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Based on observation and interview, it was determined the facility failed to maintain the Patient Shower (in the Nurses' Corridor) in a clean and orderly fashion by not replacing non-skid strips on the shower floor, repairing cracked paint on 1 of 2 painted walls, not repairing cracked tiles, and not keeping the tile free of mildew. This had the potential to affect all patients who utilized the shower by not assuring the floor would not be a slip and fall hazard and that the shower would be a sanitary environment. There was a census of 7 patients on 04/17/2016. Findings follow:

A. During a tour of the facility on 05/17/2016 at 1350, observations revealed:
1) Non-skid strips on the tile floor of the patient shower were peeling and eroding.
2) 1 of 1 crack was observed in the tile floor in the area where the shower entrance abuts the shower floor.
3) Cracks in the paint on 1 of 2 painted walls.
4) Mildew was forming near the base of the tile in the grouting.
B. While on the tour, the Facilities Director confirmed that the Patient Shower was not maintained.

Based on observation, Preventative Maintenance Tech Log review and interview, it was determined the facility did not meet Life Safety Code requirements as follows:

A. The facility failed to maintain the smoke resistance of the smoke barriers by sealing the spaces between penetrating items such as conduit, pipe, and ductwork through the smoke barriers with a material capable of maintaining the smoke resistance of the smoke barrier in two of two (Medical Gas Storage room and Fire Wall in Nurses' Corridor) areas observed. The failed practice had the potential to affect all patients, staff, and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next. See K0025.
B. The facility failed to ensure the emergency power generator was tested under load for at least 30 minutes monthly for 2 (August 2015 and November 2015) of 12 (May 2015 through April 2016) months. The failed practice had the potential to affect the health and safety of patients, staff, and visitors because the reliability of the generator to provide emergency power to the facility in the event of the loss of normal power was not evaluated and could not be assured. See K0144.
C. The facility failed provide documentation to show the required monthly testing [NFPA 99 3-3.3.4.2 (b) (1999 edition)] for two of two Line Isolation Monitors (LIMs) for the isolation panels serving the Operating Room (OR) and Emergency Room #1 and #2 had been performed. See K0130.

Based on review of sterile package labeling, observation and interview, it was determined the facility failed to prevent the use of opened sterile supplies (suction tubing and Yankeur suction tips) for patient care and did not control the spread of infection in one of one Trauma Room in the Emergency Department. Failure to prevent the use of opened supplies for patient care did not assure the supplies remained clean and patients were not exposed to contaminants. The failed practice was likely to affect all patients admitted to the Emergency Department. Findings follow:

A. On observation 05/17/16 at 1419 in the Emergency Department Trauma Room, opened suction tubing and opened Yankeur suction catheters were hanging on the suction canisters attached to the wall.
B. Review of the package label for suction tubing revealed "Do not use if package is opened or damaged. "Review of the package label for Yankeur suction tip revealed "Do not use if package is opened or damaged."
C. Findings listed in A and B were verified at the time of observation with the Director of the Emergency Department.


Based on review of policy, review of employee records and interview, it was determined the facility failed to identify and control infections in that the facility failed to assure tuberculosis (TB) skin testing was conducted for one of one Infection Control Officer (ICO), one of one (Speech Therapist (ST) #1) and one of one (Certified Occupational Therapy Assistant (COTA) #1); and failed to follow facility policy to record employee hepatitis B vaccination status for two (Respiratory Therapist (RT) #1 and RT #2) of two respiratory therapy staff. Failure to assure TB skin testing was conducted did not assure the facility knew staff's immunity status to tuberculosis. Failure to record hepatitis B vaccination status prevented the facility from formulating an effective (vaccine booster, immune globulin, complete hepatitis B vaccine series) plan in the event of potential blood borne pathogen exposure to the staff. The failed practices were likely to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of employee records for Infection Control Officer, ST #1 and COTA #1 revealed no evidence of a current TB skin test, questionnaire or chest x-ray.
B. Review of policy "Employee TB Skin Testing" revealed "All new employees will receive a TB skin test upon employment and annually."
C. Review of the employee records for RT #1 and RT #2 revealed no evidence of hepatitis B vaccination status.
D. Review of policy "Hepatitis B Vaccination" revealed "Immunization recommendations for health care workers at (Named) hospital include protections against hepatitis B. Vaccinations for hepatitis B are offered routinely and free of charge to all employees. "Review of policy Hepatitis B Vaccination Information revealed "I have been given the opportunity to be vaccinated with hepatitis B vaccine at no charge to myself. However, I decline hepatitis B vaccination at this time."
E. Findings listed in A and B were verified by Nursing Administrative Secretary on 05/18/16 at 1210.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery for three of three (#18-#20) surgical patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Clinical record review on 05/18/16 at 1430 revealed Patient #18 had an EGD (esophagogastroduodenoscopy) on 05/12/16. There was no time of the surgery documented on the operative report.
B. Clinical Record review on 05/18/16 at 1415 revealed Patient #19 had an EGD on 05/11/16. There was no time of the surgery documented on the operative report.
C. Clinical record review on 5/18/16 at 1435 revealed Patient #20 had an EGD on 05/11/16. There was no time of the surgery documented on the operative report.
D. The Director of Surgical Services confirmed there was no time of surgery documented on the operative reports at the time of clinical record review for Patient #18-#20.

Based on clinical record review and interview, it was determined the facility failed to assure three of three surgical patients (#18, #19 and #20) had a current history and physical prior to a surgical procedure. Failure to have an updated history and physical did not assure the clinical record contained complete and up to date patient information. The failed practice affected Patient #18 - #20 and was likely to affect all surgical patients. The findings were:

A. Patient #18's clinical record reviewed on 05/18/16 at 1430 revealed the History and Physical was completed on 05/02/16. Patient #18 had an EGD (esophagogastroduodenoscopy) on 05/12/16. There was no update of the History and Physical prior to the surgical procedure and this was confirmed on 05/18/16 at 1433 by the Director of Surgical Services.
B. Patient #19's clinical record reviewed on 05/18/16 at 1415 revealed the History and Physical was completed on 05/03/16. Patient #19 had an EGD on 05/11/16. There was no update of the History and Physical prior to the surgical procedure and this was confirmed on 05/18/16 at 1417 by the Director of Surgical Services.
C. Patient #20's clinical record reviewed on 5/18/16 at 1435 revealed the History and Physical was completed on 01/20/16. Patient #20 had an EGD on 05/11/16. There was no update of the History and Physical prior to the surgical procedure and this was confirmed on 05/18/16 at 1436 by the Director of Surgical Services.



Based on clinical record review and interview, it was determined the facility failed to assure one (#20) of three (#18-#20) surgical patients had physician orders for pre-operation, post-operation and discharge after the operative procedure. The facility could not be assured the pre-printed orders were individualized and the health care needs of Patient #20 would be met. The failed practice affected Patient #20 and was likely to affect all surgical patients. The findings were:

A. Clinical record review of Patient #20 on 5/18/16 at 1435 revealed pre-printed orders dated and noted by a Registered Nurse on 05/11/16 at 1130 for "Physician Orders-Endoscopy". The pre-printed orders included: "Consent for colonoscopy, EGD (esophagogastrodeudenoscopy), monitor vital signs and oxygen saturation, start IV(intravenous) of NS (normal saline) and infuse 500 (milliliters), then KVO (keep vein open), and oxygen per nasal cannula at 4l/min." and also to "Discharge form PACU (Post Anesthesia Care Unit) when discharge criteria met." The pre-printed Physician Orders were not signed by a physician and there was not a verbal or telephone order instructing the staff to implement the pre-printed orders.
B. The findings in "A" were confirmed by the Director of Surgical Services on 05/18/16 at 1438.