HospitalInspections.org

Based on Life Safety Code (LSC) survey, St. Vincent Dunn Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This facility was determined to be a six story fully sprinklered building of Type II (222) construction. The facility has a monitored fire alarm system with smoke detection in the corridors and in areas open to the corridor. The facility has a capacity of 25 and had a census of 13 at the time of this survey.

All areas where patients have customary access were sprinklered and all areas providing facility services were sprinklered.

Based on LSC survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure 2 of 4 open use areas on the second floor were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception and 1 of 1 Allergy and Asthma Office, 1 of 1 Lab Check In Office and 1 of 1 Patient Access Office were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception (see K 017), failed to ensure 1 of 1 kitchen service metal rolling door/window was held open only by a device arranged to automatically close upon activation of the fire alarm system (see K 021), failed to ensure 2 of 6 ceiling smoke barriers were maintained to provide at least a one half hour fire resistance rating (see K 025), failed to ensure 3 of over 20 hazardous area room doors on the second and third floors, such as rooms over 50 square feet containing combustible material, were equipped with self closing devices on the doors and 1 of 1 sets of hazardous area double doors to the corridor, such as kitchen doors, were equipped with positive latches that automatically latched into the door frames when closed (see K 029), failed to ensure the lighting for 2 of 9 exit means of egress were arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness (see K 045), failed to ensure 18 of over 200 smoke detectors were not installed where air flow would adversely affect their operation (see K 052), failed to ensure the sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (see K 056), failed to ensure sprinkler heads in 3 of over 2000 sprinkler locations were free of paint and only one type of sprinkler head, i.e., quick response or standard sprinklers was installed in a compartmented space in 1 of 7 smoke compartments on the first floor (see K 062), failed to ensure 11 of 93 fire dampers and 14 of 17 smoke dampers in the facility were inspected and provided necessary maintenance at least every six years (see K 067) and failed to maintain system integrity for 1 of 1 piped gas systems (see K 077).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review and observation, the hospital failed to ensure premises were clean and orderly in 5 areas (rehabilitation therapy, dumpster area, 4th floor/office restrooms, maintenance shop and bio-hazardous waste storage/mechanical room).

Findings:

1. Review of the policy titled Infection Control: Department Plan indicated the following:
Affected departments: Rehabilitation (rehab) services, environmental services. E.1. Environmental services will: e. clean desk surface areas in the rehab department. F. The Rehab Services associates will: 1. clean clinical equipment as appropriate. 2. clean toys as appropriate. The policy also indicated in V. Cleaning Clinical Equipment. B. All major equipment, i.e. exercise equipment, ...exercise balls are cleaned weekly with a hospital approved cleaning agent. C. The hydrocollator machine is drained, cleaned with a hospital approved cleaning agent and re-filled once every 2 weeks. If contamination of the water occurs, i.e., pack breaks, the unit is cleaned more frequently as appropriate. D. The paraffin machine is drained, cleaned with a hospital approved cleaning agent and re-filled every 6 months. The policy was approved 3/2015.

2. Review of the procedure titled Environmental Services Department indicated all offices and lobbies located throughout the facility were included in daily cleaning. The policy further indicated "Daily Cleaning" to include, but not be limited to "High dust all vents, ledges and door frames." "Daily Restroom Cleaning:" ...damp clean sink, fixtures, shower, toilet and urinals. The procedure was issued 11/1/13.

3. On 12/08/15 at 11:20 a.m. in the presence of staff member #A7, Rehabilitation Manager, the following was observed while on tour throughout the rehabilitation department:
a. The interior underside of the hydrocollator lid contained 4 irregular areas of a brownish rust-like substance.
b. The fluid inside the hydrocollator unit was cloudy and did not allow sufficient viewing of the floor of the unit.
c. Three therapy balls' surfaces, 1 orange and 2 yellow, contained irregular blackish and brownish marks with small tears.
d. The interior of the paraffin bath contained irregular blackish marks throughout its surface.
e. The gym counter top contained an irregular 2 x 3 inch tear which did not afford easy cleaning.

4. Review of cleaning documentation for the rehabilitation department indicated the paraffin bath had been drained within the past 6 months, but lacked evidence of the hydrocollator having been drained and cleaned every 2 weeks and lacked evidence of therapy ball surfaces cleaned weekly.

5. On 12/8/15 at 10:45am, in the rest room across from the conference room of the 4th floor, the following was observed: a shower stall that appeared dusty and a ceiling vent heavily covered in black dust type debris.

6. On 12/9/15 at 9:30am, in the presence of A5, Regional Safety Director, in the maintenance shop, heavy grayish dust was observed along the top edge of the window to an office and on a small flag in the same area.

7. On 12/9/15 at 10:45am, in the presence of A5, Regional Safety Director, in the loading dock and dumpster area, the following was observed: Trash type debris on the ground around the dumpster and a large blackish mold type stained, wet appearing, cardboard box on the dock against a wall behind a large pile of empty cardboard boxes.

8. On 12/8/15 at 12:00pm, A1, acknowledged the shower in the restroom across from the conference room on the 4th floor was dusty appearing and that the ceiling vent was heavily covered in black dust type debris.

9. On 12/9/15 at 10:45am, A5 indicated that the moldy appearing box contained a piece of equipment that was to be returned and that the vendor had neglected to pick it up.

Based on observation, record review and interview, the facility failed to ensure 2 of 4 open use areas on the second floor were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception and 1 of 1 Allergy and Asthma Office, 1 of 1 Lab Check In Office and 1 of 1 Patient Access Office were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception, failed to ensure 1 of 1 kitchen service metal rolling door/window was held open only by a device arranged to automatically close upon activation of the fire alarm system, failed to ensure 2 of 6 ceiling smoke barriers were maintained to provide at least a one half hour fire resistance rating, failed to ensure 3 of over 20 hazardous area room doors on the second and third floors, such as rooms over 50 square feet containing combustible material, were equipped with self closing devices on the doors and 1 of 1 sets of hazardous area double doors to the corridor, such as kitchen doors, were equipped with positive latches that automatically latched into the door frames when closed, failed to ensure the lighting for 2 of 9 exit means of egress were arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness, failed to ensure 18 of over 200 smoke detectors were not installed where air flow would adversely affect their operation, failed to ensure the sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, failed to ensure sprinkler heads in 3 of over 2000 sprinkler locations were free of paint and only one type of sprinkler head, i.e., quick response or standard sprinklers was installed in a compartmented space in 1 of 7 smoke compartments on the first floor, failed to ensure 11 of 93 fire dampers and 14 of 17 smoke dampers in the facility were inspected and provided necessary maintenance at least every six years and failed to maintain system integrity for 1 of 1 piped gas systems.

Findings include:

1. Observation on 12/08/15 at 12:55 p.m. during a tour of the facility with the Facilities Manager (FM#1) and Safety Director (SD#1) noted the second floor Vending Machine Room and the Cafeteria serving area were each open to the corridor without doors separating the rooms from the corridor.

2. This was acknowledged by the Facilities Manager and Safety Director at the time of observations.

3. Observations with the Safety Director and the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15 noted the Allergy and Asthma Office in the northwest addition portion of the facility had a two foot by two foot sliding glass window to the corridor. There was a one fourth inch gap between the window panes when closed. In addition, the Lab Check In Office on the first floor had a four foot by three foot sliding glass window to the corridor and the Patient Access Office on the first floor had a four foot by five foot sliding glass window each with a one fourth inch gap between the window panes when closed.

4. This was acknowledged by the Safety Director and the Facilities Manager at the time of the observations.

5. Observation on 12/08/15 at 12:50 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the metal rolling service door between the kitchen and adjoining corridor was held open with a chain and fusible links on both sides of the kitchen wall which would not allow the metal rolling door/window to close automatically when the fire alarm system is activated.

6. In interview at the time of observation, the Facilities Manager and Safety Director acknowledged the metal rolling door/window between the kitchen and adjoining corridor was held open with a chain and fusible links which would not allow the door/window to close automatically when the fire alarm system was activated.

7. Observations with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15 noted in ceiling smoke barriers:
a. A one foot by one foot hole was noted in the ceiling above the kitchen fire suppression system cylinders in the Air Handler 7 Room in the kitchen on the second floor.
b. A five inch by eighteen inch hole and a four inch by four inch hole was noted in the ceiling of the Cleaning Chemical Storage Room in the kitchen on the second floor.
c. A one foot by one foot hole was noted in the ceiling of Room 119 (Women's Locker Room) on the first floor.
d. A three foot by eighteen inch suspended ceiling tile was missing in the 1st floor Radiology Storage Room above the LSGB electrical panel. In addition, an eight inch by six inch hole was noted in a ceiling tile of the aforementioned storage room for the passage of six conduits.

8. In interview at the time of the observations, the Facilities Manager acknowledged the aforementioned openings in ceiling smoke barriers failed to maintain at least a one half hour fire resistance rating for the ceiling smoke barrier.

9. Observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the following:
a. The third floor Pink Lady storage room was over 50 square feet and had over 25 cardboard boxes and plastic/rubber totes full of combustible material. There was no self closing device on the door.
b. Room 232 in the second floor west hall was over 50 square feet and was full of paint cans, cardboard boxes, totes and other combustible items. There was no self closing device on the door.
c. Room 231 (O.R. storage room) in the second floor west hall was over 50 square feet and was full of cardboard boxes, totes and other combustible items. There was no self closing device on the door.

10. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

11. Observation on 12/08/15 at 1:41 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the set of double doors to the kitchen were not provided with positive latches that automatically latched into the door frames when closed. They were equipped with manual latches located at the top of the inside of the doors.

12. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

13. Observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the exit means of egress outside the northeast stairwell exit door was equipped with one light fixture with only one bulb, furthermore, the exit means of egress outside the northwest stairwell exit door was not provided with any light fixture.

14. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

15. Observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the following:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8, 7, 4, 3 and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.

16. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

17. Observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the following:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8, 7, 4, 3 and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.

18. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

19. Observations on 12/08/15 between 10:00 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director noted the following:
a. one of two sprinkler heads in the Cart Exchange room (room 375) was partially covered with paint.
b. the sprinkler head in the Aid room (room 332) was partially covered with paint.
c. the sprinkler head in the I.T. room (room 238) was partially covered with paint.

20. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

21. Observation on 12/08/15 at 2:35 p.m. during a tour of the facility with the Safety Director noted the Ambulance Bay had a mixture of one green tube upright type sprinkler head which was an intermediate type sprinkler head with a temperature rating of 200 degrees F and three regular standard type pendent sprinkler heads.

22. This was acknowledged by the Safety Director at the time of observation.

23. Review of Life Safety Services (LSS) "Comprehensive Damper Summary" documentation dated 09/11/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15 indicated documentation of inspection and maintenance performed for 11 of 93 fire dampers within the last six years on 09/11/15 was listed as "fail." In addition, the aforementioned documentation identified six fire damper locations as failing testing because the fire damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Inside the lab drop off area across from room #115.
b. Two locations across from room #243 for which "pipes blocking" was listed as the reason for being non-accessible.
c. Inside storage room #312.
d. Two locations inside of the penthouse.

The aforementioned documentation of inspection and maintenance performed for 14 of 17 smoke dampers within the last six years on 09/11/15 was listed as "fail." In addition the aforementioned documentation identified three smoke damper locations as failing testing because the smoke damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Above the double doors near room #115.
b. Inside storage room #312.
c. Above the double doors near room #328.

24. In interview at the time of the exit conference, the Facilities Manager stated fire damper and smoke damper accessibility work and retesting was performed recently but stated documentation of retesting the fire dampers and smoke dampers listed as failing 09/11/15 testing was not available for review.

25. Review of Midwest Medical Gas Service "Facility Overview"" documentation dated 07/16/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15 indicated the piped gas system contractor was unable to locate zone valves for the vacuum system in the OR/Recovery Area. In addition, the aforementioned documentation stated "there is no emergency Oxygen Supply Connection" and "a zone valve on the second floor controls outlets on the second and third floor which is prohibited by NFPA 99".

26. In interview at the time of the exit conference, the Facilities Manager stated corrections to the facility's piped gas system had been made recently but acknowledged written documentation of the corrections to the system was not available for review.

Based on document review and interview, the facility failed to follow manufacturer's recommendations for glucose monitoring control solutions for one medical-surgical inpatient unit.

Findings:

1. Facility Policy Glucose Monitoring, Bedside, last revised 01/2015, and Glucometer II Manufacturer's Recommendations, indicated that control solutions:
a. consist of high and low solutions.
b. When opening a new bottle, write the discard date on the bottle label. Each bottle of control solution is stable for 90 days after opening or until the expiration date printed on the label, whichever comes first.

2. While touring the medical-surgical inpatient unit of the hospital on 12/8/2015 at 0845 hours, accompanied by staff member #A4, it was noted that the Accu-Chek Inform II glucometer control solutions had not been dated when opened.

3. Staff member #A4 concurred with this finding at the time of observation.

Based on document review and staff interview, the hospital failed to administer blood transfusions in accordance with approved medical staff policies and procedures regarding vital signs and consents for 3 of 10 patient medical records reviewed (Patient #1, Patient #4, Patient #6) and failed to ensure blood transfusions were administered in accordance with approved staff policies and procedures regarding signatures and time blood discontinued for 4 of 4 patient records examined (patient #s N27, N28, N29 and N30).

Findings:

1. The policy, "Blood Product Administration", PolicyStat ID: 1859157, reviewed 10/2015, read:
"Consent
A signed Consent to Blood or Blood Component Transfusion is required for all nonautologous blood transfusion-emergent transfusions.
Monitoring the Transfusion
The patient must be monitored during the entire transfusion event. Care and observations in addition to the required vital signs pre-transfusion, 15 minutes into the transfusion..."

2. Review of three patients receiving six blood units indicated five of these received-units did not have complete documentation, per policy, on the Transfusion Record form including:

Patient #1
--Unit 1a, was administered on 11/02/15 at 2:32 p.m.: The 15 minute vitals were documented at 2:42 p.m. which was at 10 minutes.
--Unit 1b, was administered on 11/02/15 at 4:05 p.m.: The 15 minute vitals were documented at 4:18 p.m. which was at 13 minutes.

Patient #4
--Unit 4a, was administered on 11/24/15 at 11:56 p.m.: The 15 minute vitals were documented at 12:13 a.m. which was at 17 minutes.

Patient #6
--Unit 6a was administered on 11/21/15 at 4:45 p.m. and Unit 6b was administered on 11/21/15 at 8:37 p.m. These two units were administered without a signed consent.

3. On 12/08/15 at 9:00 a.m., staff member #A1, Registered Nurse, Quality Review, acknowledged that the five above-listed patient blood units had incorrect or incomplete documentation, per policy.


33212


4. Policy "Administration of Blood and Blood Products", reviewed 10/2015, indicated the following: "Transfusion of the blood/blood product including initiation, discontinuation, patient assessments and documentaton is the responsibility of the transfusionist".

5. Review of the following blood transfusion medical records indicated:
a. Patient N27 had a blood transfusion on 6/30/2015 and documentation lacked a signature of person discontinuing or completing transfusion.
b. Patient N28 had two blood transfusions on 6/27/2015 and documentation of both lacked a signature of person discontinuing or completing transfusions.
c. Patient N29 had a blood transfusion on 9/29/2015 and lacked documentation of vital signs at 15 minutes after transfusion was begun.
d. Patient N30 had a blood transfusion on 11/18/2015 and documentation lacked a signature of person discontinuing or completing transfusion.

Based on document review and interview, the hospital failed to ensure that the quality assurance and performance improvement (QAPI) program evaluated 9 services (audiology, bariatric services, contracted biomedical engineering, contracted blood bank, computed tomography, endoscopy, infusion therapy, mammography and magnetic resonance imaging)

Findings:

1. Review of the policy titled Performance Improvement Plan 2015 indicated the following: SCOPE: This Performance Improvement Plan encompasses all key functions of care and services provided. Clinical Support Services: The quality and appropriateness of patient care in all the following services are systematically monitored and outcomes evaluated. The policy was approved 11/2014.

2. Review of Quality Council Committee meeting minutes and reports from January 2015 through November 2015 lacked documentation of reports or evaluations for audiology, bariatric services, contracted biomedical engineering, contracted blood bank, computed tomography, endoscopy, infusion therapy, mammography or magnetic resonance imaging.

3. On 12/8/15 at 1:30pm, A1, Quality Review, indicated the QAPI evaluations did not include the services of audiology, bariatric, contracted biomedical engineering, contracted blood bank, computed tomography, endoscopy, infusion therapy, mammography or magnetic resonance imaging.

Based on document review and interview, the hospital failed to ensure that the quality and appropriateness of diagnoses and treatments were evaluated by an outside entity during 2015.

Findings:

1. Review of the policy titled Performance Improvement Plan 2015 indicated the following: SCOPE: Medical Staff Activities: 4. Utilization review and care management activities related to determining the appropriateness of admissions and continued hospitalization. Hospital Activities: 1. Utilization Management/Care Management/Discharge Planning. ORGANIZATION/RESPONSIBILITY: Medical Staff: (2nd section) 6. Utilization Management by the Care Management Committee will measure processes related to the appropriateness of admissions and continued hospitalization in the most cost-effective manner. Page 6 of the 7 page document, under the heading Quality Council/Case Management, indicated The Quality Council consists of the following: Chief Medical Officer, Chief Executive Officer, Chief Clinical Officer, Chief of Staff, Chief of Staff-Elect, Past Chief of Staff, and five staff members to serve as liaison. The policy was approved 11/2014. The document lacked documentation of quality review by an outside entity.

2. Review of the document titled By-Laws of the Medical Staff, indicated the following in the respective areas: 1.2 RESPONSIBILITIES AND FUNCTIONS, 1.2-1. To conduct, participate in, coordinate and evaluate the effectiveness of the Hospital's quality/safety/utilization review programs, by conducting all required and necessary activities for assessing and improving the effectiveness and efficiency of medical care provided in the Hospital. The document lacked documentation of review of quality and appropriateness of diagnosis and treatment by an outside entity. The By-Laws were approved 6/17/15.

3. Review of 2015 quality meeting minutes and reports lacked documentation of review or reports of quality and appropriateness of diagnosis and treatment by the quality committee or an outside entity.

4. On 12/8/15 at 11:00am, A13, Case Management, indicated the hospital did not utilize an outside agency for utilization review and did not employ services of a Quality Improvement Organization (QIO) for review of quality and appropriateness of diagnosis and treatment.

5. On 12/8/15 at 1:30pm, A1, Quality Review, indicated utilization review was part of case management and that the Quality Council did not include those reports in it's evaluations. A1 also indicated that the hospital did not have an arrangement with an outside QIO.