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Based on hospital policy review, medical record reviews and staff interview, the hospital staff failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner for 1 of 7 patients sampled who were restrained for the management of violent or self-destructive behaviors (#15).

The findings include:

Review of current hospital policy "Restrictive Interventions" (RI) revised 02/2011 revealed, "I. POLICY ...B. The use of restraint is in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient, has a working knowledge of the hospital policy regarding the use of restraint and seclusion and is authorized to order restraint by hospital policy. ..."

Open record review on 03/03/2011 for Patient #15 revealed an 22 year-old male admitted to the hospital on 02/16/2011 with a diagnosis of Psychosis. Review of electronic restraint documentation for "RI-Violent/Self-Destructive" (behavior), revealed the patient was placed into a manual restraint for "Dangerous to self, Dangerous to others" on 02/21/2011 from 2143 to 2145 (2 minutes). Record review of a "Restrictive Intervention Order and Face-to-Face Assessment" form dated 02/21/2011 revealed "Physician Order (to be completed within 1 hour of initiation of RI and as appropriate to age for renewal): Type of Intervention: [X marked in the box] manual." Further review revealed the "MD signature or telephone order by RN, Date, Time" lines and "MD signature if telephone order above, Date, Time" lines were blank. Record review revealed no available documentation of a valid physician's order for the manual restraint of Patient #15 on 02/21/2011 from 2143 to 2145.

Interview on 03/03/2011 at 1645 with hospital management staff revealed a physician's order is required for the use of restrictive interventions. Interview revealed the physician's order for restrictive interventions for the management of violent or self-destructive behaviors must be time limited according to the patient's age. Interview confirmed the Restrictive Intervention Order and Face-to-Face Assessment form dated 02/21/2011 had a "X" marked in the box next to manual (restraint) for the type of intervention. Further interview confirmed no signature, date, or time, on the "MD signature or telephone order by RN, Date, Time" lines nor on the "MD signature if telephone order above, Date, Time" lines. Interview confirmed the lines were blank. Interview confirmed the hospital staff failed to follow the hospital's Restrictive Interventions policy.

Based on hospital policy review, medical record reviews and staff interview, the hospital staff failed to ensure a time limited restraint order was obtained for 3 of 7 patients sampled who were restrained for the management of violent or self-destructive behaviors (#17, #15, #13).

The findings include:

Review of current hospital policy "Restrictive Interventions" (RI) revised 02/2011 revealed, "I. POLICY ...H. Violent/Self-destructive Restraint Orders ...5. Each written order is limited to four hours for adults, two hours for children and adolescents age 9-17, and one hour for patients under nine years of age. ..."

1. Open record review on 03/03/2011 for Patient #17 revealed a 16 year-old male admitted to the hospital on 02/28/2011 with a diagnosis of Mood Disorder and Violent Behavior. Review of electronic restraint documentation for "RI-Violent/Self-Destructive" (behavior), revealed the patient was placed into a manual restraint for "Dangerous to self, Dangerous to others" on 02/28/2011 from 1355 to 1405 (10 minutes). Record review of a "Restrictive Intervention Order and Face-to-Face Assessment" form dated 02/28/2011 revealed "Physician Order (to be completed within 1 hour of initiation of RI and as appropriate to age for renewal): Type of Intervention: [X marked in the box] manual" (restraint). Further review revealed "Time Limit:" with NO marks in the boxes adjacent to the pre-printed age appropriate time limits for restraint (2 hours or less for 9-17 year olds). Record review revealed no available documentation of a age appropriate time limited physician's order for the manual restraint of Patient #17 on 02/28/2011 from 1355 to 1405.

Interview on 03/03/2011 at 1645 with hospital management staff revealed a physician's order is required for the use of restrictive interventions. Interview revealed the physician's order for restrictive interventions for the management of violent or self-destructive behaviors must be time limited appropriate to the patient's age. Interview revealed Patient #17 was 16 years old. Interview revealed restraint orders should be time limited to 2 hours or less for this patient. Interview confirmed the Restrictive Intervention Order and Face-to-Face Assessment form dated 02/28/2011 did not indicate a time limit for the restraint order. Interview confirmed the hospital staff failed to follow the hospital's Restrictive Interventions policy.

2. Open record review on 03/03/2011 for Patient #15 revealed a 22 year-old male admitted to the hospital on 02/16/2011 with a diagnosis of Psychosis. Review of electronic restraint documentation for "RI-Violent/Self-Destructive" (behavior), revealed the patient was placed into a manual restraint for "Dangerous to self, Dangerous to others" on 02/21/2011 from 2143 to 2145 (2 minutes). Record review of a "Restrictive Intervention Order and Face-to-Face Assessment" form dated 02/21/2011 revealed "Physician Order (to be completed within 1 hour of initiation of RI and as appropriate to age for renewal): Type of Intervention: [X marked in the box] manual" (restraint). Further review revealed "Time Limit:" with NO marks in the boxes adjacent to the pre-printed age appropriate time limits for restraint (4 hours or less for 18 or older). Record review revealed no available documentation of a age appropriate time limited physician's order for the manual restraint of Patient #15 on 02/21/2011 from 2143 to 2145.

Interview on 03/03/2011 at 1645 with hospital management staff revealed a physician's order is required for the use of restrictive interventions. Interview revealed the physician's order for restrictive interventions for the management of violent or self-destructive behaviors must be time limited appropriate to the patient's age. Interview revealed Patient #15 was 22 years old. Interview revealed restraint orders should be time limited to 4 hours or less for this patient. Interview confirmed the Restrictive Intervention Order and Face-to-Face Assessment form dated 02/21/2011 did not indicate a time limit for the restraint order. Interview confirmed the hospital staff failed to follow the hospital's Restrictive Interventions policy.

3. Closed record review on 03/03/2011 for Patient #13 revealed a 12 year-old male admitted to the hospital on 02/16/2011 with a diagnosis of Depression. The patient was discharged on 02/28/2011. Review of electronic restraint documentation "RI-Violent/Self-Destructive" (behavior) revealed the patient was placed into manual and 4-point restraint for "Dangerous to others" on 02/19/2011 from 1945 to (2045 {60 minutes}). Record review of a "Restrictive Intervention Order and Face-to-Face Assessment" form dated 02/19/2011 revealed "Physician Order (to be completed within 1 hour of initiation of RI and as appropriate to age for renewal): Type of Intervention: [X marked in the box] manual, [X marked in the box] 4-point" (restraint). Further review revealed "Time Limit:" with NO marks in the boxes adjacent to the pre-printed age appropriate time limits for restraint (2 hours or less for 9-17 year olds). Record review revealed no available documentation of a age appropriate time limited physician's order for the manual restraint of Patient #13 on 02/19/2011 from 1945 to (2045).

Interview on 03/03/2011 at 1645 with hospital management staff revealed a physician's order is required for the use of restrictive interventions. Interview revealed the physician's order for restrictive interventions for the management of violent or self-destructive behaviors must be time limited appropriate to the patient's age. Interview revealed Patient #13 was 12 years old. Interview revealed restraint orders should be time limited to 2 hours or less for this patient. Interview confirmed the Restrictive Intervention Order and Face-to-Face Assessment form dated 02/19/2011 did not indicate a time limit for the restraint order. Interview confirmed the hospital staff failed to follow the hospital's Restrictive Interventions policy.

Based on medical record review and staff interview, the hospital's nursing staff failed to provide supervision and evaluation of care in 1 of 1 sampled patients refusing medications (#38), and failed to ensure a dialysis prescription was present and complete in 1 of 5 sampled hemodialysis patients before initiating treatment (#4).

The findings include:

1. A review on 03/03/2011 of the closed medical record for patient #38 a 44 year old male revealed that the patient was admitted to the hospital on 06/30/2010 through 07/12/2010 with a diagnosis of "Acute Renal Failure." The review of documentation by the hospital's medical staff in the progress notes revealed "SCDs (Sequential Compression Device) for DVT (Deep Vein Thrombosis) prophylaxis, refuses medications consider Coumadin at discharge."

Review of the patient's medication administration record revealed that the patient was ordered by the physician to receive the medication "Heparin (anticoagulant medication) 5000 units per 5 milliliter subcutaneous every 8 hours" beginning 07/04/2011 for DVT (Deep Vein Thrombosis) prevention. A review of the medication administration record revealed that the patient refused the medication "Heparin" on 07/04/2011 at 1603, 07/05/2011 at 0503, 07/05/2011 at 1804, 07/05/2011 at 2200, 07/06/2011 at 0614, 07/06/2011 at 1520, 07/06/2011 at 2115, 07/07/2011 at 0607, 07/07/2011 at 1858, 07/07/2011 at 2228 and 07/08/2011 at 0544 (total of 11 missed doses in 4 days). The review revealed that the hospital's nursing staff documented each of the 11 refusals as "Patient Refused." No documentation was found where the hospital's nursing staff reported the refusals of medication to the patient's physician or the pharmacy in the hospital. No other documentation was found in the patient's medical record that the nursing staff evaluated the care of the patient based on refusal of the medication "Heparin."

An interview on 03/03/2011 at 1505 with the hospital's nursing administrative staff revealed that no further documentation was found from the nursing staff reference the patient's refusal of the medication. The interview revealed that the nursing staff usually would report a patient refusing multiple medications.

An interview on 03/04/2011 at 0915 with the hospital's pharmacy director revealed that the nursing staff should have made the physician or pharmacy aware of the patient refusals of "Heparin" so that possibly another medication choice could have been looked at as a replacement.

2. A review on 03/03/2011 of the closed medical record for patient #4 a 19 year old male, revealed that the patient presented to the hospital's emergency department on 02/05/2011 at 1916 with a need for "emergency dialysis." The review of the record revealed that the patient was sent to the hospital's inpatient kidney dialysis unit for hemodialysis treatment at 2016. Review of the physician's orders in the emergency department revealed that no blood flow rate or dialysate flow rate was prescribed for the patient. A review of the hospital's "Hemodialysis Orders" form revealed that the section of "Blood Flow Rate" was left blank. The section of the form for the "Dialysate Flow Rate" had documentation of 350 milliliters/minute. Further review of the documentation revealed that the orders documented on the "Hemodialysis Orders" form were telephone orders on 02/05/2011 at 2105 by the hospital's dialysis nursing staff from a hospital physician. The review revealed no signature from the physician verifying the orders until 02/20/2011 at 1639 (total of 15 days later). The review revealed that the patient received hemodialysis at the hospital without any physician order for a "Blood Flow Rate." The review of the patient's treatment flow sheet detailing his hemodialysis treatment revealed that the hospital's nursing staff hemodialyzed the patient on a blood flow rate of 350 milliliter/minute and a dialysate flow rate of 600 milliliters/minute. The review revealed that neither the blood flow rate of 350 or dialysate flow rate of 600 was ordered by any physician.

An interview on 03/03/2011 at 1215 with a hospital hemodialysis nurse #2 revealed that the nursing staff "wrote the wrong blood flow rate in the wrong area of the form. The nurse did get a telephone order from the physician and documented the order in the wrong place. No correct dialysate flow rate was documented in the order either. The physician usually does see the patients and the records before 15 days."

Based on hospital policy review, staff interviews, observations during tours, review of the hospital's "Main RO (reverse osmosis) Log/Checklist" and observations as referenced in the Life Safety Report of Survey completed March 4, 2011, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

1. The hospital failed to maintain the environment ensuring the safety and well being of patients as referenced in the Life Safety survey completed 03/04/2011.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A0701.

2. The hospital failed to ensure an acceptable level of safety and quality for its hemodialysis water system by failing to monitor resistivity during DI (Deionizer) backup use and failing to test water hardness at the end of each treatment day.

~Cross-refer to 482.41(c)(2) Physical Environment Standard Tag A0724.

Based on observations, tours, and staff interviews as referenced in the Life Safety survey completed 03/04/2011, the hospital failed to maintain the environment ensuring the safety and well being of patients.

The findings include:

1. Based on observation on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM of Building four (4): Room 2310 , Penetrations in firewall were not sealed in order to maintain required fire rating of wall.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0012.

2. During tour of Building one (1) observation revealed STICU (Surgical Trauma Intensive Care Unit) Room #11629 - Inactive leaf with no self closing device and self- latching. Exit access doors must provide latching with a single hand motion.(Approx 29 rooms/ and 2 add'l floors); Family waiting room - STICU: Master switch will not release exit access door near 11681 Conf (Conference) Room. Door did release as required with sensor and push pad; Dutch doors to Pharmacy Office 10682 had no self closing and self-latching device on inactive leaf. Door must be arranged to provide latching with a single hand motion; Corridor doors to patient rooms #9130 and 7133 would not latch/nor smoke tight; and Patient Room 6020 - Corridor door inactive leaf is not self-closing and self-latching - (12 rooms on 6th floor).

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0018.

3. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 1. Smoke barrier at entrance to STICU has access door above ceiling - door is not self closing/latching (Beside Family waiting room - 11th floor).

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0025.

4. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 1. Cross corridor smoke doors at Room # 10621 and 3rd floor Smoke doors outside of Nuclear Cardiology do not close smoke tight when tested.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0027.

5. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Corridor door to Ortho storage room near Room 11310/11312 - Inactive leaf of 3/4 hour fire door with-out self closing device and latching hardware. (Med Center Air Training Room); No self closing device on doors to Elev Machine room - Med Center Air - Mechanical Room and 7th Floor - West wing Nursery storage Room 7600.81; Clean storage across from Room 10115 - Transom at top of door has framing that is not listed fire door frame; Corridor door to Mech Room across from Room 10939B has excessive gap at top of door; Room 10307 - Storage area utilizes side-wall sprinkler heads and some areas have no coverage; 10 L - Storage Area/Access area (beside Gold Elevator) is not sprinklered and one hour required corridor wall has gypsum board on one side of studs with studs exposed from inside the room; and 2nd Floor Trash Chute Termination Room - abandoned access door through wall was not secured to maintain required fire rating of the wall.

Based on observation of Building three (3) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Door to O2 storage room (Pre-op) is not self closing.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0029.

6. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: This facility utilizes Special Locking (Magnetic) devices through out in various locations (Delayed egress, Access Control, and NC Special Locking), the facility is not equipped through-out (100%) with an automatic, supervised fire suppression system (Sprinkler) or an automatic, supervised smoke detection section or a combination there-of, Note:The facility has budgeted and prepared design drawings to be submitted to DHSR-Construction Section for review and approval to complete 100% sprinkler system covering remaining areas (approx 25%) within the next 4 years; Corridor doors near room 10660 equipped with delayed egress lock - lock required more than 15 lbs of pressure to activate unlocking mechanism. When activated the Card swipe would reactivate/interrupt the locking device during the 15 seconds delayed egress time frame. Delayed egress doors near Elev 33 and 34 at Room 3669 would auto relock when card reader was activated by staff card; Delayed egress lock at entry to NSICU (Neuro Surgical Intensive Care Unit) near room 9672 Required excessive force (more than 15 lbs) to activate unlocking mechanism; Incomplete dynalock on stairway door near room 9929 - device is an electromagnetic locking device used as a signaling device - device is capable of being altered and used as a locking device; Corridor 9-A, Exit door equipped with Magnetic Locking device found not to be activated. If not utilized, magnetic hardware must be removed so not to be accidently re-activated; Exit Stairwell #18, T-wing, Exit discharge door required greater than 15 lbs of pressure to open door. (No magnetic lock involved); 3 rd floor - Fire doors at Cardiology Registration were equipped with NC Special Locking with no override switch at the door or Master switch at Nurses' station; Loading Docks - No guard rails at when delivery trucks were not present.

Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: the third floor delayed egress locking device on corridor doors required more than 15 lbs of pressure to initiate the un-locking process (next to the linen and trash chutes from L to P ). The door released as required under normal operating conditions and released with activation of the Fire Alarm System as required.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0032.

7. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Stairway #18, Level 2 - No signage to indicate continuance of egress to exit discharge; Stairway #18 - Exit discharge contains less than 6 ft 8 inches of headroom from top of stair tread to landing above. The height between the finished floor and ceiling of stair landing is less than seven feet and six inches as required under the 1982 Life Safety Code; NFPA 101 edition. This area of the facility was constructed in year 1991 according to hospital data; and serves multiple patient floors; Stair #24, Fire Door will not latch, Beside room 1660; 6th Floor , 6-L/S, Door to Stairwell 6th floor to 5th floor did not close/latch/seal as required.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0033.

8. Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: the corridors at staff area on 9th floor (and floors below) are only five feet wide. Exit signs directing general public, staff and patients to these corridors require these corridors to be eight feet wide for Healthcare Occupancy.
Note: If truly staff only areas, and not intended for customary access by patients, then five feet corridors are permitted.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0039.

9. Based on observation of Building three (3) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: No Exit discharge lighting at Exit door next to parking deck.

Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 1st floor at room 1001 - Exit Discharge lighting had only one single bulb fixture. Emergency lighting connected to the Life Safety Branch of the essential electrical system must be provided from the exit discharge to the publicway.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0045.

10. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: No emergency lighting in small corridor at Room # 9422 - Epilepsy Monitoring Unit.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0046.

11. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Corridor area at Stairwell #4 - Exit directional sign did not indicate correct travel path to exit stairwell; 4th Floor Radiology Reading Rooms exit egress corridor - no exit directional sign and Stairwell 17, Level 1, T-wing, Exit sign directs people back into building, Chevron directional indicator missing.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0047.

12. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Corridor smoke detector installed more than 15 feet from end wall of corridor - Near 9 A wing and L wing intersection.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0053.

13. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: ESRD (End Stage Renal Disease) - Staff breakroom - 10th floor - No sprinkler coverage for shower stall area; Stairway #20 - Lower landing at exit passageway has no sprinkler coverage; J-Wing , 5th Floor - There was no sprinkler coverage nor heat/smoke detection in the area at construction entrance; 7th Floor - I.S. Closet at room 7719 had no sprinkler coverage.

Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Recessed corridor space (alcoves) at rooms 9023/9024 are not covered by sprinkler as required.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0056.

14. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: The Pre-Action Dry Sprinkler system (Covering ORs) - Valve at air pressure alarm not supervised; 7-D, Stairwell #5 - Tamper alarm was secured with "J" hooks; Loading dock area - Dry sprinkler system - pressure operated flow switch valve not supervised; Blythe Pkg Deck - Sprinkler System - Back flow preventers tamper switches (2 of 3 tested) did not send alarm.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0061.

15. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: CMC- Main - Penthouse - A-wing: Chair and 2 X 4 wood members found in AHU plenum - make -up air unit; 2-B Mech Room, Smoke duct detector # N7L3057 in AHU # 13, Detection tube turned 180 degrees wrong direction.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0067.

16. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Kitchen/ Dietary - New deep fryer added with no Ansul fire suppression nozzle installed to cover the new equipment.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0069.

17. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Portable Space Heater -High Temp Type- in Nurse Manager's office -across from ESRD Continuum Care.

~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0070.

18. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 10 floor - C-wing - Dumbwaiter fire rated door (Near elevator) has a hole in the door leaf; Vertical Chase across from room 9948 - access door is not required 2 hr fire rated; Trash Hold Room #1662 - door to trash chute terminal room was found to be 3/4 hr rated door instead of required 1.5 hr rating; Vertical chute fire access door 6000.3 is not self closing and latching; A-Wing Mech Room - Door to vertical chute did not close/latch/seal as required and 7th Floor - Dumbwaiter chute door in NICU large storage room does not self close and latch as required.
Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Fire Door Strike plate was taped over to prevent latching (vertical chase enclosure near room 12660); Floor 1 T, Trash chute fire door assembly does not seal and the following vertical chase was non-compliant, specific findings include: the linen chute on the third and fifth floors did not close and latch properly. (L wing attached to the LCH)
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0071.
19. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Stairway #18 - Sprinkler pipe and Valve protrude into stairway egress path - Level 2; Storage in corridor , 6th floor - B-wing and Cath Lab corridors - Lots of beds stored in corridors, (Beds, equip, etc).
Based on observation of Building four (4) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 2nd Floor, across from room 2E-86, Corridor doors to storage rooms opened into corridor. They were not equipped with self closing hardware nor would swing 180 degrees in order not to impede egress.
Based on observation of Building seven (7) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Boxes were stored blocking exit to stairwell #2 on 3rd floor.
Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: 9th Floor Staff area corridor at elevator lobby - Corridor Doors to toilets swing into corridor path; doors do not swing 180 degrees or have self closing devices. If left in the open position, doors would obstruct corridor egress path. This condition exist on other floors of this building; 10th and 11th floors- Computer on Wheels were being stored and charged in exit egress corridors near nurses' stations.
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0072.
20. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Room 10402 - Unsecured O 2 tank (freestanding on floor) and Unsecured O 2 tanks at old loading dock, also H tanks - O 2 gang chained and not individually secured as required. (Gang chain found loose and not supporting tanks as necessary to prevent damage to valves).
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0076.
21. Based on observation of Building one (1) and review of staff records on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Relative humidity levels were found to be less than 35% in OR#1 and OR #2. This data was provided by hospital reports.
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0078.
22. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Generator Annunciator did not show loss of normal power to ATS with audible/visual signaling device. Test switch did not activate audible signaling device at Security Station & Plant operations.
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0145.
23. Based on observation of Building one (1) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Unitary Light required at Generator Set control panel area - Lower Blythe Parking Deck; Unit heater to Fire Pump Room is connected to Normal power source (Blythe Pkg Deck); Electrical Snap Switch was broken at M-wing exit passageway - beside pull station N6L1M01; Electrical Panel Board circuit directory is not labeled to indicate devices served - panel board serving exit passageway beside pull station N6L1M01.
Based on observation of Building five (5) on Tuesday 03/01/2011, 9 AM onward through Friday 03/04/2011, 3:30 PM: Roof - Outside of Mech Room #12669 - Standard duplex receptacle is not GFI protected, and labeled.
~ Cross refer to Life Safety Code Standard - NFPA 101, Tag K 0147.

Based on the hospital's policy review, observation, the hospital's "Main RO (reverse osmosis) Log/Checklist" review and staff interview, the hospital failed to ensure an acceptable level of safety and quality for its hemodialysis water system by failing to monitor resistivity during DI (Deionizer) backup use and failing to test water hardness at the end of each treatment day.

The findings include:

1. A review of the facility's policy and procedure "Bypassing The Main Reverse Osmosis Water System" (Revised 12/2010) revealed the purpose of the policy was to ensure safe water for providing dialysis treatments. The review of the policy further revealed that the when bypassing reverse osmosis, that the DI tanks would be turned on and flushed for 5 minutes. The policy also revealed that the DI monitor would be turned on and the chlorine/chloramine levels would be checked hourly during bypass. The review of the policy revealed no documentation or guidance for checking and/or documenting resistivity monitors during the dialysis treatment times.

Observation on 03/01/2011 at 1345 in the hospital's "Kidney Dialysis Unit Water Treatment Area" revealed that two (2) DI tanks were attached and available for backup use. The observation revealed that the hospital's RO was in operation and the two DI tanks were not being used as the primary water system on 03/01/2011. The observation did reveal that the DI tanks were available as the RO backup and bypass if needed by the hospital.

A review on 03/02/2011 of the hospital's "Main RO Log/Checklist" for the time period of 02/12/2011 through 02/23/2011 (total of 11 days) revealed that the DI tanks were in use as the primary water system due to RO being out of service and bypassed. The review revealed that monitoring of the DI tanks by the hospital's dialysis staff consisted of documenting if the DI (De-ionizing) Tank Light was green (greater than 1.0 megohm-cms) or red (less than 1.0 megohm-cms). The review of the documentation revealed that the hospital failed to monitor 02/12/2011 through 02/23/2011 the DI tanks resistivity levels twice each treatment day in order to ensure that the readings indicated that the dialysis water had resistivity 1.0 megohm-cms or greater that would indicate safe dialysis treatments. Documentation review for 02/13/2011 revealed that the dialysis staff failed to document any resistivity monitoring for the entire treatment day. The review revealed that no documentation was done to indicate whether the green DI tank light or the red DI tank light was on for 02/13/2011.

An interview on 03/03/2011 at 1410 with the facility's dialysis water staff revealed that the hospital did not have any documentation that would indicate DI resistivity monitors were documented twice each treatment day. The interview revealed that the staff only documented that the DI tanks had a green light during the RO startup period once a day except for 02/13/2011 when the entire day documentation was missed for the DI tanks.

2. A review of the hospital's policies and procedures "Water Testing Policy in the Kidney Dialysis Unit" (Revised 01/2011) revealed "Document water hardness at SP4 (port area) using WaterSoft strips once daily in the afternoon."

Observation on 03/01/2011 at 1345 in the hospital's "Kidney Dialysis Unit's Water Treatment Area" revealed the dialysis nursing staff performing the total chlorine/chloramine testing to ensure safe dialysis water for patient use. An interview during the observation revealed that the staff member (Nurse #1) revealed while explaining the dialysis water treatment system that he would be checking the total water hardness before the end of the day. "I will be checking it anytime now (time 1345)." The observation revealed that patients were undergoing hemodialysis treatments at 1345 and that the total hardness testing for the water softener system would be checked before the end of the treatment day.

An interview with the facility's nurse manager on 03/02/2011 at 1358 revealed that the total hardness testing for the water softener needed to be done close to the end of the treatment day or late afternoon. The interview revealed that the practice is sometimes difficult due to patient's being hemodialzed throughout the day.

Based on review of the Operating Room (OR) register (log) and staff interview the Surgical Services department failed to maintain a complete and up to date register including documentation of the type of anesthesia used and/or the post-op diagnosis.

The findings include:

Review of the OR log on 03/03/2011 revealed multiple missing entries for the documentation of the postoperative diagnosis and the type of anesthesia used. Review of the log for 11/27/2010 revealed four (4) out of twenty (20) surgical cases did not have documentation for the postoperative diagnosis and thirteen (13) out of twenty (20) cases did not have documentation of the type of anesthesia used. Review of the log for 12/05/2010 revealed four (4) out of thirty two (32) surgical cases did not have documentation for the postoperative diagnosis and seventeen (17) out of thirty two (32) cases did not have documentation of the type of anesthesia used. Review of the log for 01/14/2011 revealed thirty eight (38) out of one hundred forty seven (147) surgical cases did not have documentation for the postoperative diagnosis and sixteen (16) out of one hundred forty seven (147) cases did not have documentation of the type of anesthesia used. Review of the log for 02/28/2011 revealed twenty six (26) out of eighty nine (89) surgical cases did not have documentation for the postoperative diagnosis and six (6) out of eighty nine (89) cases did not have documentation of the type of anesthesia used. Review on 03/04/2011 of the log for 03/01/2011 revealed fifty eight (58) out of one hundred thirty (130) surgical cases did not have documentation for the postoperative diagnosis and nineteen (19) out of one hundred thirty (130) cases did not have documentation of the type of anesthesia used.

Interview with administrative surgical services staff on 03/01/2011 at 1400 revealed the staff had attempted three (3) times to complete an OR log with the required components. The interview revealed the log reviewed had the component headings for postoperative diagnosis and anesthesia type used. The interview revealed the respective components were not completed and/or did not have the correct documentation. The interview revealed there was no further documentation available for an OR log.