HospitalInspections.org

Based on interview and record review the governing body failed to appoint a single chief executive officer who is responsible for managing the facilities that are under a single CMS Certification Number (CCN). Findings include:

On 6/22/10 at approximately 0830 during a visit to Campus B it was stated by staff # M that Campus B has their own President and that they are a separate facility from Campus A.

On 6/23/10 at approximately 0900 during the governing body interview when queried about the CEO that was appointed by the governing body to head up both Campus A and Campus B, staff #EE stated "We are not set up that way."

On 6/23/10 at approximately 0915 during the governing body interview staff # FF presented a System Executive Organizational Chart that indicated that four (4) different facilities with three (3) different CMS Certification Numbers all had a Senior Vice President over each facility and all four (4) then respectively report to a Corporate (System) President/Chief Executive Officer.

Based on record review and interview, the facility failed to provide all Medicare patients with the "Important Message from Medicare" document. Findings include:
Review of records on the Psychiatric Unit at Campus B on 06/23/2010, 3 of 3 Medicare patient's (#29, #77 & #78) records did not contain the " Important Message from Medicare."
During interview on 06/23/2010 @ 1300, Employee O confirmed at this time that patient's # 29, #77 and #78 were all medicare recipients, had been admitted for more than 2 days and that the records did not contain the required document "Important Message from Medicare." She went on to say that she was unfamiliar with the document and had not seen it prior to obtaining one today from patient registration.

Based on interview, record review and policy review, the facility failed to provide 4 of 11 patient's ( #84, #85, #86 & #87) with a written response regarding the resolution of a grievance. Findings include:
Meeting with Employee M at Campus B on 06/23/2010 at 1300, she began the interview by stating "I'll just tell you I'm not following the policy." When queried about what she meant by the statement she went on to say that patients had not been sent a letter regarding resolution of their grievance. Review of the files for patients #84, #86 & #87 confirmed that there were no written responses sent to patients in regards to a resolution of the grievance they filed. Employee M was unable to provide any documentation/file regarding the grievance for patient #85.
Review of Detroit Medical Center (DMC) policy on 06/22/2010, Title: Patient &Family Grievance and Complaints Policy No: 1 CLN 033 Effective Date: 07/01/08 reads under Provisions 7. "In matters determined by Patient/Guest Relations (or other appropriate site staff) to be Medical Grievances, including those involving care rendered by a physician, the involved physician management, or facility assigned designee, must send a written response, reviewed by Risk management, to the complainant(s), within 30 days, notifying them of the disposition of their complaint, the name and address of the hospital contact person, the steps taken to review and resolve the complaint and the date of completion."

Based on observation, it was determined that the facility failed to properly protect the privacy of patients who were registered for out patient surgical services in the pre op area on Campus B. Findings include:

During observation on 06/22/10 at 1000 of the pre-op area on Campus B it was determined that the facility posted the patients last name, first initial, age, surgeon's name, and the status of the surgical procedure. Patient names were being utilized and were accessible for public viewing. When the Operating Room Nurse Manager #AA was queried about patient privacy, she indicated that the facility had been posting this identifying information since she had been employed for the facility. The Operating Room Nurse Manager #AA was unable to explain why the monitor was still being used by staff.

Based upon observation, interview, and record review, the facility failed to provide a safe environment for patients in the Hemodialysis Unit of Campus A and the Psychiatric Unit of Campus B.
Findings Include:
On 6/22/10 at 10:45 AM during the tour of the Hemodialysis unit at Campus A, it was discovered that batches of bicarbonate to be used in the dialysis solution are not being recorded when mixed. Standard of Practice ANSI/AAMI RD52:2004 states that bicarbonate solutions shall be used within 24 hours of when mixed. Interview with Clinical Manager III confirmed that there is no mixing log for bicarbonate solutions. Daily log sheets available in the unit did not include bicarbonate mixing records.
On 6/22/10 at 10:45 AM during the tour of the Hemodialysis unit at Campus A, during an interview with the Clinical Manager III, it was discovered that water hardness is checked monthly and documented on the monthly log sheet. Daily log sheets available in the unit did not include hardness checks. Standard of Practice ANSI/AAMI RD52:2004 specifies that hardness shall be tested at the end of each treatment day, and that timers shall be checked at the beginning of each day and interlocked with the RO system.
On 6/24/10 between 11:30 AM and 2:30 PM based upon observation, it was discovered that the cabinet underneath the hand sink in the Psych Unit of Campus B was unlocked. Chemical cleaners were found to be stored in this cabinet unsecured. Additionally, staff food items were found stored in this cabinet. All other cabinets in the room containing activities supplies were observed locked.



27065

Based on observation, interview and policy review, the facility failed to ensure patient safety by properly securing items in two patient care areas and following policies to reduce the risk of infection in three patient areas. Findings include:

On 6/21/10 at at 1120 one crumpled-up mask was observed stored with clean patient protective equipment outside patient #3's room on Campus A. Patient #3's door indicated that contact precautions were in effect. These findings were confirmed by staff member WW.

On 6/21/10 at approximately 1400 one pair of scissors was observed in the medication cart drawer, on the psychiatric unit at Campus B, with whitish substance on the blades. At the same time, one opened suture removal kit package, containing a scissors and tweezers, was observed. At 1440 an unsecured metal grate was observed in the patient court yard on the psychiatric unit at Campus B. These findings were confirmed by the Vice President of Operations/Patient Care Services for Campus B.

Policy 2 IC 033, dated 1/31/07 states:
"Disposable supplies are used according to the manufacturer guidelines and not reused."





28267

On 6/21/2010 at approximately 1045 during the observational tour an IV cart containing intravaneous catheter needles and supplies was found and unattended in patient room 17. In patient rooms (a four bed ward) contained an IV cart that was found unlocked and unattended. Both the IV carts were accessible by patients and/or visitors. These findings were confirmed by staff # F at the time of the findings. Staff # F when queried about the carts being secured stated "the IV carts should be locked at all times unless they are attended by a staff member".



15195

During the observational tour of the 3rd floor postpartum and neonate areas, on 6/21/10 at approximately 1215, an infant old medication cart with neonate intravenous supplies in the utility room was noted to be dirty with brown/orange material. This observation was verified with the Manager Postpartum #J at that time.

Based on interview and record review, the facility failed to obtain an order for restraints from the attending physician for 1 of 3 (#15) patients restrained. Findings include:


Record review of patient #15's open chart revealed that there was an order from the physician ' s assistant for restraints dated 06/20/10 at 0611 for " soft limb X 2 " (restraints). The attending physician failed to complete the restraint order.


Interview with the Vice President of Outpatient Services on 6/24/10 on at 1130, confirmed that the order needed to be co signed by the attending physician and was incomplete for patient #15.

Based on interview and record review the facility failed to ensure the organization of a single hospital-wide nursing service under the direction of one Registered Nurse (RN). Findings include:

On 6/22/10 at approximately 0830 during a visit to Campus B it was stated by staff # M that Campus B has is a separate facility from Campus A. In addition staff # M stated "I am the CNO for this facility and I report to the President."

On 6/23/10 at approximately 1200 upon review of the document titled "Corporate Nursing Organizational Chart" with staff # UU. When staff # UU was queried regarding the set up and reporting structure, she indicated that the corresponding Chief Nursing Officer at Campus A and Campus B report to their President at the respective campus. In addition, the Chief Nursing Officer at Campus A and the one at Campus B report to a corporate Chief Nursing Officer.

Based on record review and interview the facility failed to ensure that 4 of 4 (#31, #39, #45, #83) hard copy medical records were complete, accurate, and legible. Findings include:

On 6/21/10 at approximately 1500 during an observational tour and medical record review of open charts on unit 4-WS (neuorscience) the medical record of patient # 39 consisted of the following incomplete and inaccurate medical records:

The form titled "Resuscitation Designation Order Form" was placed in the patients chart and was not filled out. Staff # Y stated that if this form is not filled out sometimes a note will be in the physician's progress note. After reviewing the physician's progress notes Staff #Y stated that no discussion was noted in the progress notes either.

A form titled "Acknowledgement of Advance Directive for Health Care" was found in patient #39's medical record and was absent of documentation and belonged to patient #45's medical record. This finding was confirmed by staff # Y at the time of the finding.

The medical staff by laws rules and regulations document indicates under section Q titled "Code Status and Advance Directives", "Code status and advance directive, if known, must be designated on all patients when admitted, in accord with DMC policy. In the event of a code change, documentation must be present to indicate the reason for change."


28273

Based on record review and interview the facility failed to ensure that 1 of 4 (#31) hard copy medical record was complete, accurate, and legible. Findings include:

During record review (of expired patient # 31) at Campus A on 06/21/2010 at 1400, a document dated 02/14/2010 titled "Patient Expiration Form" was incomplete. The area for documentation of "Authorization to Release Body and Body Released By" were left blank.
Interview with Employee P at the time of record review, she stated that the document should have been completed by staff when the body was released.

Based on record review and interview the facility failed to ensure that a properly executed informed consent procedure was followed in 3 of 14 (#38, #57, #59) patient's medical records. Findings include:

On 6/21/10 at approximately 1500 during an observational tour and medical record review of open charts on unit 4-WS (neuorscience) the medical record of patient # 38 consisted of a form titled "Consent for Surgery, Invasive and/or Diagnostic Procedures, Anesthesia, and/or Blood Transfusion" which is the form the facility utilized for evidence of the informed consent process contained under the section titled "The procedure(s) is (are): B Sphenoidal. Staff # DD stated that the procedure was the "placement of bilateral sphenoidal electrodes" and that the procedure wasn't written out like it was suppose to be, this finding was also confirmed by Staff # F.

The policy # 1CLN 006 titled "Informed Consent for Medical/Surgical Treatment, and Diagnostic Procedure" does not contain specific instructions to indicate writing out the specific procedure to be performed and consent to be given.

Based on observation, interview and policy review, the facility failed to ensure that medications dispensed to discharged patients were not stored on the medication cart on one unit. Findings include:

Policy 2 MED 300 states: "There must be regular inspection of medications stored in patient care areas of the hospitals and clinics with the purpose of determining proper labeling, product stability, product safety, and proper storage condition." The policy states that a pharmacist or designee is responsible for inspections in all areas were medications are stored.

On 6/21/10 at approximately 1400, inspection of the medication cart on the psychiatric unit on Campus B, revealed medications dispensed to five discharged patients (#66, #67, #68, #69 and #70). The Coordinator of Pharmacy Services at Campus B confirmed these findings and stated that she did not know who was responsible for removing these items from the medication cart. In addition, one Advair Diskus 100/50 with no patient name was noted. These findings were confirmed by the Vice President of Operations/Patient Care Services for Campus B.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon observation and record review, the facility failed to maintain the hospital environment to assure the safety of patients.
Findings include:
On 6/22/10, 6/23/10 and 6/24/10 between the hours of 8:00 AM and 3:00 PM, based upon observation, it was discovered that coffee dispensing machines in patient pantries throughout Campus A are not equipped with proper backflow prevention devices on water inlet lines.
On 6/22/10 between the hours of 9:00 AM and 3:00 PM, it was discovered through observation that weekly testing logs for eyewash stations located in 8 Webber South (8WS) soiled utility room and 6 Webber South Mechanical Room of Campus A are not being completed on a regular basis. Facilities Manager #FFF confirmed that the eyewash station in 8WS is not needed in that location.
On 6/22/10 at 1:50 PM, based upon observation, it was discovered that plastic laminate is damaged at charting stations on 4 Webber South, and at the 4ICU Nurse Station in Campus A.
On 6/22/10 at 2:00 PM, based upon observation, it was discovered that the exhaust in the toilet room in Exam Room 7 and the toilet room adjacent to Exam Room 6 in 3-Labor Reception Center (LRC) at Campus A is not functioning.
On 6/22/10 at 2:30 PM, based upon observation it was discovered that the Respite Nurseries are being used for storage on 2 Webber North of Campus A (Rooms 2235 and 2227). Clinical Manager JJJ stated during interview 6/22/10 at 2:40 PM that nurseries are rarely used because most babies room-in with the mothers, and that Room 2227 is never used for babies, and sometimes room 2235 is used for babies if needed.
On 6/22/10 at 2:15 PM, based upon observation, it was discovered that the ice machine located in the Pantry of Labor and Delivery/LDRP (Campus A) has a drain line for the ice bin that is directly connected to the waste drain.
On 6/23/10 between 8:30 AM and 9:30 AM, based upon observation, it was discovered that the kitchen of Campus A has damage in the following areas: walls at cart washing, walls outside of pot/pan washing, coving tiles at cart storage, coving and floor tiles in walk-in-cooler corridor.
On 6/23/10 at 10:45 AM, based upon observation, it was discovered that walls are damaged in the transportation storage and Environmental Services Equipment Room (Campus A).
On 6/23/10 at 11:00 AM, based upon observation, it was discovered that there is debris accumulation on the floor of the walk in cooler in the central pharmacy of Campus A.
On 6/23/10 at 12:45 PM, based upon observation, the following areas were observed damaged in the Laboratory Department of Campus A: Plastic laminate countertops of HLA, Biochemical genetics, blood bank, specimen processing, stat lab, and flow cytometry. Drywall damage was observed in blood bank (adjacent to tube station) and specimen processing (behind handsink).
On 6/24/10 between 8:00 and 9:00 AM, based upon observation it was discovered that the following areas of the Surgery Department of Campus A are damaged: cabinet and door frame damage throughout cores 1, 2, and 3.
On 6/24/10 between 11:30 AM and 2:30 PM, based upon observation and record review it was discovered that eyewash stations are not being tested on a weekly basis in the following locations of Campus B: Exam room 1 of the emergency department and housekeeping room 1043.
On 6/24/10 between 11:30 AM and 2:30 PM, based upon observation it was discovered that there is the following physical facilities damage in Campus B: holes underneath handsinks in ED exam rooms and ortho unit Clean Utility room; countertop damage in Radiology X-Ray 1 held together with tape; damaged flooring in Pantry of Psych unit; coffee cart damaged in Pantry of Psych Unit; plastic laminate damage at hand sink in lab; countertop backsplash damage at dirty sink in lab; wall damage in main kitchen where papers have been taped to the wall; plastic laminate damage at beverage station in main kitchen.
On 6/24/10 between 11:30 AM and 2:30 PM, based upon observation, debris accumulation was discovered in the following areas of Campus B: behind ice machine of pantry in Psych Unit; in kitchen: underneath crates used for shelving, underneath cookline prep sink on the PVC drain line and flooring; in walk-in-freezer; and in the floor drain at the 3 compartment sink.
On 6/24/10 between 11:30 AM and 2:30 PM, based upon observation it was determined that chemical dispensing units are attached to mop sink faucets in housekeeping rooms (Rooms 1012, 1043 and 1061) throughout Campus B. This set-up results in shut off valves being located downstream of the built in atmospheric vacuum breaker (AVB) subjecting the AVB to constant pressure.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on June 21-24, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated June 24, 2010, for Life Safety Code.

Based on observation and interview the facility failed to ensure that Glucometer test strips and control solutions bottles (supplies) were kept current and not outdated. Findings include:


On tour of the Pre-operative holding area on 06/22/2009 at 1000 on Campus B, it was observed that the glucometer test strips were not dated when they were opened, and the control solutions bottles were outdated on 06/11/10.
Nurse Manager #AA confirmed these findings.

Based upon observation, the facility failed to provide proper lighting in patient care and food preparation areas.
Findings include:
On 6/23/10 between 8:30 AM and 9:30 AM based upon observation it was discovered that the kitchen of Campus A has lighting levels in all walk-in-coolers below the minimum 20 foot-candles of illumination (Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities).
On 6/22/10 at 2:15 PM based upon observation lighting at hand sinks in Rooms 3412 and 3212 of Campus A were recorded at 14 and 20 foot-candles, respectively. This is below the minimum 30 foot-candles of illumination required (Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities).
On 6/23/10 at 11:30 AM based upon observation, lighting levels at handsinks in Diagnostic and Evaluation and Emergency Department South of Campus A are below the 30 foot-candles of illumination required. Lighting levels recorded at 14 foot-candles.
On 6/23/10 at 1:30 PM, based upon observation, the cardiac cath lab 3 scrub sink lighting level was recorded at 35 foot-candles; minimum required level is 75 foot-candles (IESNA Publication CP29).
On 6/24/10 at 9:00 AM, based upon observation it was discovered that the hand sink in the Central Sterile Processing (located in the basement level of Detroit Receiving Hospital) had lighting levels less than the 30 foot-candles minimum required (IESNA Publication CP29).
On 6/24/10 between 11:30 AM and 2:30 PM based upon observation it was discovered that the hand sinks in the cardiac room of the Emergency Department of Campus B were recorded at 14 and 18 foot-candles; lighting levels at the hand sink in the Psych unit Activities room were recorded at 7 foot-candles. (30 foot-candles required, IESNA Publication CP29).

Based upon observation and interview, the facility failed to provide a sanitary environment and avoid sources of transmission in 6 of 6 Endoscopy Procedure Rooms at Campus A, and the kitchen of Campus A and Campus B. This practice could affect all patients of the Endoscopy suite in Campus A, as well as all patients served food from the kitchens of Campus A and Campus B.
Findings Include:
On 6/23/10 at 11:30 AM during the tour of the Endoscopy Decontamination Room, it was discovered that scopes used in procedures are gross cleaned in the procedure room prior to being brought into the decontamination room. Sinks in the Procedure Rooms were observed to have the soap and paper towel dispensers removed.
Interview with Staff # LLL on 6/23/10 at 11:30 AM confirmed that sinks in the Procedure Rooms are no longer used for handwashing, and are dedicated to cleaning of scopes. Staff # LLL stated that staff used a handwashing sink located in an alcove in the corridor for handwashing purposes. Facilities Manager #FFF confirmed that soap and paper towel dispensers were removed to dedicate sinks within the rooms for scope cleaning, and handwashing sink in the corridor was installed for staff in this area.

On 6/23/10 between 8:30 AM and 9:30 AM, based upon observation, it was determined that a drain fly infestation is present in the dishmachine area and cart washing area of the kitchen of Campus A. Drain flies were observed flying around in these areas. Bio-film accumulation was observed in floor drains in these areas, which are breeding grounds for these flies.
On 6/23/10 between 8:30 AM and 9:30 AM, based upon observation, a food preparation employee in the kitchen of Campus A was observed adjusting their hair net and continuing food preparation activities without performing hand hygiene. General Manager KKK addressed the employee, and the employee washed hands immediately.

On 6/24/10 between 1:50 PM and 2:30 PM, based upon observation a dishwashing employee at Campus B was observed handling dirty dishes and clean dishes without handwashing in between tasks.

Based on records reviewed and interview the agency failed to follow their pre-anesthesia policy for 1 of 2 (patient # 50) records reviewed. Findings include:

During record review on 06/22/10 at Campus B, it was revealed that in the pre-op holding area patient # 50 ' s chart was reviewed. The anesthesiologist had pre- signed the " I was present for induction " area on the form titled " Anesthesia Record " when the patient hadn ' t even been back to surgery. The " Anesthesia Record " form did not contain a patient name, date, or any other identifiers.
This was confirmed by the nurse administrator of Campus B on 06/22/10 at 1100.

Based on records reviewed and interview the facility failed to ensure a post anesthesia evaluation had been documented within 48 hours after surgery for 1 of 13(patient # 55) records reviewed. Findings include;

MR #55: The patient had surgery on 06/02/10. During the review of the clinical record on 06/22/09, it was noted a 48 hour post anesthesia evaluation had not been completed. Request for the nursing unit ' s clinical supervisor to look for the presence of the post anesthesia evaluation on the clinical record produced no document confirming such.

The findings were discussed with the hospitals leadership team during the exit conference on 06/22/09 at campus B.

Based on record review and interview the facility failed to meet the patient's pain and vital sign needs in the Emergency Department at Campus B. Findings include:

On 6/22/10 at approximately 0930 during an observational tour and open medical record review at Campus B emergency department the following 3 out of 4 patients (#41, #42, #43) pain needs were not met:

Patient #41 came into the ED with a left little finger injury. A thorough pain assessment was not completed but there was documentation that her finger was "aching". No pain medication was administered in the emergency department or no reassessment of pain prior to discharge.

Patient #42 came into the ED with a complaint of chest pain and left arm pain. The patient was admitted into the ED at 1357 and his pain was assessed, the patient rated his pain a 5 out of 10. The patient was then discharged at 1543 with no reassessment of pain and no medication was administered to the patient for pain during his admission.

Patient #43 came into the ED with a complaint of acute back pain. The patient's pain was assessed upon admission into the ED at 2257 and had rated her pain as a 7 out of 10 then her pain was reassessed again at 2312 and the patient rated her pain as a 5 out of 10. The patient was discharged from the emergency department within 22 minutes and no documentation that the patient's complaint of pain was addressed.

On 6/23/10 at approximately 1015 upon review of the facility policy and procedure titled "Pain Management" Policy No. 1 CLN 043 under the section titled Policy has documented "All patients will have their pain assessed and managed."

On 6/22/10 at approximately 0930 during an observational tour and open medical record review at Campus B emergency department the following 2 of 2 (#42, #44) out of a total sample of 4 emergency department patients vital signs were not taken within one hour of their discharge as follows:

Patient #42 was admitted into the Emergency Department at 1357 and discharged at 1543. The only set of vital signs documented was at 1357.

Patient #44 was admitted into the Emergency Department at 2037 and discharged at 2245. The only set of vital signs documented was at 2041.

On 6/23/10 at approximately 1015 upon review of a facility policy and procedure titled "Patient Assessment, Documentation/Data Collecting" has documented under the section Provision the following: number 4 - "Vital signs may include temperature, respiratory rate, pulse, blood pressure, pain, Glasgow Coma Score (GCS) and Capillary Blood Glucose." and number 5. stated "All patients discharged from the emergency department must have vital signs taken within one hour prior to discharge, transfer, or admission.

The above findings were witnessed and confirmed at the times posted above by staff # M.