HospitalInspections.org

Based on observation, staff interviews, and review of maintenance records on 07-17-17 through 07-18-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

Bldg. 02
K-0131 (Multiple Occupancies),
K-0321 (Hazardous Areas - Enclosure),
K-0324 (Cooking Facilities),
K-0341 (Fire Alarm System - Installation),
K-0346 (Fire Alarm System - Out of Service),
K-0353 (Sprinkler System - Maintenance and Testing),
K-0354 (Sprinkler System - Out of Service),
K-0364 (Corridor - Openings),
K-0372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-0521 (HVAC),
K-0711 (Evacuation and Relocation Plan),
K-0712 (Fire Drills),
K-0918 (Electrical Systems - Essential Electrical System Maintenance and Testing),
K-0919 (Electrical Equipment - Other),
K-0923 (Gas Equipment - Cylinder and Container Storage).

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623(d)(1) and were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff O.

Based on observation and interview the facility failed to maintain blanket warmer temperatures within the safety limits set by the manufacturer of the blanket warmer in 1 of 3 blanket warmers (Obstetrics Unit). This deficient practice has the potential to affect 2 patients on the Obstetrics unit at the time of this survey.

Findings include:

On 7/17/17 at 2:30 PM observed a Steris blanket warmer containing blankets and baby garments on the Obstetrics unit. This warmer was at temperature of 155 degrees. The Steris blanket warmer indicated by the manufacturer "Do Not Exceed 150 degrees."

An interview was conducted with Director D on 7/17/17 at 2:45 PM. Per Director D the Obstetrics unit does not track or check the Steris blanket warmer temperature at this time.

Based on observation, staff interviews, and review of maintenance records on 07-17-17 through 07-18-17, the facility did not ensure that the building & building systems are constructed, installed, and maintained to ensure life safety to patients as revealed by the following deficiencies:

Bldg. 02
K-0131 (Multiple Occupancies),
K-0321 (Hazardous Areas - Enclosure),
K-0324 (Cooking Facilities),
K-0341 (Fire Alarm System - Installation),
K-0346 (Fire Alarm System - Out of Service),
K-0353 (Sprinkler System - Maintenance and Testing),
K-0354 (Sprinkler System - Out of Service),
K-0364 (Corridor - Openings),
K-0372 (Subdivision of Building Spaces - Smoke Barrier Construction),
K-0521 (HVAC),
K-0711 (Evacuation and Relocation Plan),
K-0712 (Fire Drills),
K-0918 (Electrical Systems - Essential Electrical System Maintenance and Testing),
K-0919 (Electrical Equipment - Other),
K-0923 (Gas Equipment - Cylinder and Container Storage).

Please refer to the full description of the deficient practices at the individual K-tags. These deficiencies are not compliant with 42 CFR 485.623(d)(1) and were confirmed at the time of discovery by a concurrent record review, observation, and interview with Staff O.

Based on record review and interview the facility failed to ensure that facility policies and procedures are being updated on an annual basis in 282/1084 policies and procedures in 1 of 1 policy and procedure directory. This has the potential to affect all 6 patients in house during this survey.

Findings include:

The facility policy titled "Policy Manager Document Compliance" dated effective 10/09 was reviewed on 07/19/17 at 8:30 AM. This document states under "Standardized Elements for Policy Manger" bullet point number 5 "Review dates should always reflect 1-year out from last revision date to ensure they go through the annual review process by the Committees that are involved and over see the policy."

The facility "Policy Manager" lists Policy and Procedures, their published date, last review date, and next review date was reviewed on 7/19/17 at 8:00 AM. The following policies all had a "last review date" greater than 1 year from 7/19/17: 82737-64, Adenosine stress test policy and procedure, Advance Directives Procedure, AICD Policy, Allen's Test Policy, Anticoagulation Care Policy, Arterial Blood Gas Policy, Attendance Policy, Blood Administration Policy, Blood Pressure Guidelines for Cardiopulmonary Rehab Policy, Blood Pressure Guidelines in Pulmonary Rehab Policy, Blood Recipient Identification Procedure, Bottle Feeding Infants Procedure, Bronchial Drainage CPT Hill Rom Vest Policy, Cardiac Arrest Policy, Cardiac Monitor Policy for enrollment and hookup, Cardiac rehab inpatient documentation policy, Cardiac rehab inpatient documentation procedure, Cardiac rehab phase I policy, Cardiac rehab phase I procedure, Cardiac rehab phase II policy, Cardiolite protocol procedure, Cardiopulmonary rehab phase II procedure, Cardiopulmonary resuscitation guidelines procedure, Chemical dependent patients procedure, Chest tube insertion and care procedure, Child abuse and neglect procedure, Circumcision assisting the provider procedures, Classification of information facility directory policy, Clinic strep standing order procedure, Collection policy, Communication policy, Community care policy, Computer use policy, Conditional reappointment procedure, Consent for treatment for minors and unconscious patients policy, Continuous Passive Motion device policy, Contraindications in participation in Pulm. rehab policy, Contraindications to exercise testing policy, Contraindications to exercise testing procedure, CPSI Downtime procedure, CR QI policy, Criteria for admission into Pulm Rehab Procedure, Daily progress notes in Pulm Rehab policy, Daily progress notes in Pulm Rehab procedure, Data Management and Backup Policy, Definitions of cardiac rehab services policy, Definitions of cardiac rehab services procedure, Department responsibilities policy, Diabetic ketoacidosis management procedure, Discharge criteria for Pulm rehab policy, Discharge evaluation phase II policy, Discharge evaluation phase II procedure, Discharge of infant to social service agency policy, Discharge phase II policy, Discharge summary and charging for services procedure, Disclosure policy, DNR DNI procedure, Dobutamine stress testing policy, Dobutamine stress testing procedure, Document archives procedure, Documentation and record keeping in Pulm rehab policy, Documentation for outpatient cardiac rehab procedure, Doptone (Doppler) use in OB policy, ED diversion procedure, Education in phase 3 rehab policy, Education in Pulm rehab policy, Emergency access to supplies policy, Emergency notification for cardiac monitoring with CardioNet procedure, Emergency notification for cardiac monitoring with Life Watch policy, Emergency Protocol in phase 3 rehab policy, Emergency protocol in Pulm rehab policy, Emergency protocol in Pulm rehab procedure, Emergency procols in cardiac rehab policy, EMR medication reconciliation procedure, EMR computer CPSI sign off procedure, EMR hospital bedside charting procedure, EMR hospital Medact procedure, EMR hospital nursing shift change procedure, EMR hospital PC backup checks procedure, EMR hospital verification of medication orders procedure, EMR medication reconciliation procedure in Evident, EMR procedure for admit to swingbed for medication reconciliation and orders, Epistaxis nose bleed procedure, Esmolol admin in dobutamine stress testing policy, Esmolol admin in dobutamine stress testing procedure, Esmolol bolus dosing chart policy, Esmolol bolus dosing chart procedure, Established guidelines for determining number of phase II visits policy, Established guidelines for determining number of visits procedure, Event monitor procedure, Exercise prescription cardiac rehab phase I and II policy, Exercise prescription cardiac rehab phase I and II procedure, Exercise prescription in Pulm rehab policy, Exercise prescription in Pulm rehab procedure, EZ IO policy and procedure, Final discharge session for Pulm rehab procedure, Financial reimbursement for cardiac rehabilitation programs policy, Frostbite procedure, General PFT policy, GL-01-136.1, Glucose tolerance 2 HR non-OB policy, HAM operator orientation procedure, Heart care oxygen therapy procedure, Heat exhaustion or heat stroke procedure, Hepatitis immune globulin and vaccine newborns procedure, Holding Plavix related to stents procedure, Holter and event monitor patient log policy, Holter and event monitor patient log procedure, Holter diary policy, Holter diary procedure, Holter event referrals policy, Holter monitor procedure, Home exercise during Pulm rehab policy, Home exercise during Pulm rehab procedure, Home exercise program policy, Hydro bath policy, Important message from medicare appeal rights notice procedure, Incentive spirometry policy, indication for police notification policy, Indications for terminating exercise testing policy, Indications for terminating exercise testing procedure, Individualized treatment plan for Pulm Rehab policy, Individualized treatment plan in Pulm rehab procedure, Infant care center radiant warmer procedure, Infection control in Pulm rehab policy, Informed consent in Pulm rehab policy, Informed consent in Pulm rehab procedure, Informed consent outpatient exercise rehab policy, Initial application process procedure, Initial intake and assessment evaluation appointment policy, initial intake and assessment evaluation appointment procedure, Initial intake for Pulm rehab policy, Inpatient phase I cardiac rehab education guide procedure, Inpatient phase I cardiac rehab exercise guide policy, Inventory control policy, Lab results critical values procedure, Laboratory orientation policy, LET gel procedure, Lexiscan procedure, Long term IV procedure, Lookback policy, Lumbar puncture procedure, Magazine maintenance procedure, Maintenance of ventilator policy, MCOT cardiac monitor procedure, Medical director Cardiac rehab policy, Mental health patients procedure, Nasogastric tube (feeding tube) procedure, Nasogastric tube irrigation procedure, Neurological assessment procedure, New product policy, Non imaging stress test procedure, Non imaging treadmill stress test procedure, Non-response at reappointment procedure, Non-stress (NST) test procedure, Non-stress test (SNT) policy, Nose and throat suction procedure, Ordering lab tests in CPSI procedure, Orientation policy, Orientation Procedure, Outpatient blood glucose policy, Outpatient blood glucose procedure, Outpatient cardiac rehab after a clinical discharge procedure, Outpatient cardiac rehab post procedure, Outpatient cardiac rehab post procedure policy, Oxytocin induction/augmentation procedure, Paging and parked calls policy, Pain management procedure, Paracentesis procedure, Patient progress reports policy, Patient progress reports procedure, Payroll deduction policy, Payroll deduction procedure, Pharmacy security procedure, Phase 3 blood pressure guidelines procedure, Phase 3 check in procedure, Phase 3 check out procedure, Phase 3 collecting payment procedure, Phase 3 contraindications for participation policy, Phase 3 criteria for admission procedure, Phase 3 daily progress notes policy, Phase 3 emergency protocol procedure, Phase 3 infection control policy, Phase 3 informed consent policy, Phase 3 monitoring blood glucose levels policy, Phase 3 monitoring blood glucose levels procedure, Phase 3 program definition policy, Phase 3 rehab order procedure, Phase 3 reimbursement policy, Phase 3 scheduling participants procedure, Phase 3 strength training procedure, Phase 3 supplemental oxygen and oximetry monitoring policy, Phase 3 supplemental oxygen and oximetry monitoring procedure, Phase 3 telemetry monitoring policy, Phase 3 termination to exercise policy, Phase I cardiac rehab protocol policy, Phase I cardiac rehab protocol procedure, Philosophy of maternity care policy, Philosophy policy, Philosophy procedure, Physician order procedure, Placenta/cord examination and disposal of procedure, Plan for emergency handling of hazardous chemical accident cases policy, Platelet transfusion procedure, Post partum care routine procedure, Power outage procedure emergency department, Pre op screening policy, Precautions in L&D policy, Precipitous vaginal delivery procedure, Purchase orders policy, Purchasing policy, Quality improvement opportunity QIO reporting policy, Quinton stress test policy, Rapid sequence intubation procedure, Reappointment process for physicians procedure, Receiving shipments policy, Reference requests procedure, Referral and patient selection for outpatient cardiac rehab policy, Referral and patient selection for outpatient cardiac rehab procedure, Reimbursement in Pulm rehab policy, Reimbursement in Pulm rehab procedure, Relationships with various departments policy, Release of practitioner information procedure, Removal of terminated Pt procedure, Rental equipment policy, Risk management reporting policy, Risk stratification policy, Risk stratification procedure, Rooming in policy, SBAR hand off communication policy, Security and observation of a newborn procedure, Security incident reporting and response policy, Serum Albumin administration policy, Setting inventory levels policy, Six minute walk policy, Sotalol procedure, Special care criteria procedure, Specimen rejection criteria policy, Standing nitroglycerin order policy, Standing nitroglycerin order procedure, Strength training in Pulm rehab policy, Strength training in Pulm rehab procedure, Strength training procedure, Stress choice tool for providers policy, Stress test guide flowsheet policy, Stress test interpretation protocol policy, Stress test interpretation protocol procedure, Suicide precautions procedure, Supervision in Pulm rehab policy, Supervision of stress testing policy, Supplemental oxygen and oximetry monitoring in Pulm rehab policy, Supplemental oxygen and oximetry monitoring in Pulm rehab procedure, Supplies in Pulm rehab policy, Surge capacity for facility procedure, System access policy, Technical access control policy, Telemetry monitoring in Pulm rehab policy, Telemetry monitoring in Pulm rehab procedure, Telemetry monitoring policy, Telemetry monitoring procedure, Temporary privileges procedure, Termination of exercise in Pulm rehab policy, Termination Phase II session policy, Termination Phase II session procedure, Therapeutic hypothermia procedure, Thoracentesis procedure, Tracheostomy care procedure, Tracheostomy reinsertion procedure, Transcutaneous pacing procedure, Transfer-infant procedure, Transtracheal airway (Needle Crocothyroidoctomy) procedure, Unsafe discharge procedure, Urethral catheterization procedure, Urine culture Foley catheter procedure, Urine culture procedure, Use of contrast (Definity/Optison) during echocardiography policy, Use of TTY telephone communication system procedure, Verification process procedure, Visitors in the OB department procedure, and wound irrigation procedure.

An interview was conducted with Chief Nursing Officer B on 7/19/17 at 9:10 AM B when asked how often policy and procedures were expected to be reviewed B stated "I knew we were behind in some departments but not this much" and confirmed that the above policies had not been reviewed in over a year.

Based on observation and interview the facility failed to ensure clean and dirty supplies are separated in 1 of 4 areas where biohazard waste is stored (biohazard storage room near loading dock) to prevent and control the potential spread of infection.

Findings include:

On 7/17/2017 at 1:15 PM observed a refrigerator/freezer in the biohazard storage room near the loading dock. This freezer contained multiple ice packs.

An interview was conducted with Plant Operations Manager O on 7/18/17 at 4:00 PM. Plant Operations Manager O stated the ice packs stored in the freezer in the biohazard room near the loading dock are for emergent situations in which the hospital may need to transport vaccines in the case of a power outage. Plant Operations Manager O verbalized understanding the clean items can not be commingled with biohazard waste.

Per Chief Nursing Officer B on 7/18/17 at 4:00 PM, the facility does not have a policy on the separation of clean and dirty storage.

Based on record review and interview the facility failed to ensure that a comprehensive and individualized care plan is developed and kept current for each inpatient in Patient #'s 1-20 medical records reviewed. This has the ability to affect all 6 patients admitted in the facility during this survey.

Findings include:

The facility policy titled "Nursing Standards of Care" effective date May 2010 and last revised 1/2017 was reviewed on 7/19/17 at 11:00 AM. This document states under "PROCEDURE: 1. Patient Assessment", bullet point e "Patient Problem Lists - After an initial admission assessment has been completed, the Registered Nurse will initiate appropriate "problems" based on identified nursing diagnoses. These "problems" must be individualized for the patient. All Patient Problem Lists must be initiated and discontinued or resolved by the Registered Nurse initialing and dating where indicated. Patient Problem Lists are to be updated at least once every 12 hour shift."

In 20 of 20 medical records were reviewed on 7/18/17 and 7/19/17. Nursing care plans lacked measureable goals and individualized interventions that are based on assessing the patient's nursing care needs and not solely those needs related to the admitting diagnosis. Nurses did not develop care plans with appropriate nursing interventions in response to the identified nursing care needs and of the patient's needs and response to interventions.

An interview was conducted with Chief Nursing Officer B on 7/19/17 at 11:15 AM stated "We know our care plans are lacking and we have been searching for new electronic medical record software that is better than what we are using".