HospitalInspections.org

Based on document review and interview the facility failed to maintain proper humidity levels in the main operating room for one (April 2018) of four months of temperature and humidity logs review for operating room (OR) 1 resulting in the potential for less than optimal patient outcomes. Findings include:

On 5/1/2018 at approximately 1445 review of temperature and humidity log for OR 1 from January 2018 to April 2018 revealed for the month of April 2018 8 days were documented with humidity levels below 20 % relative humidity (RH). There was no indication on the log of any action taken to bring the humidity back up above the required 20% RH minimum. This was confirmed by the Supervisor of Facilities Maintenance, Staff E. The operating rooms are equipped with individual room humidifiers but the facility could not verify what the humidity set points were to enable on site verification that the system was working effectively.

Based upon observation and interview review by Life Safety Code (LSC) surveyors on 5/2/2018, the facility does not comply with the applicable provisions of the 2012 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 5/2/2018, for Life Safety Code.

K-0223
K-0225
K-0321
K-0353

Based on observation and interview the facility failed maintain a clean and sanitary environment in patient care areas throughout the hospital. This could result in transmission of infectious agents and potential health care aquired infections for all patients. Findings include:

1. On 5/1/2018 at approximately 1040 observed that the tops of the radiation equipment and cabinets in Radiology Room 1 had an accumulation of dust.

2. On 5/1/2018 at approximately 1045 observed that there was an acumulation of dust on the top of the metal cabinet in the Med room by the main nurse station.

3. On 5/1/2018 at approximately 1205 observed an acumulation of dust on the top of the cabinets in Radiology Room 250.

4. On 5/1/2018 at approximately 1315 observed an acumulation of dust on the top of the upper cabinet in Emergency Room (ER) 1.

5. On 5/1/2018 at approximately 1340 observed three shelving units in the ER Supply Room 273 with the bottom shelf within 3 inches of the floor making it difficult for housekeeping staff to properly clean under the shelves. There was an accumulation of dust and debris under these shelves.

6. On 5/1/2018 at approximately 1310 observed medical supplies that were placed on the counter within 18 inches of the sink in ER 1 that could become contaminated from the hand wash sink water splashes.

These findings were confirmed by staff E, Supervisor of Facilities Maintenance at the time of discovery.

The CAH must provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. All areas of the CAH must be visibly clean and sanitary. This was not done.

Based on medical record review, document review and interview the facility failed to ensure that all in patients had a nursing care plan documented in the medical record for one of 16 (#8) inpatient medical records reviewed, resulting in the potential failure to provide individualized goal directed nursing care for inpatients treated at this facility. Findings include:

On 5/3/2018 at 1100 review of the electronic medical record for patient #8, an 89 year old female who was admitted as an inpatient on 03/15/2018 and discharged on 03/20/2018 , revealed a nursing care plan could not be located in the medical record for the patient's admission.

On 5/3/2018 at 1110 staff O was asked if all patients are to have nursing care plans completed. She stated "Yes, I do not know what happened."

On 5/4/2018 at 1000 the policy titled "Patient Care Planning" #2952731 dated revised 05/2013 was reviewed. On page 1 of 3 under definition it states "Patient care planning reflects standards of nursing practice. Individualized, goal directed nursing care shall be provided through the use of the nursing process. The nursing process is an organized systemic evaluating the nursing care needs of each patient. On page 3 of 3 it states"Care plans will be reviewed and documented on Q shift."

Based on medical record review, document review and interview the facility failed to ensure that all Medicare beneficiaries receive the "Important Message from Medicare" (IMM) form that explains discharge appeal rights on admission as an in patient and prior to discharge for three of three patients (#8, 20, & 21) that had a qualifying length of stay, resulting in the potential failure for all Medicare beneficiaries or their representative to exercise their rights to appeal the discharge. Findings include:

On 5/3/2018 at 1100 the electronic medical record for patient #8 was reviewed. Patient #8 was a 89 year old female who was admitted as an inpatient on 03/15/2018 and discharged on 03/20/2018. Patient #8's first IMM was signed and dated 3/15/2018, there was no second IMM before discharge located in the medical record.

On 5/3/2018 at 1110 staff O was asked if all Medicare beneficiary/representatives are expected to have two opportunities to be educated on their right to appeal the plans to be discharged from the hospital. Staff O stated "Yes, I believe so, I will have to check on our policy."

On 5/3/2018 at 1115 the electronic medical record for patient #20 was reviewed. Patient #20 was a 90 year old female who was admitted as an inpatient on 2/11/2018 and discharged on 2/15/2018. The first IMM was signed and dated 2/11/2018, there was no second IMM located on the medical record.

On 5/3/2018 at 1130 the electronic medical record for patient #21 was reviewed. Patient #21 was a 67 year old male who was admitted as an inpatient on 3/20/2018 and discharged on 3/25/2018. Patient #21 did not have any IMMs located on the medical record. Staff O stated "I think the admission clerk did not get a IMM signed, was because Medicare was the secondary insurance instead of the primary."

On 5/3/2018 at 1300 the policy titled "Process for the Delivery of Important Message from Medicare" #4174149 dated reviewed 10/2017 was reviewed. On page 1 of 3 under initial delivery it states "1. Admitting office will give Medicare beneficiary's/representatives a copy of the IMM on admission. A. Any questions the beneficiary/representative has will be addressed and they will be asked to sign and date the form." On page 2 of 3 under Follow up copy it states "a. Social Services will deliver a follow up copy to the beneficiary or representative and explain the recipients rights within 2 calendar days before discharge. A copy of the IMM...will return to the chart...c. If a follow up copy is given on the day of discharge, the hospital must give the beneficiary at least 4 hours to consider..."