HospitalInspections.org

Based on observation, staff interview, and policy review, the facility failed to provide call lights in the Emergency Room (ER) to meet the needs of patients in a safe manner during one (1) of three (3) days of survey.

Findings Include:

Observation on 10/16/17 at 11:25 a.m. revealed ER exam room 1, 2, and 3 had a patient call system (a nurse call system) mounted to the wall on the left side of the entrance door. The three (3) patient beds in the room had no patient call system available for patient use. The patient call system mounted to the wall was not accessible to patients while in bed.

During an interview on 10/16/17 at 11:30 a.m. the Director of Nurses (DON) confirmed that the only patient call system available for the patients to use was the patient call system mounted to the wall.

Review of the facility's "Safety devices and measures for patients" policy (effective 4/19/12) revealed: Many devices and measures have been initiated to insure optimal safety, which include, but are not limited to the following: 1) A nurse-call system exists in all patient rooms and emergency call in the bathrooms...".

Based on observation, staff interview, and document review, the facility failed to ensure the environment was maintained and safe on three (3) of three (3) days of survey.

Findings Include:

Observation of the facility environment on 10/16/17 from 2:00 p.m. to 3:00 p.m. revealed:

Room #20, on the acute/swing bed floor, had four (4) cracked floor tiles at the door entrance.

The "Dietary Employee Only" entrance door had uneven floor tile in the visitor hallway.

All observations were confirmed by the Administrator and Plant Operations Manager on the same day and time.

During an interview on 10/18/17 at 11:35 a.m., the Director of Plant Operations and Administrator both confirmed the facility uses the "Maintenance Request" form for environmental repairs. Both confirmed there was no written policy and procedure for environmental repairs and that each department submitted request for needed repairs.

Review of the facility's "Director of Maintenance" position description, dated June 2015, revealed: " ...Job Summary: To plan, organize, supervise, coordinate and control the activities of the plant operations and maintenance functions which are necessary in maintaining the physical structure ...Schedules and supervises maintenance repair work ...".

Review of the facility's "Maintenance Request" form, revealed: " ...Date: ...Location: ...Problem: ...Assigned To: ...Date Completed: ....Remarks ...".

During Exit Conference on 10/18/17 at 12:15 p.m., no further documentation was submitted for review concerning environmental repairs.

Based on temperature and cleaning log review, staff interview, review of manufacturer guidelines, and policy review, the facility failed to ensure patient-care equipment is maintain in a safe operating condition during one (1) of three (3) days of survey.

Findings Include:

Review of temperature and cleaning logs for January 2017 through October 2017 for small and big hydrocollator revealed the hydrocollator was cleaned and a temperature check completed once a month. Review of manufacturer guidelines for hydrocollator revealed, "Caution: the recommended operating temperature is 160 degrees to 165 degrees. The temperature of the water should be checked with a thermometer after every adjustment before using Hot Pac ... Maintenance: the tank should also be drained and cleaned systematically, at minimum intervals of every two weeks."

In an interview on 10/16/17 at 2:10 p.m. the Physical Therapy Assistant stated, "We only check the temperature for the hydrocollator once a month when we clean it, however we use the hydrocollator every day."

Review of facility's "Guideline for Hydrocollator Packs" (reviewed 9/18/17) revealed, "Procedure: the hydrocollator is checked for temperature each morning prior to patient use ... The packs are kept thermostatically controlled water, which is kept heated to 160-166 degrees."

Review of facility's "Infection Control-Hydrocollator" (reviewed 9/18/17) revealed, "Explanation: To outline procedures to clean and maintain the hydrocollator unit and the hot packs that are used with it. General Instructions ...4) clean tank bi-weekly ..."