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Based on observation, interview and policy review, the facility failed to maintain the confidentially of patient record information and provide safeguards against unauthorized use as evidenced by radiology films stored in an unlocked cabinet. This had the potential to affect all patients who receive radiology services at the facility. The facility census was 16.

Findings include:

1. A tour of the respiratory overflow storage room was completed on 07/31/13 at 11:50 AM. Electroencephalography results (the recording of electrical activity of the brain films) from patients tested at the facility were observed in an unlocked cabinet.
The findings were shared with Staff #1 on 08/01/13 and confirmed. On 07/30/13 at 8:02 AM, the facility's "Records Management" policy was reviewed. The policy stated chart storage sites were to be secure locations that safeguard the records from unauthorized use.

Based on observation of the facility, review of facility documentation and staff interview and verification, during the life safety code inspection, it was determined the facility failed to ensure it was maintained in a manner safe from fire. The facility failed to: to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating and that in sprinkler buildings, partitions were required to resist the passage of smoke; to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes; that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Windows were to be protected by fire-rated glazing or by wired glass panels and steel frames.

The facility also failed to ensure; one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas and that when the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted.

The facility failed to ensure that; emergency lighting of at least 1½ hour duration was provided in accordance with 7.9. with regards to monthly and yearly testing, that all required smoke detectors, including those activating door hold-open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications, that required automatic sprinkler systems are continuously maintained in reliable operating condition, that heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications.

The facility failed to ensure; laundry chutes were provided with automatic extinguishing protection in accordance with 9.7., linen gravity chutes were to be limited access so that they could be used only by authorized personnel and the door at the chute discharge was self-closing, that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. ; that generators were exercised under load for 30 minutes per month in accordance with NFPA 99.

The facility failed to ensure that where a required automatic sprinkler system and /or a required fire alarm system is out of service for more than 4 hours in a 24-hour period, an approved fire watch system was provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service.

The cumulative effect of there systemic practices resulted in the facility's inability to ensure that all patients recieving care in a safe enviornment.

Based on facility observation, review of facility documentation and staff interview during the life safety code inspection, it was determined the facility was not maintained in a manner safe from fire. This had the potential to affect all patients, visitors and staff members. The facility had a census of 16 patients at the time of the survey.

Findings included:

1. The facility failed to ensure that corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating. In sprinkler buildings, partitions are only required to resist the passage of smoke. In non-sprinkler buildings, walls properly extend above the ceiling. (K17)

2. The facility failed to ensure doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas were substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. (K18)

3. The facility failed to ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Windows were to be protected by fire-rated glazing or by wired glass panels and steel frames. (K25)

4. The facility failed to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option is used, the areas were to be separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. (K29)

5. The facility failed to ensure emergency lighting of at least 1½ hour duration was provided in accordance with 7.9. with regards to monthly and yearly testing. (K46)

6. The facility failed to ensure all required smoke detectors, including those activating door hold-open devices, were approved, maintained, inspected and tested in accordance with the manufacturer's specifications. (K54)

7. The facility failed to ensure required automatic sprinkler systems are continuously maintained in reliable operating condition. (K62)

8. The facility failed to ensure heating, ventilating, and air conditioning comply with the provisions of section 9.2 and were installed in accordance with the manufacturer's specifications.(K67)

9. The facility failed to ensure laundry chutes were provided with automatic extinguishing protection in accordance with 9.7., linen gravity chutes were to be limited access so that they could be used only by authorized personnel and the door at the chute discharge was self-closing.(K71)

10. The facility failed to ensure that smoke detectors in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors. The requirement is located in the National Fire Protection Association (NFPA) 72, National Fire Alarm Code,1999 Edition, Chapter 2-3.5.1* with the specific information for the placement of smoke detectors addressed at A-2-3.5.1. (K130)

11. The facility failed to ensure generators were exercised under load for 30 minutes per month in accordance with NFPA 99. (K144)

12. The facility failed to ensure that where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, an approved fire watch system was provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. (K154)

13. The facility failed to ensure that where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, an approved fire watch was provided for all parties left unprotected by the shutdown until the fire alarm system was returned to service. (K155)

Please see the Life Safety Code report for more specific detail.

Based on observation, interview, job description review and policy review, the facility failed to ensure drugs and biologicals were appropriately stored in secure areas and failed to ensure outdated or otherwise unusable drugs were not available for patient use. This had the potential to affect all patients who receive treatment at the facility.
Findings include:
1. Observation of the clean supply room on the short hall of the medical surgical unit was completed on 07/29/13 at 1:09 PM. There were 15 five milliliter containers of 0.9% Sodium Chloride Inhalation Solution lot # U-122 which had an expiration date of 04/2011.

2. A tour of the intensive care unit was completed on 07/29/13 at 2:00 PM. One arterial blood gas kit lot # 185633-4 was observed hanging on a wall in room two with an expiration date of 06/2013. Two sterile, water-soluble lubricating jelly packs lot # 5L04 were observed hanging in room two with an expiration date of 11/2007.
These findings were shared with Staff #1 on 07/29/13 at 1:09 PM and confirmed.
The facility's medical/surgical registered nurse job description was reviewed on 08/01/13 at 9:22 AM. The document stated registered nurses are responsible for checking supplies for expired products and disposing of the expired products properly.

3. A tour of the materials management room was completed on 07/31/13 at 8:40 AM. There were boxes of sodium chloride, sodium chloride with potassium, sodium chloride with dextrose and lactated ringers intravenous fluids stored in the area. The door to the materials management room (supply room) was not locked.
These findings were observed with Staff #2 and confirmed. On 08/01/13, Staff #9, a Pharmacist stated the intravenous solutions should be in a locked area.

On 08/01/13, the facility's Materials Management policy was reviewed. The policy stated there will be no storage of pharmaceuticals in the supply room.
The facility's Security Incident Reports were reviewed on 08/01/13 at 11:32 AM. There was documentation of the supply room doors being left unlocked on 02/06/13, 03/09/13 and 05/14/13. Review of a security incident report dated 03/23/13, the back door of the pharmacy was found unlocked.

4. A tour of the respiratory overflow supply room was completed on 07/31/13. There were five boxes of syringe aspiration kits lot # 042130009 observed with an expiration date of 10/2011. The findings were shared with Staff #2 and confirmed on 07/31/13.

5. A tour of the radiology department was completed on 07/30/13. The ultrasound room storage cabinet had a bottle of Isopropyl Rubbing Alcohol 70% lot # F9206 with an expiration date of 06/2009. The cabinet had a bottle of Cidex (disinfectant) test strips lot # 021281 with an expiration date of 08/2012. There was a box of E-Z Lubricating Jelly 0.1 ounce packettes lot # 1116 with an expiration date of 04/2013. A box of providone-iodine swab sticks lot # 804014749 had an expiration date of 10/2011. There were two Aquaflex ultrasound gel pads lot # C970 with an expiration date of 03/2012.
On 07/30/13, these findings were shared with Staff #10 and confirmed.

6. A tour of the facility's laboratory department was completed on 07/30/13 at 9:35 AM. The lab draw room one had five Glucose Tolerance Test beverages lot # 983171 in the refrigerator with an expiration date of 12/2012.
These findings were shared with Staff #11, a phlebotomist, and confirmed at the time of discovery.

Based on observation, policy review and staff interview the facility failed to ensure infection control measures were followed in the area of contact isolation. The facility census was 16. This has the potential to affect any patient receiving care at the facility.

Findings include:

1. Observation during tour of the facility on 07/29/13 from 1:55 PM revealed in the Intensive Care Unit an isolation unit was set up for the patient in room # 3 (Patient #17). The isolation was in place for antibiotic resistant infection history of the patient. At 1:55 PM the patient and two visitors were in the isolated patient's room and did not have protective equipment on. One of the visitors was in the patient's bed with the patient. The nurse (#3) entered Patient #17's room without protective equipment on and his/her leg was touching the patient's bed. The nurse did not wash her hands after leaving the patient area and walked back to the nursing station. Interview of the nurse #3 at 2:00 PM confirmed he/she did not wash his/her hands after being in Patient #17's room.

The contact isolation policy calls for offering visitors protective equipment and, for staff to wear protective equipment when in the patient's room and to wash hands with an anti-microbial agent after leaving the isolated patient's room.

Interview of Staff #1 on 07/31/13 at 3:00 PM revealed isolation procedures are to be followed until the patient leaves the hospital.

2. Observation of the biohazard room on 07/29/13 at 1:00 PM revealed it was located in the short hall on the first floor medical surgical in-patient area in a small room directly behind the clean equipment storage room. In the identified "clean" equipment area there was a bladder scanner, a walker, three oxygen tanks and two linen bags. The linen bags had used linen within them. In order to remove biohazard materials out of the room staff had to go through the small clean storage area, therefore potentially contaminating the clean items stored. The dirty linens were stored in the clean area which could contaminate the clean patient care items. This was confirmed by Staff #1 on 07/29/13 at 1:00 PM

Based on record review, policy review and staff interview the facility failed to complete an initial assessment of three of three patients identified by staff as having documented pressure areas. (Patient's #1, #18 and #19) The sample size was 28 patient medical records. The facility census was 16.

Findings include:

1. Review of the medical record of Patient #1 on 07/30/13 revealed this patient was admitted to the hospital on 03/26/13 with a documented stage I pressure sore on the tailbone area. There was no measurement of the identified stage I pressure area.
Review of the facility's policy call "Wound Assessment" revealed that wounds must be measured on admission.
Interview of Staff #1 on 07/30/13 at 4:07 PM confirmed this finding.


2. Review of the medical record of Patient #18 on 07/30/13 revealed this patient was admitted to the hospital on 05/17/13 with a diagnosis of Sacral Decubitus (pressure area). The admission nursing assessment identified a stage I pressure area on the patient's tailbone area. There was no documented measurement of the identified stage I pressure area.
Review of the facility's policy call "Wound Assessment" revealed that wounds must be measured on admission.
Interview of Staff #1 on 07/30/13 at 4:07 PM confirmed this finding.


3. Review of medical record of Patient #19 on 07/30/13 revealed this patient was admitted to the hospital on 02/01/13 and was assessed as being bedfast. The initial nursing assessment described the patient as having a blackened stage II pressure sore on the right lateral ankle. The assessment did not include whether the patient was able to turn him/herself while in bed. There was no documented evidence this patient was being assisted in turning in bed to alleviate pressure from the right ankle.
Interview of Staff #1 on 07/30/13 at 4:07 PM confirmed this finding.

Based on interview and medical record review, the facility failed to ensure a physician's order was obtained before nursing catheterized Patient #3, and failed to perform a detailed nursing assessment of Patient #10's anxiety complaint. The sample size was 28 patients, the census was 16 patients.
Findings:
1. The medical record review for Patient #3 was completed on 07/31/13. The medical record revealed the patient was triaged on 07/06/13 at 3:36 PM with a chief complaint of abdominal pain and dysuria (pain with urination). The medical record revealed a nursing note dated 07/06/13 at 5:21 PM that stated the patient was straight catheterized for a urine specimen. The medical record did not reveal a physician's order for the patient to be straight catheterized for a urine specimen. An undated and untimed physician's assessment revealed the patient was alert and oriented. On 07/29/13 at 3:40 PM Staff #1 confirmed the finding.
2. The medical record review for Patient #10 was completed on 07/31/13. The medical record revealed the patient was triaged on 05/09/13 at 5:37 AM for a chief complaint of anxiety. Review of the physician's record dated 05/09/13 at 5:35 AM stated the patient was complaining of a panic attack that started 05/08/13 and he/she was unable to sleep. The medical record did not reveal any nursing assessment that stated what the patient's precipitating factors were, nor did it reveal where nursing assessed the patient's anxiety prior to discharge. On 07/30/13 at 11:00 AM in an interview, Staff #1 confirmed the finding.

Based on medical record review and staff interview, the facility failed to ensure physician's orders were documented and signed by an authorized physician according to federal requirements for three patients (Patient #12, #14 and #28) of 28 sampled medical records reviewed. This had the potential to affect all patients who receive treatment at the facility. The facility census was 16.

Findings include:

1. The medical record review for Patient #12 was completed on 07/30/13. The record contained orders written by a registered nurse for Xarelto 10 milligrams orally, physical therapy, bed side commode and a wheeled walker. The record did not specify whether the order was a telephone or verbal order. The registered nurse did not document the order was repeated back to the prescribing practitioner. The orders did not have a time documented.

2. The medical record review for Patient #14 was completed on 07/30/13. The record contained telephone orders for Xarelto (blood thinner) 10 milligrams orally, bed side commode and a roller walker. The record did not contain evidence the registered nurse had repeated the telephone orders back to the prescribing physician. The orders did not contain a date or time.

3. The medical record review for Patient #28 was completed on 07/31/13. The record contained telephone orders written by a registered nurse for Xarelto 10 milligrams orally, a bed side commode and a roller walker. The record did not contain evidence the registered nurse had repeated the telephone orders back to the prescribing physician. The orders did not have a date or time documented.
The above findings were reviewed with Staff #2 on 07/31/13 and confirmed.

Based on interview and medical record review, the facility failed to ensure each record completely documented all orders and test results. This affected two of 28 sampled patients, (Patient's #7 and #8). The census was 16 patients.

Findings include:

1. The medical record review for Patient #7 was completed on 07/31/13. The medical record revealed patient presented to the emergency department on 07/18/13 at 4:42 P.M. with a chief complaint of shortness of breath. The medical record revealed a physician's order dated 07/18/13 at 4:52 P.M. for cardiac monitoring. The medical record did not reveal an initial rhythm strip. The medical record review revealed a nursing note dated 07/31/13 at 6:09 P.M. that stated the patient was in atrial fibrillation. The medical record did not reveal a rhythm strip demonstrating the change in the patient's rhythm. On 07/30/13 at 9:30 A.M. in an interview, Staff #1 confirmed rhythm strips had not been posted.

2. The medical record review for Patient #8 was completed on 07/31/13. The medical record revealed the patient was triaged on 07/10/13 at 2:21 P.M. with a chief complaint of left ankle pain. The medical record revealed on 07/10/13 at 3:31 P.M. the patient was auscultated for expiratory wheezes, and was given a hand held nebulizer. The medical record did not reveal a physician's order. On 07/30/13 at 10:00 A.M. in an interview Staff #12 stated Patient #8's physician had ordered the hand held nebulizer but that pharmacy had canceled it because it appeared on the medication administration record. He/she then stated it should have been under respiratory.

Based on staff interview, policy review, and medical record review, the facility failed to have two of five sampled surgical patients have their consents completed with a physician's signature (Patient #24 and #26), failed to have three of five sampled surgical patients' records have a date and time of when a timeout occurred (Patient #23, #24, and #25), and failed to have four of nine sampled emergency department patients have the physician entry with a date and/or time. (Patient #3, #5, #11, and #18) The census was 16 patients.

Findings include:

1. The medical record review for Patient #3 was completed on 07/31/13. The medical record revealed the patient came to the emergency department's triage on 07/06/13 at 3:36 P.M. for a chief complaint of abdominal pain. Although the medical record revealed a completed assessment on the emergency physician's record, the physician had neither dated or timed when the examination. On 07/29/13 at 3:45 PM in an interview, Staff #1, the Director of Nursing confirmed the assessment did not have a date or time.

2. The medical record review for Patient #18 was completed on 07/31/13. The medical record review revealed the patient came to the emergency department on 07/10/13 at 2:21 P.M. for a complaint of left foot ankle pain. Although the medical record review revealed a completed assessment on the emergency physician's record, the physician had neither dated or timed the examination.

3. The medical record review for Patient #5 was completed on 07/31/13. The medical record revealed the patient came to the emergency department on 07/11/13 at 3:56 PM with a chief complaint of left shoulder pain following a motorcycle accident the night before. Although the medical record review revealed a completed assessment on the emergency physician's record, the physician had neither dated or timed the examination.

4. The medical record review for Patient #11 was completed on 07/31/13. The medical record review revealed the patient came to the emergency department on 05/25/13 at 1:07 PM with a chief complaint of needing someone to talk to because he/she was having suicidal thoughts with taking too many medications. Although the medical record revealed a completed assessment on the emergency physician's record dated for 05/25/13, but the physician had not timed the assessment.
On 05/30/13 at 12:00 P.M. in an interview, Staff #1 confirmed the findings for Patient #3, #5, #11, and #18.

5. The medical record review for Patient #23 was completed on 07/31/13. The medical record revealed the patient had surgery on 07/09/13 for total hip replacement arthroplasty. The medical record did confirm a timeout occurred, but did not show a date and time for the time out.

6. The medical record review for Patient #24 was completed on 07/31/13. The medical record revealed the patient had surgery on 07/12/13 for left ankle hardware removal. The medical record did confirm a timeout occurred, but the review did not show a date and time for the time out. The medical record for Patient #24 revealed an informed consent signed on 07/12/13 at 6:45 A.M. by the patient. The informed consent was not signed by the physician informant.

7. The medical record review for Patient #25 was completed on 07/31/13. The medical record revealed the patient had surgery on 07/26/13 for a diagnosis of open reduction and internal fixation of the left humerous. The medical record did confirm a timeout occurred, but did not show a date and time for the time out.

8. The medical record review for Patient #26 was completed on 07/31/13. The medical record revealed the patient had surgery on 06/26/13 on the right ankle for a closed reduction. The medical record did confirm a timeout occurred, but did not show a date and time for the time out. The medical record revealed the dictation for the surgery was done on 07/11/13.
On 07/30/13 at 3:55 P.M. in an interview, Staff #8 confirmed these findings.

9. The medical record review for Patient #26 was completed on 07/31/13. The medical record revealed on 06/26/13 the patient had surgery on his/her right ankle. The medical record revealed an informed consent signed on 06/26/13 at 10:17 A.M. by the patient's closest relative. Review of the informed consent revealed it was not signed by the physician.
On 07/30/13 at 3:00 P.M. in an interview, Staff #8 confirmed the findings.

Review of the facility's policy, "Obtaining Consent for Treatment and/or Surgery," last revised on 03/13, revealed the consent form needed to be filled out completely.

Based on observation, interview and policy review, the facility failed to maintain the confidentially of patient record information and provide safeguards against unauthorized use as evidenced by radiology films stored in an unlocked cabinet. This had the potential to affect all patients who receive radiology services at the facility. The facility census was 16.
Findings include:
1. A tour of the respiratory overflow storage room was completed on 07/31/13 at 11:50 AM. Electroencephalography results (the recording of electrical activity of the brain films) from patients tested at the facility were observed in an unlocked cabinet.
The findings were shared with Staff #1 on 08/01/13 and confirmed.
On 07/30/13 at 8:02 AM, the facility's "Records Management" policy was reviewed. The policy stated chart storage sites were to be secure locations that safeguard the records from unauthorized use.