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Based on observation and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 laundry rooms (refer to tag 221), failed to ensure there were ground-fault circuit interrupters (GFCI) for 3 of 3 wet procedure locations in the O.R. (refer to tag 221) failed to ensure cleanliness of the Emergency Department (refer to tag 225), based on observation and interview, the facility failed to ensure continuity of egress lighting for 5 of 16 emergency exits (refer to tag 235) and failed to ensure there were battery-powered lighting for 3 of 3 anesthesia areas (refer to tag 235). The cumulative effect of these systemic problems resulted in the facility'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 and interview, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 laundry rooms in accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building and failed to ensure there were ground-fault circuit interrupters (GFCI) for 3 of 3 wet procedure locations in the O.R.

Findings include:

1. Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 at 1:14 p.m., the rear dryer access in the laundry room lacked sprinkler coverage. Based on an interview at the time of observation, the Facilities Director and the Environmental Care Coordinator acknowledged there was no sprinkler head behind the dryers.

2. Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/02/16 between 9:00 a.m. and 10:00 a.m. the following O.R. rooms did not have all electrical outlets GFCI protected:
a) O.R. #1 had a 220 volt (v) outlet and one 110v outlet.
b) O.R. #2 had a 220v outlet and one 110v outlet.
c) O.R. #3 had a 220v outlet and one 110v outlet.
The 110v outlets were providing power to anesthesia equipment that were sitting on the ground. Based on interview at the time of observation, the Environmental Care Coordinator acknowledged the 220v outlets confirmed there were not GFCI protected. Facilities Director stated the 110v outlets were not GFCI protected because the equipment plugged into them would trip a GFCI outlet and the equipment takes 15 minutes to restart. Also, the Facilities Director stated there was not a risk assessment conducted to show that the 110v outlets could be unprotected by a GFCI.

Based on document review, observation and interview, the facility failed to ensure the cleanliness of the ED (emergency department).

Findings Include:
1. Review of the policy Refrigerator/Freezers and Microwaves: Cleaning and Food Storage, policy number 1963854, last revised/approved 12/2015, indicated under "Policy": "Each department utilizing a refrigerator/freezer and/or microwave for staff or patient use will be responsible for the cleaning, disinfecting, and disposing of expired items monthly AND as spills occur...".

2. Review of the document "Monthly Cleaning Duties" for the ED for September 2016 indicated:
A. The refrigerator area lacked documentation of having been cleaned during that month.
B. The portable room dividers stored in the hallway were not on the list for monthly cleaning.

3. At 11:25 AM and 11:45 AM on 10/11/16, while on tour of the ED in the company of the ED director, staff member #61 and the chief nursing officer, staff member #56, it was observed that two sets of room dividers stored in the hallway had an accumulation of dust present on the frames of the equipment.

4. At 11:25 AM and 11:45 AM on 10/11/16, staff members #56 and #61 confirmed the presence of dust on the dividers.

5. At 11:30 AM on 10/11/16, while on tour of the ED in the company of the ED director, staff member #61 and the chief nursing officer, staff member #56, it was observed that at least two bugs/light were present in the four overhead lights in the back ED hallway between the nursing station and the patient nourishment refrigerator area (near the bio hazard room).

6. At 11:30 AM on 10/11/16, staff members #56 and #61 confirmed the presence of bugs in the light fixtures and reported that it was unknown if the lights were on a periodic cleaning schedule with EVS (environmental services) or maintenance staff.

7. At 10:45 AM on 10/13/16, interview with maintenance staff member #58 confirmed that:
A. Previously the ED lights had only been cleaned when requested by staff in a "work order", and were not on any routine periodic scheduling.
B. The last time the ED lights had documentation of cleaning was 6/7/16.
C. Terminex had been at the facility since the 6/7/16 date and may have stirred up bugs causing the light fixtures to need further cleaning.

8. At 11:35 AM on 10/11/16, while on tour of the ED in the company of the ED director, staff member #61 and the chief nursing officer, staff member #56, it was observed that the patient nourishment refrigerator had an accumulation of debris under the vegetable drawers and some dried brown liquid on the base of the refrigerator.

9. At 11:35 AM on 10/11/16, staff member #61 confirmed that the refrigerator was not clean and there was no documentation on the monthly cleaning list for September that the refrigerator had been cleaned.

10. At 11:30 AM on 10/13/16, staff member #56 confirmed that the room dividers in the ED were not on the monthly cleaning checklist.

Based on observation and interview, the facility failed to ensure continuity of egress lighting for 5 of 16 emergency exits. LSC 7.9.1.1 Emergency lighting for the means of egress shall be provided. 7.9.2.3 The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any interruption of normal lighting and failed to ensure there were battery-powered lighting for 3 of 3 anesthesia areas. 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.

Finding include:

1. Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 11/01/16 between 12:00 p.m. and 3:00 p.m. and on 11/02/16 between 9:00 a.m. and 11:30 a.m., the exit discharge sidewalks from exit #1, #2, #12, #15, and #16 had lighting fixtures down the sidewalks to the common way, but none of the fixtures were provided with back up emergency power. Based on interview at the time of observations, the Facilities Director and the Environmental Care Coordinator confirmed that aforementioned emergency lights were not on the generator.

2. Based on observations during a tour of the facility with the Environmental Care Coordinator on 11/02/16 between 9:00 a.m. and 11:00 a.m., operating rooms one, two, and three did not have battery-powered lighting. Based on interview at the time of observation, the Environmental Care Coordinator acknowledged all three operating room that used deep sedation and general anesthesia did not have backup battery-powered lighting.

Based on document review and interview the facility failed to ensure the implementation of patient policies related to the measuring of a pediatric head circumference on admission for 1 of 1 pediatric patient less than two years of age, Patient #10, and in regard to the policy on glucose meter strip and control solution maintenance.

Findings Include:
1. Review of the policy Pediatric Head Circumference and Growth Chart, policy number 2343330, last approved 4/2015, indicated under "Objective": "On Admission: Head circumference, height, and weight will be measured on children 2 years of age and under. The measurements will be recorded on the pediatric admission Initial Interview...".

2. Review of pediatric medical records indicated that patient #10 was a 20 month old admitted 1/21/16 and lacked documentation of a head circumference having been measured on admission.

3. At 9:15 AM on 10/13/16, interview with staff members #54, the med/surg manager and #56, the chief nursing officer, confirmed that nursing staff failed to document a measurement of head circumference for patient #10 on admission, as required per facility policy.

4. Review of the policy Stat Strip Glucose Meter Patient Testing Care and Maintenance, policy number 2361031, last approved 4/2016, indicated under "General" on page two: "Important: Test Strips are stable until the expiration date on vial. Vials should be dated when first opened. Test strips are stable for 180 days after opening or until the expiration date on vial, whichever comes first. QC (quality control) solution is stable for 3 months after opening, then discard...".

5. At 11:50 AM on 10/11/16, while on tour of the ED (emergency department) in the company of staff members #56, the chief nursing officer, and #61, the ED manager, it was observed that the Stat Strip bottles (2) had no open or discard date marked on the bottles and the Level 1 and Level 3 control solutions had expiration dates marked on the vials of 10/1/16.

6. At 11:55 AM on 10/11/16, staff members #56 and #61 confirmed that the glucose strips were not marked as per facility policy, and the control solutions had expired.

7. At 9:10 AM on 10/12/16, while on tour of the pre operative nursing unit in the company of the surgery manager, staff member #53, it was observed that the two vials of glucometer control solutions were marked with discard dates of 4/1/16.

8. At 9:10 AM on 10/12/16, staff member #53 confirmed that the two vials of glucometer control solutions had expiration/discard dates of 4/1/16.

Based on document review and interview, the facility failed to follow its policy/procedure and ensure its policies and procedures were reviewed and approved at least annually by members of the medical and professional staff or committee with oversight for the area or service.

Findings include:

1. The policy/procedure Policy Management (reviewed 11-15) indicated the following: "Hospital-wide policies, procedures, protocols or guidelines... must be approved/reviewed by: at least one senior leadership staff member... or a director with overarching responsibility for the departments impacted, or the department director from each impacted department... Patient care/medical care policies, procedures or protocols must be reviewed by at least one physician... Policies governing infection control and prevention of communicable disease must be reviewed by Infection Prevention... At a minimum, policies, procedures, protocols and guidelines will be reviewed on an annual basis."

2. Review of the policy/procedure Obtaining Signatures for Authorization to Treat (no approval date) indicated the following: "Purpose: To inform all patients of their rights and responsibilities and to obtain signature for their consent for treatment." The policy/procedure failed to indicate it was approved within the past year by a representative of the medical and/or professional staff.

3. At 0935 hours on 10-13-16, the director of quality, staff A5 confirmed the policy for obtaining a patient's consent for treatment at the facility failed to indicate it was approved and confirmed no other documentation was available.

4. Review of the patient care policy/procedure Care Coordination and Discharge Planning (approved 12-15) failed to indicate approval by a member of the medical staff within the past year.

5. At 1140 hours on 10-13-16, the director of performance improvement, staff A6 confirmed the policy/procedure failed to indicate an annual approval by a member of the medical staff.

6. Review of the environmental services policy/procedure In-House (OPL) Laundry Procedures (approved 1-16) failed to indicate approval by a representative of the Infection Prevention (IP) committee within the past year.

7. At 1030 hours on 10-13-16, the director of performance improvement, staff A6 confirmed the policy/procedure failed to indicate an annual approval by a representative of the IP committee.

Based on document review and interview, the facility failed to maintain a list of all contracted services, including the nature and scope of services provided for 3 contracted services.

Findings include:

1. Review of facility documentation indicated periodic service for dietary dishwashing equipment by a service provider CS1, radiation badge monitoring by the service provider CS2, and medical physicist services by the service provider CS3.

2. Review of the list of contracted services provided on request failed to indicate the dietary or radiology department services indicated above.

3. At 1110 hours on 10-12-16, the director of performance improvement A6 confirmed the list of contracted services lacked the indicated services and had not been maintained.

Based on observation and interview, the facility failed to ensure the security of patient medical records in one off site location.

Findings Include:
1. At 8:25 AM on 10/13/16, while on tour of the off site Urgent Care facility in the company of the chief nursing officer, staff member #56, and the Urgent Care Manager, staff member #59, it was observed that patient medical records were stored in boxes in cabinets that had no locking mechanism.

2. At 8:30 AM on 10/13/16, interview with staff members #56 and #59 confirmed that the cabinets that patient medical records were stored in had no locks to secure them.

3. No policy regarding the securing of patient medical records was provided prior to exit.

Based on document review and interview the facility failed to ensure the pre anesthesia evaluation was documented with a time of the evaluation to ensure it was completed prior to anesthesia administration for 3 of 3 surgery records reviewed, Patients #17, #18 and #19, and failed to ensure the documentation of the time of a post op evaluation for 1 of 3 patients, Patient #17.

Findings Include:
1. Review of the policy Basic Standards For Preanesthesia Care & The Pre-Anesthesia Evaluation Note, policy number 2675745, last approved 8/2016, indicated under "Purpose": "These standards apply to all patients who receive anesthesia care including all general anesthetics, regional anesthetics and monitored anesthesia care...", and under "Policy": "A pre-anesthesia evaluation must be performed for each patient who receives general, regional or monitored anesthesia by a person qualified to administer anesthesia...within 48 hours immediately prior to the delivery of the first dose of medication(s)...".

2. Review of surgical medical records indicated patients #17, #18 and #19 lacked documentation of the time of a preoperative evaluation on 8/22/16 prior to the administration of medications by the anesthesiologist. Patient #17 also lacked a time of the "Postoperative Note".

3 At 2:55 PM on 10/12/16, interview with staff member #53, the surgery director, confirmed that the anesthesiologist failed to document the pre operative evaluation time for patients #17, #18 and #19 and failed to document the post op evaluation time for patient #17, as required per policy, making it impossible to determine the pre op evaluations occurred prior to the administration of anesthesia medications.