HospitalInspections.org

Based on document review and interview, the facility failed to have a monitor for quality activities for 1 of 16 contracted services, and failed to have a standard for 4 of 16 contracted services, as part of its comprehensive quality assessment and performance improvement (QAPI) program for calendar year 2016.

Findings include:

1. Review of the facility's QAPI minutes and reports for calendar year 2016 indicated they did not include a monitor for the contracted service of dietary.

2. Review of the facility's QAPI minutes and reports for calendar year 2016, indicated they did not include a standard for the contracted services of ambulance, dietary, lithotripsy, and housekeeping.

3. In interview on 08-31-2017 at 1:20 pm, employee #A21, Manager Performance Improvement, confirmed all the above and no further documentation was provided prior to exit.

Based on document review and interview, failed to include a report to the governing board for 1 of 43 directly-provided services and 3 of 16 contracted services, as part of its comprehensive quality assessment and performance improvement (QAPI) program for calendar year 2016.

Findings include:

1. Review of the facility's QAPI minutes and reports for calendar year 2016 indicated they did not provide a report to the facility's governing body for review of the directly-provided service of central supply, and contracted services of dietary, laundry and nursing.

2. In interview on 08-31-2017 at 1:20 pm, employee #A21, Manager Performance Improvement, confirmed all the above and no further documentation was provided prior to exit.

Based on document review and interview the facility failed to ensure specialized qualifications and competence of nursing staff in four (SN3, SN7, SN8 and N11) of 15 personnel files reviewed.

Findings include:

1. Review of facility policy, Orientation of New Employees, reviewed 5/22/2017, indicated, each department will document orientation and significant training activities carried out for each employee.

2. Review of RN (registered nurse) Checklist Competencies, Personnel files, indicated the preceptor had not signed orientation completion for SN3, SN7 and SN8 (registered nurses).

3. Interview on 8/30/2017 at approximately 3:15 pm, in the conference room with N29 (Human Resources Director) confirmed, SN3, SN7 and SN8, files lacked completion of orientation signatures.

4. Review of personnel files indicated SN11 (registered nurse) lacked documentation of Blood Administration Training.

5. Interview on 8/30/2017 at 3:15 pm, in the conference room with N29 (Human Resources Director) confirmed, SN11 files lacked documentation of Blood Administration training.

Based on interview and document review, a radiology technologist failed to appropriately store a radiation measuring badge according to the employee's competency training, in 1 instance.

Findings include:

1. On 8-27-2017 at 3:05 pm, in the presence of employee #A19, Director Facility Resources, and employee #A18, Director of Imaging, in Computer Tomography Room A1333, employee #A23, Radiology Technologist, indicated he/she, at the end of the shift, placed the radiation measuring (dosimeter) badge in his/her backpack and took it home.

2. Review of a document titled St. Joseph Regional Medical Center - Diagnostic Imaging Competency Evaluation for employee #A23, dated 4/7/17, indicated the employee was familiar with proper Radiation Badge Locations.

3. In interview on the above-stated date and time, employee #A18 indicated the badges were to be stored in a designated place in the department and not to be taken home.

4. In interview on 08/18/2017 at 2:30 pm, employee #A18 confirmed the Imaging Competency Evaluation for employee #A23 and no other documentation was provided prior to exit.

A Life Safety Code Validation Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

Survey Date: 08/29-30/17

Facility Number: 005017

At this Life Safety Code survey, Saint Joseph Regional Medical Center was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

Saint Joseph Regional Medical Hospital is comprised of the main hospital in Mishawaka, In (Building 01), and Center for Woman's Health (Building 02), and SJRMC Outpatient Pediatric Rehabilitation (Building 07), and SJRMC Cardiac Rehab (Building 08), and SJRMC Family Medicine Residency (Building 09), and SJRMC Outpatient Rehabilitation (Building 10), and SJRMC Pediatric Specialty Clinics (Building 11), and St Joseph Wound Healing Center (Building 14).

Saint Joseph Regional Medical Center main building, Building 01, an seven story fully sprinklered building of Type II (222) construction and a fire alarm system with smoke detection in the corridors and spaces open to the corridors was surveyed with Chapter 19, Existing Health Care occupancies. Building 01 provides overnight care. Building 01 has a capacity of 294 and had a census of 212 at the time of this survey.

Based on record review, observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect all patients, staff, and visitors on the third and fourth floor (see tag K131) and the facility failed to ensure 2 of 2 exterior fabric canopies were provided with sprinklers in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 8.15.7.1 states unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior canopies or similar projections exceeding four feet in width. Sprinklers shall be permitted to be omitted where canopies are constructed with materials that are noncombustible, limited combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect over 20 residents, staff and visitors if needing to exit the facility at the Emergency Room exit (see tag K351) and the facility failed to ensure there were battery-powered lighting for 2 of 2 Mother/Baby C-section Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and up to 14 patients (see tag K911).

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 observation, interview, and record review, the facility failed to ensure there were battery-powered lighting for 2 of 2 Mother/Baby C-section Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and up to 14 patients.

Findings include:

Based on observation with the Director of Facility Resources on 08/29/17 at 3:09 p.m., operating room A4139 and A4150 in the Mother/Baby area battery operated emergency lighting was not obvious. Based on interview at the time of observation, the Director of Facility Resources was unable to locate which lighting fixture was battery powered. Based on record review, Director of Facility Resources confirmed that the facility's battery operated emergency lighting testing documentation does not indicate any testing for that area. Director of Facility Resources confirmed that battery operated emergency lighting is not provided for the Mother/Baby operating rooms.

Based on observation and interview, the facility failed to maintain a minimum two-hour rated construction for 1 of 1 separation walls between business occupancy and health care occupancy. This deficient practice could affect all patients, staff, and visitors on the third and fourth floor and the facility failed to ensure 2 of 2 exterior fabric canopies were provided with sprinklers in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 8.15.7.1 states unless the requirements of 8.15.7.2, 8.15.7.3, or 8.15.7.4 are met, sprinklers shall be installed under exterior canopies or similar projections exceeding four feet in width. Sprinklers shall be permitted to be omitted where canopies are constructed with materials that are noncombustible, limited combustible, or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect over 20 residents, staff and visitors if needing to exit the facility at the Emergency Room exit.

Findings include:

1. Based on observations with the SJRMC Manager of Emergency Preparedness and the Property Management Technician for Cressy & Everett during a tour of the facility from 10:40 a.m. to 10:55 a.m. on 08/30/17, the following was noted:
a. a six inch by four inch rectangular shaped hole for the passage of data cables was noted in the two hour rated fire wall separating the Medical Office Building from the hospital on the third floor above the suspended ceiling above the rolling fire door. In addition, the six inch annular space surrounding a two inch in diameter copper colored pipe which penetrated the aforementioned fire wall was filled with clear plastic.
b. a one inch in diameter hole was noted in the two hour rated fire wall separating the Medical Office Building from the hospital on the fourth floor above the suspended ceiling above the rolling fire door.
The clear plastic and the holes failed to maintain the minimum two-hour rated construction for the separation wall between the Medical Office Building and the health care occupancy. Based on interview at the time of the observations, Property Management Technician agreed the aforementioned clear plastic and the holes in the tenant separation wall failed to maintain the minimum two-hour rated construction for the tenant separation wall.

2. Based on observation and interview, the facility failed to ensure 1 of 1 2nd floor Health Care/ MOB occupancy separation fire barrier walls was maintained to ensure the fire resistance of the barrier. Centers for Medicare & Medicaid Services (CMS) requires sets of fire barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect staff and at least 25 residents.

3. Based on an observation with the Director of Facility Resources on 08/30/17 at 11:43 a.m., the 2nd floor Health Care/ MOB occupancy separation fire barrier had set of cross corridor doors that swung in the same direction. When the doors were closed they left a three quarter inch gap between the doors. The cross corridor doors lacked an astragal and coordinating device. Based on interview at the time of each observation, the Director of Facility Resources acknowledged the gap between the doors was not covered by an astragal and lacked a coordinating device.

4. Based on observations with the SJRMC Construction Manager and the Maintenance Technician during a tour of the facility from 3:20 p.m. to 4:00 p.m. on 08/30/17, the red fabric canopy attached to the building at the Emergency Room exit extended more than four feet from the building and was not provided with sprinkler coverage. In addition, the silver fabric canopy attached to the building at the Associate Entrance also extended more than four feet from the building and was also not provided with sprinkler coverage. Flame spread rating documentation was not affixed to either fabric canopy. Based on interview at the time of the observations, the SJRMC Construction Manager stated no other fabric canopy flame spread rating documentation was available for review and verified the aforementioned two fabric canopies which extended more than four feet from the building were not provided with sprinkler coverage.

5. Based on observation and interview, the facility failed to maintain the ceiling construction in 2 of over 1000 rooms. NFPA 13, 2010 edition, Section 6.2.7 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff and up to 12 staff in the facility.

6. Based on observation with the Maintenance Technician #1 on 08/30/17 between 11:00 a.m. and 4:07 p.m. the following was noted:
a) Room A 1114 was missing an escutcheon
b) The Medical Air room outside Ultrasound near room A 1229 had a missing escutcheon
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each of the above mentioned areas as having missing escutcheons.

7. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in 1 of 1 Penthouse in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect staff only.

8. Based on observations with the Director of Facility Resources on 08/29/17 at 10:48 a.m., eight CAT5 cables were zip tied around the sprinkler pipe in the Penthouse Additionally, three drip pans were attached on separate sprinkler pipes. Based on interview at the time of each observation, the Director of Facility Resources agreed the cables and drip pans were being supported by the sprinkler pipe.

9. Based on observation and interview, the facility failed to install 1 of 1 Electrical room A3250 sprinkler head deflectors within 12 inches of the ceiling. NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler. This deficient practice could affect staff only.

10. Based on observation with the Director of Facility Resources on 08/30/17 at 10:19 a.m., the 2nd floor Electrical room A2050 contained one sprinkler head. The upright sprinkler head deflector was about thirty six inches from the ceiling. Based on interview at the time of observation, the Director of Facility Resources provided the measurement and confirmed the sprinkler head should have been mounted higher.

Based on document review, observation and interview, the facility failed to ensure supplies and equipment maintained to ensure an acceptable level of safety in one of one facility.

Findings include:

1. Review of facility policy, Cylinder Gas Storage, approved 01/20/17, page 1, indicated, cylinders must be secured at all times to prevent falling.

2. On 8/29/2017, at approximately 2:38 pm, in the emergency department respiratory storage area, with (Manager) the following was observed, oxygen tanks stored in cabinet not secured to keep from tipping over.

3. Interview on 8/29/2017, at approximately 2:38 pm, in the emergency department respiratory storage area, with N28 (Manager) the following was confirmed, oxygen tanks stored in cabinet not secured to keep from tipping over.

4. Review of facility policy, Crash Cart/Defibrillator/AED Monitor Operational Checks, approved with no changes 08/28/17, indicated, Clinical Supervisor or designated personnel will perform operational checks for all defibrillator/monitors each day that the department is open for business.

5. Review of Code Blue/Crash Cart log indicated lacked documentation of the following defibrillator operational checks in August 2017, West Core on 3, 4 and15, East Core on 3, 4 and 15.

6. On 8/29/17, at 11:35 am, in the operating room hall with N23 (Manager Pre/Post operating/Endoscopy) confirmed the defibrillator log lacked documentation on above dates.

7. Review of facility policy, Hazardous Chemical Identification, Criteria & Handling, revised 12/06/13, indicated, on page 3, Disposal of small amounts of liquid chemical wastes may be disposed of by diluting 1 part chemical to 100 parts water and flushed down the sewer system.

8. On 8/29/2017, at approximately 11:42 am, in the operating East Core hall, with N26 (Manager Surgery) the following was observed, formalin dispenser dripping in sink.

9. Interview on 8/29/2017, at approximately 11:42 am, in the operating East Core hall, with N26 (Manager Surgery) the following was confirmed, formalin dispenser dripping in sink.

10. Review of Material Safety Data Sheet section 1: Neutral Buffered Formalin/Histology transport System indicated, section 5: Health Hazard Data. This product is poisonous and a potential cancer hazard.

11. On 8/29/17, at approximately 1:24 pm, in the Endoscopy unit procedure room, with N23 (Manager Pre/Post, Endoscopy), the following was observed, in the drawer of mobile table, formalin containers stored with sterile supplies.

12. Interview on 8/29/17, at approximately 1:24 pm, in the Endoscopy unit procedure room, with N23 (Manager Pre/Post, Endoscopy), the following was confirmed, in the drawer of mobile table, formalin containers stored with sterile supplies.

Based on document review, interview and observation, the facility failed to ensure controlling infections in patients in one of one facility and the facility failed to provide a clean environment in 7 out of 11 areas toured (Areas A1, A2, A3, A4, A5, A9, and A10).

Findings include:

1. Review of facility policy, Reprocessing Of Single Use Devices By a Third Party Reprocessor, revised 6/30/17, B. Used items to be reprocessed shall be collected in designated containers at the point of use.

2. On 8/29/17, at approximately 1:24 pm, in the Endoscopy Unit, with N23 (Manager Pre/Post, Endoscopy), the following was observed, approximately 30 dirty biopsy forceps stored in Endoscopy procedure room in a plastic container.

3. Interview on 8/29/17, at approximately 1:24 pm, in the Endoscopy Unit, with N23 (Manager Pre/Post, Endoscopy), the following was confirmed, approximately 30 dirty biopsy forceps stored in Endoscopy procedure room in a plastic container.

4. On 8/30/17, at approximately 11:02 am, in the conference room with N10 (Administrative Director Surgical Services) the following was confirmed, dirty biopsy forceps should not be stored in the endoscopic procedure room.

5. Review of facility policy, Shelf Life For Sterile Supplies, reviewed 11/12/2016, indicated, events that may compromise the sterility of a package may include, but are not limited to: multiple handling that leads to seal breakage or loss of package integrity, moisture penetration and airborne contaminates.

6. On 8/29/17 at approximately 12:26 pm, in the Central Processing Department, with N25 (Manager of Sterile Processing and Decontamination) the following was observed, a 3mm long unipolar instrument in a sterile package with tape color faded and not sticking to the package.

7. Interview on 8/29/17, at approximately 12:26 pm, in the Central Processing Department, with N25 (Manager of Sterile Processing and Decontamination) the following was confirmed, a 3mm long unipolar instrument in a sterile package with tape color faded and not sticking to the package.

8. On 8/29/17, at approximately 2:34 pm, in the Emergency Department with N28 (Manager) the following was observed, drills in packaging with discolored lose tape.

9. Interview on 8/29/17, at approximately 2:34 pm, in the Emergency Department with N28 (Manager) the following was confirmed, drills in packaging with discolored lose tape.

10. Review of facility policy, Sanitation, reviewed 8/28/2017, indicated, patients shall be provided with a safe and clean environment free from dust and organic debris.

11. On 8/29/17, at approximately 12:00 pm, in the Surgery Department, with N26 (Manager Surgery), the following was observed, in the 5th drawer of the Emergency Trach Cart, heavy visible dust.

12. Interview on 8/29/17, at approximately 12:00 pm, in the Surgery Department, with N26 (Manager Surgery), the following was confirmed, in the 5th drawer of the Emergency Trach Cart, heavy visible dust.

13. On 8/29/2017, at approximately 11:20 am, in the Pre-Operative area with N23 (Manager Pre/Post Endoscopy), the following was observed, in the pantry area, lots of drips and spills in corner of shelves and drawers.

14. Interview on 8/29/2017, at approximately 11:20 am, in the Pre-Operative area with N23 (Manager Pre/Post Endoscopy), the following was confirmed, in the pantry area lots of drips and spills in corner of shelves and drawers.



38371

15. Review of policy Patient room discharge Cleaning, last date approved with no changes is 08/29/17, includes numerous items to be completed, some included:

a. High dust everything above shoulder level: ceiling, vents, lights, walls, blinds, television and horizontal ledges.

b. Raise bed; damp wipe the bed frame and the bedrails on each side.

c. Damp wipe behind the bed.

16. The following observations made on 8/28/17 at approximately 1:50pm.

a. A1 -- empty room 4424 had large amounts of dust on windowsill, chair rail, top of cabinet over the head of the bed and a dirty sink and room 4427 had large amount of dust on window sills, chair rail and top of cabinet over the head of the bed.

b. A2 -- empty room 4410 had large amount of dust on window sill, bottom of cart that holds the baby scale, pull out arm for computer and the desk ledge...large amount of dust on top of Ice/H20 machine, patient and medication refrigerator and top of blanket warmer in area behind nurse's station.

c. A3 -- large amount of dust on the bottom of 2 baby warmers.

d. A4 -- large amount of dust on the top of the automatic door closer and top of lights located at ceiling height and go the perimeter of the room.

e. A5 -- large amount of dust on top of all picture frames in the hallway.

f. A9 -- large amount of dust on top of Ice/H20 machine on East side nurse's station.

g. A10 -- empty room 3307 had large amount of dust on window sill, counter top and computer stand.

17. Interview with P9, Administrative Director and P21, Director of Environmental services, on 08/28/17 at 4:00 pm confirmed observations on A1, A2, A3, A4, and A5.

18. Interview with P9, Administrative Director and P21, Director of Environmental Services, on 08/29/17 at 3:00 pm confirmed observations on A9 and A10.

19. Review of the Bed Tracking report for A1 shows that room 4424 was discharge cleaned at 6:59 am on 08/28/17 and room 4427 was discharge cleaned at 8:02 am on 08/28/17. Tour was at 1:50 pm on 08/28/17.