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Based on observation, record review, and interview, the governing body failed to obtain a permit from the Department of Community Health (Department) when a name change occurred.

Findings include

Observation on arrival to the facility on 4/1/2014 revealed signage identifying the facility with a name different than the name other than the one identified by the Department.

On introduction and entrance to the facility, the Director of Nurses provided a business card identifying the facility with a different name other than the one listed on the hospital permit.

A review of the facility governing body minutes dated December 14, 2010 revealed the approval of a new hospital name, website, logos, and letterhead changes.

A review of Department records revealed no evidence of a name change.

Interview on 4/2/2014 at 4 p.m. with the hospital administrator revealed that all administrative notifications to the Department are completed at the corporate office. The administrator stated, no knowledge that notification had not occurred.

Based on observation and interview, the facility failed to ensure a system was in place in bathrooms that patient use in the Outpatient Therapy Department, Emergency Department and in the Radiology Department. Each area is a high risk area increasing the likelihood of injury and/or harm to patients using the three (3) areas.

Findings include:

1. Observation on 4/1/14 at 11:15 a.m. in the Outpatient Therapy Department revealed no patient emergency call system in the patient restrooms. The restrooms were outside of the treatment area and across the waiting room. Interview at the time of the findings the physical therapy supervisor confirmed that there were no emergency call system for patient use in the event of an emergency.

2. Observation on 4/1/14 at 1:00 p.m. in the Emergency Department revealed no emergency call system in the patient restrooms. The restrooms were outside of the department and about twenty (20) feet from the department.

3. Observation on 4/1/1 at 3:00 p.m. of the Radiology Department revealed no evidence of an emergency call system in the patient restrooms.

Based on observations, interviews and policy review, the facility failed to ensure that patient care equipment was safe for use in two (2) patient care areas.

Findings include:

1. Observation on 4/1/14 at 10:30 a.m. in the respiratory department revealed no evidence of a biomedical electrical safety inspection on the only hospital ventilator (a device used to breathe for the patients when they are unable to do so).

Interview with the Director of Respiratory Care confirmed the above findings, and revealed that that the ventilator machine was about fifteen (15) years old.

2. Observation on 4/1/14 at 11:15 a.m. the outpatient therapy department revealed the following:
-the electrical stimulation machine had a biomedical safety inspection with an expiration date of 9/6/13;
-the whirlpool machine had a biomedical safety inspection with an expiration date of 1/24/12 and;
-the traction machine had no evidence of a biomedical safety inspection.

At the time of the observation the Director of Inpatient and Outpatient Physical Therapy confirmed the findings.

A review of facility policy 395, revealed that in order to maintain safe practices for use of all electrical equipment in the Hospital that all electrical equipment shall be labeled with an inspection sticker indicating: date of inspection, name of inspector, date of next required inspection and equipment identification number.

Based on observation, interview, policy review, and manufacturer's safety data sheet the facility failed to provide an appropriate and safe storage area for one (1) can of flammable anesthetic medication and over twenty-five (25) liters of intravenous fluids and dozens of needles and syringes.

Findings include:

Observation on 4/1/14 at 1:00 p.m. revealed one (1) can of Gebauer Ethyl Chloride (a flammable medication used to numb the skin for injection or incision) in one (1) of three (3) emergency rooms. The can of Gebauer Ethyl Chloride was secured in an unvented metal and glass cabinet with other potential fuels (paper products, etc.).

The Head Nurse of the Emergency Room (ER) and the Assistant Chief Nursing Officer (ACNO) confirmed the above findings.

Review of facility ER policies revealed no evidence of a policy on storage of Ethyl Chloride.

A review of the Manufacturer's Safety Data Sheet confirmed that the storage of Ethyl Chloride should be in a "well ventilated" area.

During the same observation it was observed that there were unlocked intravenous fluids, needles, and syringes (dozens of each) throughout the ER rooms.

The Head Nurse and ACNO confirmed that the fluids, needles and syringes could be relocated to locked cabinets.

Review of facility ER policies revealed no evidence of a policy on storage of fluids, needles and syringes.

Based on observations, policy and procedures, facility logs, professional standard review, and interview the facility failed to provide adequate ventilation and humidity controls in two (2) of two (2) operating rooms and recovery room to decrease the likelihood of infection and/or bacterial growth.

Findings include:

Observation on 4/2/14 at 9:30 a.m. in the operating room suite, operating rooms #1 and #2 and in the recovery area revealed portable air conditioner units. Temperature and humidity monitors were located in the operating rooms. Interview during the observation with the Director of Surgical Services confirmed the findings and revealed it was difficult to keep the rooms cool.

Review of Policy 186 revealed that the facility policy was "to monitor the temperature and humidity of the center on a daily basis and to maintain temperature ranges from sixty to seventy-three (60-73) degrees Fahrenheit and humidity level of twenty - sixty percent (20-60%).

Review of the temperature and humidity logs for January, February, and March of 2014 revealed a total of sixty (60) operating days the temperature and humidity were not in the acceptable range.

Interview on 4/3/14 at 12:00 p.m. via telephone with the Director of Surgical Services revealed that the facility uses the Association of Peri-Operative Registered Nurses (AORN) Standards. The Standards were reviewed at www.aorn.org. Operating room temperature recommended range of sixty-eight to seventy-three (68-73) degrees and the humidity ranges is recommended to be twenty to sixty percent (20-60%).

Based on record review, and staff interview, the governing body failed to notify the Department of Community Health (Department) of a change in the designation of hospital administrator.

Findings include:

A review of the facility governing body minutes dated October 16, 2013 revealed the appointment of the new hospital administrator.

A review of the facility organization chart dated December 2013 revealed, the former hospital administrator, was appointed to the role of Chief Executive Office, and the new hospital administrator was identified.

A review of the Department records revealed, no evidence of change in administrator notification.

Interview on 4/2/2014 at 4 p.m. the hospital administrator revealed, all administrative notifications to the Department are completed at the corporate office. The administrator stated no knowledge of notification that the department had not been informed of the above organizational changes.

Citation Text for Tag 0279, Regulation 6R40

Davis-Frank, Ronnett
Based on observation , review of policies and procedures and interview the facility failed to assure dietary personnel used proper hand hygiene and failed store food in a manner to prevent foodborne pathogens for all patients, staff and visitors who consume orally.

Findings include:

1. Observation on 4/1/14 at 10:30 a.m. revealed the inside of the cooler/refrigerator was dark with no operating light.

The following items in the cooler were in containers with two labels attached. One label indicated the date the item was placed in the cooler and the other label contained an expiration date indicating when food should be discarded. The following foods were available for human consumption past the expiration date:

Cheese sauce- Placed in cooler on 3/9/14, expiration date 3/17/1;4
Mixed Vegetables- Placed in cooler on 3/24/14, expiration date 3/31/14;
Sloppy Joe- Placed in cooler on 3/21/14, expired 3/31/14;
Stew Pork- Placed in cooler on 3/26/14, expiration 3/31/14 and;
Turkey Franks- Placed in cooler on 1/24/14 expiration date 3/30/14.

Review of facility policy # 175 1. K,.entitled, "Dietary nutritional services infection control, revision date of June 27, 2013 revealed lighting, ventilation and humidity would be controlled to prevent the growth of microorganisms. Item 19. D revealed all prepared foods would be dated and discarded after three (3) days if not used.

Interview on 4/1/14 at 10:35 a.m. the cook confirmed the above findings.

2. Observation on 4/1/14 at 10:40 a.m. revealed a brush, on the sink counter.

Interview on 4/1/14 at 10:40 a.m. with the cook revealed that the brush is used by food service employees to clean beneath their fingernails during hand washing

Review of policy #45 entitled, " Hand Hygiene" revealed to always follow standard precautions. The policy provided techniques for proper hand washing, which did not include the use of a shared brush to clean beneath the fingernails.

Based on record review, policy and procedure review, and interview, the hospital failed to provide evidence of a written grievance resolution that included the steps taken on behalf of the patient to investigate complaints for three (3) of three (3) sampled patients (#1, #2, and #3).

Findings include:

Three patient grievance records were selected for review from July 1, 2013 through January 1, 2014.

A grievance was filed on 7-3-2013 by patient #1. No evidence was found to identify how the hospital investigated the complaint and that the hospital issued a written response to the complainant, or the investigative steps taken on behalf of the patient.

A grievance was filed on 7-17-2013 by patient #2. No evidence was found to identify how the hospital investigated the complaint and that the hospital issued a written response to the complainant, or the investigative steps taken on behalf of the patient.

A grievance was filed on 8-19-2013 by patient #3. No evidence was found to identify how the hospital investigated the complaint. No evidence was found that identified that the hospital issued a written response to the complainant, or the investigative steps taken on behalf of the patient.

A review of hospital policy and procedure revealed, policy #40 titled Patient Grievance, the hospital will investigate all grievance complaints, and provide a written response to the complainant within seven (7) days.

Interview on 4-3-2014 at 11:00 a.m. with the Director of Nursing confirmed the above findings.

Based on record review, policy and procedure review, and interview the facility failed to provide evidence of safety checks for two (2) of two (2) sampled patients using restraints.

Findings include:

A closed record review revealed patient #12 was placed in soft limb, and vest restraints on 7/24/2013 trough 7/25/2013 for management of safety, related to altered mental status and fall risk. Continue record review revealed no documented evidence that safety checks were performed every 30 minutes as required by policy and procedure. Twenty-one (21) safety checks were missing from record.

A second closed record review revealed patient #13 was placed in soft limb restraints on 9/9/2013 trough 9/10/2013 for management of safety, related to altered mental status and fall risk. Continue record review revealed no documented evidence that safety checks were performed every 30 minutes as required by policy and procedure. (8) Eight 30 minute safety checks missing from the record.

A review of hospital policy and procedure revealed, policy # 260 titled, Restraints and Seclusion that documented staff should observe the patient every thirty (30) minutes and reassess or encourage release of restraints.

An interview with the Director of Nursing on 4/4/2014 at 10:00 am confirmed the above findings. He/she stated, it is the hospital policy to check patients for safety every 30 minutes. I am unsure why the documentation is not present.