.
~Administrative staff told surveyors that the NICU was moved to the 4th floor where outpatient surgical services was previously located in 2013.

3. Surveyors observed room 744 and room 745. The 2 rooms were connected by a constructed and finished opening in the wall between the 2 rooms.

4. Administrative staff told surveyors that OB services including the newborn nursery would be moving to a newly renovated location in a few weeks.

6. Administrative staff told surveyors the average daily census was 1-2 babies.

7. Room 745, the newborn procedure room did not have adequate counter top workspace and had limiited storage capacity. Room 745 had one infant radiant warmer located in the room.

8. Room 744, the newborn nursery room did not have adequate counter top workspace and had limited storage capacity. Room 744 had two infant radiant warmers located in the room.

Based on hospital document review, observation, and staff interview, the hospital failed to maintain medical equipment at an acceptable level of safety and quality.

Findings:

1. At 12:30 P.M. April 13, 2015, surveyors toured the newborn nursery on the 7th floor of the hospital.

2. Surveyors observed a refrigerator/freezer that was labeled "breast milk only." There was a log on top of the refrigerator/freezer where the staff documented daily temperatures.

3. There was a log kept on daily temperatures of the freezer and there was another log kept on daily temperatures of the refrigerator.

4. The log for the freezer, documented, "...range is 20 C or below...If the recorded temperature is in the shaded zone: this represents an unacceptable temp range. Call maintenance. Note the time the call is made, corrective action must be noted..." The freezer log contained two areas shaded in grey.
One shaded zone on the log documented, "...Too Warm: Take immediate action if the temperature is in the shaded section..." The other shaded zone on the log documented, "...Too Cold: take immediate action if the temperature is in the shaded section..."

5. The freezer log documented temperature ranges in the Too Warm shaded zone on several dates in January, February and March of 2015.

~There were 10 days in the month of January 2015 that the temperature range was in the "Too Warm" range. Five of the 10 days did not contain documentation of corrective actions taken. One day of the 10 days contained documentation that maintenance was notified but there was no documentation of corrective actions taken.

~The freezer log documented temperature ranges in the Too Warm shaded zone on 13 days in February 2015. One of the 13 days contained documentation of corrective actions taken. There was a note on another day that documented a work order had been placed. There was no documentation of any corrective actions taken.

~The freezer log documented temperature ranges in the Too Warm shaded zone on 9 days in March 2015. Only one day contained documentation of maintenance notified but there were no corrective actions noted by maintenance.

6. The refrigerator temperature log documented, "...Range 2-4 degrees C...if the recorded temperature is in the shaded zone: this represents an unacceptable range. Call Maintenance. Note the time the call is made..." The refrigerator log contained two areas shaded in grey. One shaded area on the log documented, "...Too warm: take immediate action if the temperature is in the shaded section..." the other shaded area documented "...Too Cold: take immediate action if the temperature is in the shaded section..."

The refrigerator log documented 1 day in January 2015 in the "Too Cold" shaded area. There was no documentation that maintenance was notified. The refrigerator log documented 6 days in the "Too Warm" shaded area. There was no documentation that maintenance was notified.

The refrigerator log documented 1 day in February 2015 in the "Too Cold" shaded area. There was no documentation that maintenance was notified or any corrective action taken. The log documented 9 days in February 2015 in the "Too Warm" shaded area. There was no documentation that maintenance was notified. Five days contained no documentation of corrective actions taken.

The refrigerator log documented 10 days in March 2015 in the "Too Warm" shaded area. There was no documentation that maintenance was notified.

7. At 12:45 P.M., staff C told surveyors she did not know why maintenance had not been notified on dates the log contained out of range documentation.

Based on policy and procedure review, observations, and staff interviews, the infection control officer failed to ensure there was compliance with all policies, procedures, protocols and maintenance of a sanitary hospital environment.

Findings:
1. On April 13, 2015 at 12:30 p.m., surveyors toured medical/surgical rooms that was converted into the newborn nursery (Room 744) and newborn procedure room (Room 745) and observed:

~Bathroom in the newborn nursery had no soap in the soap dispenser, dark dirt particles in the sink, a bath towel covering the toilet, and the floor was not clean.

~Room 745 was designated as the newborn procedure room off of the newborn nursery.

~Bathroom in the newborn procedure room was used by the hospital staff for toileting needs.

~ Newborn procedure room had filing cabinets, office supplies (which cannot be terminally cleaned), a refrigerator/freezer, supply pyxis (automated dispensing system), and covered supply rack. There was a plastic caddy container that held needles and syringes that was stored on the window sill (supplies/equipment integrity cannot be protected with the change in temperature and direct sunlight) in the procedure room.

~Newborn nursery and newborn procedure room both contained oscillating fans. A Fan Risk Assessment had not been completed for the current location of OB (obstetrical), nursery, and NICU (neonatal intensive care unit) locations.

2. On April 13, 2015 at 1:45 p.m., surveyors toured the NICU (neonatal intensive care unit) and observed:

~Staff B in the NICU assisting Staff A during a PICC (peripherally inserted central catheter) line procedure. Staff B was not wearing a surgical head cover.

~an oscillating fan on high in the NICU during a PICC line procedure.

3. On April 13, 2015 at 1:50 p.m., Staff D told surveyors that anyone in the room during a PICC line procedure should be wearing a surgical head cover and that Staff B was not following hospital policy.

4. On April 14, 2015 at 9:15 a.m., surveyors requested the hospital's PICC line policy and procedure and the use of oscillating fans policy.

5. At 9:30 a.m., Staff D provided a document titled, "Central IV Therapy Management (Short-Term Vascular Access Devices)." The policy documented, "SET UP/ASSISTING WITH INSERTION OF CENTRAL LINES...Assure that all persons in room have on surgical head covers and surgical masks..."

6. At 9:30 a.m., Staff D provided a document titled, "Use and Maintenance of Wall Fans." The policy documented, "...Fans must be turned off in patient rooms during the following procedures:...Central line insertions...Any procedure that causes a break in the skin..."

7. On April 14, 2015 at 9:30 a.m., Staff D told surveyors that the NICU staff was not following the hospital policy on use of wall fans.

8. On April 14, 2015 at 2:15 p.m., Staff E told surveyors that she was not aware that Staff had wall fans on during PICC procedures. Staff E told surveyors that she was not aware that Staff assisting during PICC procedures were not following hospital policy.