HospitalInspections.org

Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the outside view into the rooms of 4 (g, h, i, j) of 12 patient rooms observed.
Findings:

Observation on 04/26/2021 at 9:05 a.m. revealed there were no window coverings for patient rooms g, h, i and j.

Interview on 04/29/2021 at 09:15 a.m., S9EOC acknowledged there were no window coverings for rooms g, h, i, and j.

Based on record review, observation and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to maintained ordered observation levels for 1 sampled patient on line of site observation (Patient #1) and 3 sampled patients (Patients #2, #3, #7) on every 15 minute observations in a total sample of 9.
Findings:

Review of the hospital policy titled, Admission/Assessment - Close Observation, revealed in part that for all patients admitted to the hospital, regular precautions or close observations, will be performed to ensure the safety of the patient, their peers and staff. Every patient will be seen by a staff member every 15 minutes, or more frequently as needed, and checked off on the Close Observation Sheet as present. Line of Sight Observation-The patient continuously remains in the line of sight view of the observer.

Review of the medical record for Patient #1 revealed an admit date of 04/21/21 with a line of sight observation level ordered.

On 04/26/21 at 9:15 a.m., observation revealed Patient #1 lying in his bed in his room. The patient's room was at the end of the hall and the patient was not being observed by any staff. Further observations revealed there was no staff on the hall.

On 04/26/21 at 9:30 a.m., observation revealed several patients were in the dining room with two techs. Interview with S4Tech at that time revealed that she was responsible for observing four patients, including Patient #1 and #2. The surveyor requested the Close Observation Sheets for the four patients. Review of the sheets revealed that they were blank. Further interview with S4Tech revealed that her shift began at 7:00 a.m. but she had not had time to fill out the sheets. She further stated that all four patients were on every 15 minute observations. When asked the whereabouts of Patient #1, S4Tech stated that she thought he was in his room.

On 04/26/21 at 9:40 a.m., interview with S5Tech, who was also in the dining room, revealed that she was responsible for observing four patients, including Patient #3 and #7. The surveyor requested the Close Observation Sheets for the four patients. Review of the sheets revealed that they were blank. Further interview with S5Tech revealed that her shift began at 7:00 a.m. but she had not had time to fill out the sheets.

On 04/26/21 at 3:20 p.m., observation revealed Patient #1 was lying in his bed in his room without being in line of sight of staff. Further observations revealed there were no staff on the hall.

On 04/26/21 at 3:25 p.m., the surveyor reviewed Patient #1's medical record with S3RN and she confirmed the patient had a current physician order for line of sight observation level. S3RN stated that the patient should be in the staff's line of sight at all times. At that time, the surveyor and S3RN observed Patient #1 in his room without any staff observing him. S3RN confirmed the staff was not following the physician order for line of site observations.

Based on observation and interview, the hospital failed to properly file and store patient records in a manner to protect them from water damage in case of fire as evidenced by storing incomplete records in the baskets of open metal carts.
Findings:

On 04/28/21 at 10:00am, observation of the medical records storage area revealed several open metal carts with baskets containing numerous patient records sitting inside the medical records office beneath sprinkler heads.
An interview at this time with S10HIM confirmed there were approximately 93 charts in the carts that had been reviewed, flagged and were waiting for staff to complete the records. She confirmed that this it is her usual practice to store the records in the open carts until completed. She further confirmed that the records would not be protected from water damage if the sprinkler system was activated.

Based on record review and interview, the hospital failed to ensure policies and procedures were developed that addressed proper safety precautions against radiation hazards to provide for the safety of patients and staff during radiological procedures performed by the hospital's contracted mobile x-ray service.
Findings:

Review of the current list of contracted services revealed the hospital's radiological services were provided via a contracted mobile x-ray service.

Review of the hospital's radiological policy revealed no documented evidence that the policy addressed proper safety precautions for protection of the patients and staff against radiation hazards during radiological procedures performed by the hospital's contracted mobile x-ray service.

Interview on 04/28/2021 at 9:20 a.m., S1CEO acknowledged the hospital's radiological policy did not address proper safety precautions for protection of patients and staff against radiation hazards during radiological procedures performed by the hospital's contracted mobile x-ray service.

Based on record reviews and interviews, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist supervised the hospital's Radiology Services.
Findings:

Review of the hospital's staffing list and physicians with privileges failed to reveal a radiologist appointed and credentialed to supervise the radiology services.

Review of the Service Agreement with the portable x-ray imaging services and the hospital failed to reveal the imaging service provider would ensure the radiologist performing interpretation were credentialed.

Interview on 04/28/2021 at 1:20 p.m., S1CEO confirmed the hospital did not have a radiologist appointed and credentialed to supervise the radiology services.

Review of Patient #3's Medical Record revealed a chest x-ray dated 04/24/21 and interpreted and signed by S11MD on 04/24/2021 at 3:36 p.m.

Interview on 04/28/2021 at 1:20 p.m., S10HIM stated S11MD was not a credentialed radiologist with the hospital and did not have privileges as a radiologist with the hospital.

Interview on 04/28/2021 at 1:30 p.m., S1CEO reviewed the contract and acknowledged the hospital did not have a process for assuring the radiologist were credentialed to interpret radiology imaging performed for the hospital.

Based on observation and interview, the hospital failed to employ methods for preventing the transmission of infections within the hospital by failing to maintain a sanitary environment.
Findings:

On 04/26/21 at 8:30 a.m., observation of unoccupied patient rooms and the clinical area at the main campus revealed the following:
Room a had an unclean bedspread crumpled in a pile laying on top of bed B near the window with pieces of toilet tissue laying nearby on the floor. There was a dried spill noted on the floor at the bottom of bed A. An empty milk carton with paper trash was sitting on the counter near the sink, and there was hair noted in the bottom of the shower stall and on the bathroom floor. There was a piece of cloth tape noted on the grab bar in the bathroom near the toilet.

On 04/26/2021 at 9:30 a.m., observation revealed 7 culture swabs with an expiration date of 01/31/202.

On 04/26/2021 at 9:32 a.m., an interview with S9EOC confirmed the culture swabs were expired and should not have been available for use.

On 04/26/21 at 3:30 p.m., an interview with S9EOC confirmed that the room had been cleaned and was ready for a new patient.

On 04/26/21 at 8:45 a.m., observation of the medication pill crusher in the medication room revealed it was coated with a black powdery substance that was easily wiped off. Interview with S3RN at that time confirmed it was in need of cleaning.

On 04/26/21 at 3:45 p.m., interview with S9EOC revealed room b had been cleaned and was ready for a patient. At that time, observation of room b revealed grime and debris on the shelves against the wall. Debris was observed on the bare mattress and on the floor. Further observations revealed algae and debris in the shower stall.

On 04/27/21 at 8:10 a.m., observation of unoccupied patient rooms at the off-site campus revealed the following:
- Room c had pillows with rips, holes and tears in them sitting inside the baskets in the cubbyholes for beds A and B. The bathroom floor had areas covered with grime, debris, hair, and several small crawling ants.
- Room d had a strip of old cloth tape stuck on the bottom of Bed B and 2 medication stickers stuck to the floor - one was dated 4/08; there was dirt, grime and hair noted on the bathroom floor.
- Room e had dirt, grime and hair on the bathroom floor.
- Room f had a cloth pillow with no protective covering sitting inside the basket in the cubbyhole for bed A.
An interview at this time with S9EOC confirmed that the above patient rooms were cleaned and ready for new patients.