HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure 1 of 2 pharmacy use areas was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception, failed to ensure 1 of 2 cafeteria doors likely to be mistaken for a way of exit was identified as "No Exit", failed to ensure 1 of 8 exits were arranged to minimize tripping hazards, failed to ensure the exterior exit discharge path for 1 of 8 emergency exits was provided with emergency powered egress lighting, failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 quarters and included information about which staff participated and failed to maintain 1 of 2 portable fire extinguishers in the kitchen cooking area.

Findings:

1. Observation with the Physical Plant Director, PPD1 on 04/07/15 at 1:15 p.m. indicated a four by three foot window provided access to the corridor from one room in the pharmacy by two sliding glass panel which gapped 1/4 to 1/2 inches when closed. The corridor was protected by an electrically supervised automatic detection system but the room was not.
2. PPD1 acknowledged, at the time of observation, the windows could not prevent the passage of smoke between the pharmacy room and corridor.

3. Observation with PPD1 on 04/07/15 at 12:40 p.m. noted a glass panel door opened to the outside of the cafeteria.
4. PPD1 said at the time of observation, the door was not an emergency exit which was evidenced by the lack of any signage above the door to indicate it was to be used as an exit. The door was not posted with a sign indicating it was not an exit. PPD1 agreed at the time of observation, the door could be mistaken for a means of exit.

5. Observation with PPD1 on 04/07/15 at 3:08 p.m. demonstrated the concrete exit discharge surface for the exit discharge for exit #25 was damaged by pitting and holes in the concrete which made the surface unlevel. In addition, irregular cracks ran across the width of the surface adding to irregularities in the walking surface.

6. PPD1 said at the time of observation, the damage was weather related.

7. Observation with PPD1 on 04/08/15 at 1:05 p.m. determined the exit discharge path from the exit near Respiratory Therapy had a single bulb light fixture above the exit discharge connected to the emergency generator. There was no lighting for the 90 foot length of the exit discharge path winding around the building to an evacuation point at the public way.

8. PPD1 acknowledged at the time of observation, the discharge lighting provided could not illuminate more than the point of exit discharge from the building to the public way for emergency evacuation purposes.

9. Review of the facility's Fire Drill records evidenced there was no record of a third shift fire drill for the second quarter of 2014.

10. In interview with PPD1 on 04/07/12 at 2:15 p.m., it was acknowledged a drill for this period was missing.

11. Observation on 04/07/15 at 12:20 p.m. with PPD1 noted no placard was posted near the K class fire extinguisher in the kitchen.
12. PPD1 acknowledged at the time of observation, there was no placard.

Based on document review, observation and staff interview, the facility failed to provide an environment that controlled infection risk for patients for 2 of 3 units toured.

Findings include:

1. Facility policy titled "Hand Hygiene" last reviewed/revised 6/14 states on page 1: "1.2 Hands shall be washed with soap and water or by hand antisepsis with alcohol based hand rubs (if hands are not visibly soiled): 1.2.1 Before and after patient contact.....1.2.3 After removing gloves......." Page 2 states "3.2.2 Health care workers that provide patient care are not allowed to wear artificial nails. Artificial nails are defined as anything other than natural nails and are substances or devices applied to natural nails to augment or enhance the natural nail. They include, but are not limited to, .........gels......"

2. Manufacturers recommendations for the "Accu-Chek Inform II" states on page 4 "For multiple patient use, the meter should be cleaned and disinfected between each patient use......"

3. Facility policy #230.29/245.157 titled "Infection Control" last reviewed/revised 11/14 states on page 2: "3.2 I.V. pumps and reusable equipment will be cleaned with germicidal solution between patient use."

4. Facility policy titled "Environmental Services/Housekeeping/Laundry" last reviewed/revised 4/21/14 states on page 3: "5. Daily unit cleaning procedure 5.5 Damp clean or wipe with a germicidal solution. 5.5.1 Chairs, tops of bedside cabinets, lamps, tops with over bed trays, exposed areas of patients' beds, electrical cords, kick plates, foot stools, window sills, low vents and other low level ledges.........."

5. During observations on the medical/surgical unit beginning at 11:30 a.m. on 4/6/15, the following was observed:
(A) Staff member #N1 (Certified Nursing Assistant- CNA) was observed performing accu checks on patients #7, 8, and 9. He/she did not perform hand hygiene after removing gloves and completion of the accu check on patient #7.
(B) He/she did not disinfect the glucometer between patients or when the accu checks were complete. He/she brought the meter to the nursing station and placed it in the docking station upon completion.

6. Staff member #R1 (Registered Respiratory Therapist-RRT) was observed performing a nebulizer treatment on patient #12 beginning at 2:30 p.m. on 4/6/15. He/she did not clean the meter after use. Additionally, staff member #R1 had gel overlay on his/her nails.

7. During observation of daily room cleaning on the medical surgical unit beginning at 10:20 a.m. on 4/8/15, staff member #H1 (Housekeeper) failed to follow facility policy for daily room cleaning. He/she only wiped the top of the overbed table and the sink within the patient room with germicidal solution.

8. Staff member #H1 indicated in interview at 10:25 a.m. on 4/8/15 that he/she only wipes the overbed table and sink within the room for daily room cleaning.

9. Staff member #N8 (Director of Nursing) indicated in interview beginning at 4:30 p.m. on 4/8/15 that staff member #R1 did have gel overlay on nails.