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Based on record review and staff interviews during the Title 18 Validation Survey, it was determined that the facility 1) failed to ensure that three (3) patients (#83, #85 and #86) or their designated representative received the standardized IM ("Important Medicare Notice") within two (2) days of admission and 2) failed to ensure that nine (9) patients or their designated representative out of a sample of ten (10) patientss received the required standardized IM notice on admission and prior to discharge (Patients #12, #13, #14, #16, #17, #43, #83, #85 and #86).

Findings:

1) Review of the record for Patients #83, #85 and #86 revealed that the patients' IM form was not signed by the patient or patient representative within two (2) days of admission.

2) Review of the record for Patients #12, #13, #14, #16, #17, #43, #83, #85 and #86 revealed no documented evidence that these patients or their designated representative received the required standardized IM notice prior to discharge.

This finding was confirmed with the Assistant Director of Care Management and Performance Improvement on 7/13/10 at 10:30AM.
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Based on record review and staff interviews during the Title 18 Validation Survey, it was determined that the facility did not ensure that the physician documented the complete hemodialysis orders for two (2) of two (2) acute dialysis patients receiving inpatient hemodialysis (Patients #1 and #2).

Findings:

1) Observation on 7/7/10 revealed that Patient #1 was receiving hemodialysis treatment in the Acute Dialysis Unit.

Review of the record revealed that the patient was admitted to the hospital's Psychiatric Unit. The physician's order sheet dated 7/7/10 documented to dialyze the patient for three (3) hours with a 2K (potassium) dialysate bath. The order did not specify the blood flow rate and ultrafiltration rate which must be prescribed by the physician.

The Registered Nurse providing treatment to the patient was interviewed on 7/7/10 at 2:30PM and stated that she knew what treatment to give to the patient by looking at the previous treatment sheet.

2) Patient #2 was admitted to the hospital on 6/21/10 with diagnoses including Acute Renal Failure, Hyperkalemia and Anemia.

Review of the record revealed that the physician's orders on 6/22/10 at 8:00AM and 3:00PM documented for the patient to receive daily hemodialysis for four (4) hours using a 2K dialysate bath. The orders did not specify the blood flow rate and ultrafiltration rate which is required as part of the hemodialysis prescription for the patient and must be prescribed by the physician.

Review of the acute hemodialysis flow sheets revealed that the patient received hemodialysis treatments daily from 6/22/10 - 6/24/10, then every two (2) days until 7/7/10. There was no documented evidence that there was a physician's order for this change in schedule.

The Unit Manager was interviewed on 7/8/10 at 1:20PM. She acknowledged that the orders were incomplete and stated that they do have standing physician's order sheets which should be utilized by the physicians.
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Based on record review and staff interviews during the Title 18 Validation Survey the facility 1) failed to ensure the informed consent form documented the time the informed consent was signed by the patient or the patient's legal representative for five (5) of nine (9) records reviewed (Patients #13, #43, #52, #53 and #60) and 2) failed to insure the Informed Consent policy and procedure included documenting the time the informed consent was signed by the patient or the patient's legal representative.

Findings:

1) Review of the medical records for Patients #13, #43, #52, #53 and #60 revealed the patients' "Consent For Surgery, Diagnostic/Therapeutic Procedures, Anesthetics And Other Medical Services" did not document the time the informed consent was signed by the patient or the patient's legal representative.

This was confirmed with the facility's staff during the onsite visit.

2) Review of the policy and procedure entitled "Informed Consent dated 4/19/10, revealed the policy and procedure did not include the informed consent must document the time the consent form is signed by the patient or the patient's legal representative.

This was confirmed with the facility's staff during the onsite visit.
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Based on observation and staff interviews during the Title 18 Validation Survey, it was determined that the facility did not ensure that drugs stored for patients' use on two (2) of seventeen (17) units reviewed were within manufacturer's expiration guidelines.

Findings:

1) A review of the Medication Room during the tour of Unit 2 South conducted on 7/7/10 revealed that nine (9) carpuljets of 60 mg/ml Sodium Luminal were expired 6/1/10.

The covering Unit Manager who was present at the time of this observation, removed this medication so that it could be sent back to pharmacy. She revealed that the nursing staff is responsible for checking for expired medications when they do their daily narcotic counts.

2) A review of the anesthesia cart during the tour of the Labor and Delivery Unit on 7/9/10 revealed three (3) bottles of Lidocaine with 2% Epinephrine were expired on 7/1/10 and one (1) 600 mg/20 ml vial of Chloroprocaine was expired June 2010.

The Anesthesiologist present at the time of this observation revealed that the anesthesia cart is maintained by the Anesthesia Technician who is also responsible for checking the expiration dates of these medications.
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Based on observations and staff interviews, the facility's Director of Food Services did not ensure that kitchen sanitation standards were adhered to at all times.

Findings:

a) On 7/8/10 at 8:45AM, a heavy build-up of dust was found on the housing of the blower unit in the kitchen "Jell-O" walk-in storage cooler. As per concurrent interview with the facility's Director of Dietary Services, she would have this area cleaned as soon as possible.

b) Food contact surfaces on dietary equipment were not maintained in a clean and sanitary condition. On 7/8/10 at 8:47AM, a heavy build up of dried, encrusted food residues was noted on the food contact surfaces of a Hobart brand chopper/grinding machine in the kitchen. Concurrent interview with the facility's Director of Food Services indicated the machine would be immediately cleaned.

c) On 7/8/10 at 8:50AM, a heavy build-up of dust was found on the blower unit fan guards in the kitchen "Vegetable" walk-in storage cooler. As per concurrent interview with the facility's Director of Dietary Services, she would have this area cleaned as soon as possible.

d) On 7/8/10 at 8:52AM, a heavy build-up of dust was found on the housing of the air curtain blower unit outside the entrance to the kitchen "Vegetable" walk-in storage cooler. As per concurrent interview with the facility's Director of Dietary Services, she would have this area cleaned as soon as possible.

e) Food contact surfaces and non-food contact surfaces on dietary equipment were not maintained in a clean and sanitary condition. On 7/8/10 at 8:51AM, a build up of dried, encrusted food residue was noted on the food and non-food contact surfaces of a Globe brand slicing machine in the kitchen. As per concurrent interview with the facility's Director of Food Services, the machine would be immediately cleaned.

f) On the morning of 7/8/10, several floor tiles and floor/wall juncture (coving) tiles were found to be in disrepair/damaged (chipped, cracked, or had pieces that had broken off). As per concurrent interview with the facility's Director of Engineering, he would have the damaged tiles repaired or replaced.

g) On the morning of 7/8/10, a slight to moderate build-up of dust was found on ceiling tiles and along ceiling tile/wall junctures in the kitchen area, particularly near ceiling ventilation registers. As per concurrent interview with the facility's Director of Food Services, she would have the ceiling cleaned immediately.

h) On 7/8/10 at 9:00AM, a metal pot scraper was found to be improperly stored in the crevice between a three (3) compartment ware wash sink and a wall in the kitchen. The facility's Director of Food Services took immediate corrective action by removing the pot scraper and having it cleaned. She said that she would ensure that the pot scraper is appropriately stored in the future.

i) On 7/8/10 at 9:06AM, two (2) ceiling-mounted fluorescent light fixtures in the kitchen Cart Wash Area were found to lack shatterproof shields or other effective means to protect them from damage. As per concurrent interview with the facility's Director of Engineering, he would have shatterproof shields or other protective covers installed.

Food and Drug Administration (FDA) Food Code
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1) Based on observations, floor and wall surfaces and their appurtenances in the first and third floor psychiatric units were not maintained clean and in good repair.

Findings:

a) On 7/8/10 at 8:36AM, two (2) cracked worn floor tiles were noted in the vicinity of the entrance to the 3 East ADA Shower Room.

b) On the morning of 7/8/10 it was noted that two (2) of the four (4) wall surfaces in the 3 East "Small TV Lounge" were marked and marred. In addition walls in the entrance alcove to Rooms #342 - #343 were marked and marred.

c) On 7/8/10 at 1:32PM, it was noted that the rear wall of the 1 North Activity Room was marked and marred. In addition, there was some graffiti scrawled on the wall.

d) On 7/8/2010 at 1:35PM, it was noted that walls in patient Rooms #166 and #163 on 1 North were marked and marred. In addition, there was a three (3) inch x four (4) inch hole in the wall near a baseboard in Room #163.

e) On 7/8/10 at 1:35PM, it was noted that a twenty (20) square foot section of the floor in the 1 North dining room/cafeteria was marked and marred. In addition, a one (1) inch long crack was noted in some corner guard material that was applied to a column in the room. The cracked material had a sharp edge and presented a safety hazard.

f) On 7/8/10 at 1:40PM, it was noted that the painted finish on the room side surface of the doors to the 1 North dining room/cafeteria was damaged. The painted doors had large areas where the paint had chipped off.

42CFR: 482.41(a)


2) Based on observations, doors in the 1st floor Operating Room Suite were not maintained in good repair.

Findings:

On 7/9/10 at 1:33PM, both doors to Operating Room #5 were found to be in disrepair due to delaminated surfaces, particularly along the meeting edges of these doors.

42CFR: 482.41(a)
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1) Based on observations, the facility did not ensure that designated accessible parking spaces were designed and maintained in accordance with the recognized accessible construction guidelines (e.g., the American's with Disabilities Act).

Findings:

On 7/7/10 at 10:58AM, five (5) designated accessible parking spaces in the Northwest parking lot (near the Laboratory Unit) were found to lack any access aisles. Designated accessible parking spaces are required to be provided with access aisles that are at least sixty (60) inches wide.

482.41 (c), 28 CFR Part 36 ADA Standards for Accessible Design: 4.1.2 (5) (a), 4.6.3


2) Based on observations, the facility did not ensure that accessible room identification signs were installed in accordance with the recognized accessible construction guidelines (e.g., the American's with Disabilities Act).

Findings:

On 7/9/10 at 9:40AM, accessible room identification signage was improperly installed directly on one of the doors to Emergency Department "Cardiac/Trauma Room 16 & 17". Accessible room identification signs are to be installed on the wall next to the latch side of the door and not on doors themselves.

482.41 (c), 28 CFR Part 36 ADA Standards for Accessible Design: 4.30







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