HospitalInspections.org

Based on document review and interview, the quality assurance program did not identify opportunities for improvement from collected data and/or implement strategies to improve the quality of care for the high number of emergency department patients who leave before being triaged and prior to receiving a medical screening to determine if a emergency medical condition exists. This could lead to patients not receiving needed emergency treatment for undiagnosed problems.

Findings include:

Review of ER/Stroke Quality Assurance committee meeting minutes revealed the following monitoring of patient discharge dispositions for AMA (against medical advice), elopement, left prior to triage, and left without being seen:
July 2015:
- 212 patients presented to the ED, but left before triage.
- 122 patients were triaged, but left before being seen by the physician.
August 2015:
- 124 patients presented to the ED, but left before triage.
- 126 patients were triaged, but left before being seen by the physician.
The committee attributed the high rates to Cerner (electronic medical record system). Actions recommended were to continue to monitor on a monthly basis and continue to request Keystone to provide additional PA (physician assistant) coverage. No evidence was found that PA coverage was increased.
September 2015:
- 151 patients presented to the ED, but left before triage.
- 124 patients were triaged, but left before being seen by the physician.
The Action recommendation was to continue to monitor on a monthly basis. A task force was being developed. No evidence was found to indicate a task force was created.

These findings were confirmed with Staff #2 on 10/08/15 at 1:50 PM.

Based on medical record review, document review and interview, for 1 of 10 patients, the hospital did not ensure medications were administered per provider order. This has potential for an adverse event occurring to the patient.

Findings include:

Medical record review on 10/06/15 of documentation dated 12/27/14 for Patient BB revealed the following:
- Medication Order dated 12/27/14 at 4:53 PM: Rocephin (ceftriaxone), IV (intravenous) 1 gram once, STAT.
- Medication Administration Record dated 2/27/14 at 6:35 PM indicated Rocephin was given.
- Physician note on 12/28/14 at 12:30 PM indicated he was "informed by nursing that Rocephin was hanging on the pole, but not hooked up this morning. It is now running. Azithromycin was running."

Review of the Medication Event Report dated 01/09/15 revealed the 6:35 PM dose of Rocephin on 12/27/14 for Patient BB was found hanging on IV pole unopened, not attached to IV tubing. The Zithromax (azithromycin) dose from 5:41 PM had infused and was attached to IV tubing and pump. Interview on 10/07/15 with Staff #1 revealed that no follow-up was conducted with the nurse who did not connect and administer the IV dose of Rocephin per physician order.

Based on observation and interview, the facility did not maintain the physical plant and overall hospital environment; specifically:
1) The roof was not maintained in a clean manner.
2) Not all components of the heating, ventilation, and air conditioning (HVAC) system were maintained.
These lapses placed patients at increased risk for hospital-acquired infections.

Findings include:

Finding #1:

Observation during facility tour on 10/06/15 at 10:30 AM of the roof located near maternity and the stairwell that discharges to the outside in the vicinity of the laundry revealed extensive vegetation growth on the roof. The area of growth was approximately 4 by 10 feet wide. Having vegetation, along with the dirt, on the roof membrane holds in moisture and can cause the roof to rot and lead to moisture penetration in the building.

This finding was confirmed during interview with Staff #25 on 10/07/15.

Finding #2:

Observation during facility tour on 10/05/15 at 10:45 AM revealed that the "Evapco" cooling tower, located at the exit discharge for the Hodge building on the west side of the building, was discharging water onto the ground. The area covered with water was approximately 6 by 8 feet. This finding was verified with Staff #25 on 10/05/15 at 1:15 PM.

Observation during tour of the radiology department on 10/07/15 at 2:00 PM revealed the HVAC unit located in the closet had evidence of a water leak in the past. There damage to the flooring, and there was a bed sheet on the floor at the threshold. There were two boxes of the floor, which Staff #25 stated contained filters for the HVAC unit. The drywall on the other side of the wall, which formed the corridor wall, had three areas each approximately 3 by 3 inches that were damaged, which appeared to be caused by moisture. During interview at that time, Staff #25 confirmed these findings and indicated that the condensate pump had failed, leading to moisture accumulation. The sheet on the floor could harbor insects, and could grow mold if it became wet. Items stored in the closet could damage the condensate pump, as it was exposed without protection.

Observation during tour on 10/07/15 at 10:00 AM of the shower rooms on the A-2 and A-3 patient units revealed each shower stall had an exhaust vent. Each vent had a large amount dust accumulation, and it did not appear that there was any air being drawn at the exhaust. Staff #25 verified this finding, and stated that he would have maintenance remove an exhaust diffuser and assess the component.

Based on observation and interview, the facility did not ensure for the proper storage of trash. This has potential for infection control risk and physical hazard.

Findings include:

Observation during tour of the intensive care suite on 10/05/15 at 8:45 AM revealed the trash room contained two trash cans that were full, and five bags of garbage on the floor. The floor surface had filth on it.

This finding was verified with Staff #2 on 10/06/15 at 9:00 AM.

Based on observation, interview and document review, the facility did not maintain evidence of regular fire control and safety inspection and approval, specifically:
1) There were incorrect markings for the path of egress.
2) Not all components of the sprinkler system were tested and demonstrated to be functional.
These lapses have potential for impacting the safety of patients, staff and visitors related to fire hazard.

Findings include:

Finding #1:

Observation during facility tour on 10/05/15 at 11:00 AM of the emergency department waiting room revealed two exit signs were directing occupants to a path of egress in which the door was not in service due to construction.

This finding was verified with Staff #2 on 10/05/15 at 4:15 PM.

Finding #2:

Observation during tour of the elevator room on 10/06/15 at 11:00 AM revealed that there was an inspector test port in the piping near the ceiling, with the port located above the elevator equipment. This finding was verified by Staff #25.

Review on 10/06/15 of the sprinkler inspection report, completed by "Davis-Ulmer" on 09/11/15, revealed that the inspector test port located in room 222 A - Elevator Equipment Room did not have an adequate drain, and was not tested.

Based on observation and interview, the hospital did not ensure the availability and reliability of needed supplies for patient care, as evidenced for 1 of 5 patient care areas inspected. This could lead to erroneous patient laboratory test results.

Findings include:

Observation during tour of the S-2 patient unit on 10/05/15 at 10:35 AM revealed that the medication room contained 56 expired green-top phlebotomy vacutainers with an expiration date of 09/2015. This was confirmed with Staff #1 at the time of inspection.

Based on document review, medical record review and interview, the facility did not ensure that all patients received care according to its policies and current standards of practice related to vital sign monitoring for 1 of 15 patients. This could cause staff to have lack of awareness that a patient was unstable.

Findings:

Review on 10/06/15 of policy ED-30 "Assessment of Emergency Department Patient", last reviewed 02/2004, revealed that patients who are triaged as a Level 3 should have vital signs performed every 2 hours or as needed per ED attending order.

Medical record review on 10/06/15 of documentation dated 08/12/15 for Patient G revealed the following:
- At 10:20 AM: Patient G presented to the ED and was triaged at an ESI Level 3 due to a complaint of feeling hot and congested. Vital signs included a temperature of 36.7 C (degrees centigrade) and pulse of 140.
- At 10:43 AM: Temperature was 37.7 C.
- At 1:31 PM: Temperature was 38.0 C and pulse was 180.

These findings were confirmed with Staff #1 on 10/07/15 at 4:00 PM.