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Based on observations as referenced in the Life Safety Report of survey completed on 01/10/2013, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700

Based on hospital policy review, the hospital's "Inpatient Total Chlorine Log" review, and staff interview, the hospital failed to ensure document total chlorine results for the performance of the first granular activated carbon filter in the RO (reverse osmosis) water system and failed to ensure water system staff mixing bicarbonate concentrate for hemodialysis patients were able to describe contraindications and validate education and training for dialysate proportioning to maintain a safe environment for the hospital's hemodialysis patients.

Findings include:

1. Review on 01/09/2013 of the hospital's policy "Instructions for Completing the Inpatient Total Chlorine Log for Central Water Systems" (effective 03/03/2010) revealed "Document the Total Chlorine reading as determined by the test method in use."

Review on 01/09/2013 of the hospital's Inpatient Total Chlorine Log for Central Water Systems" dated 11/08/2012 revealed the hospital's hemodialysis staff failed to document the total chlorine results at the 1400 testing. The log review revealed the space for "____ppm" was left blank with no results documented. The review of the log did revealed a dialysis technician and a registered nurse authenticated the testing, but without actual results documented. The review revealed that no results for the 1400 testing were completed in order to determine if the chlorine reading were below 0.10 ppm (parts per million) that would ensure the water used in hemodialysis patients was safe during treatment.

Interview on 01/09/2013 at 1410 with the hospital's hemodialysis director revealed that the total chlorine results should have been documented. The interview also revealed that two staff members have to sign the results and both should have known what result was being signed. The interview confirmed the findings.

2. Interview on 01/08/2013 at 1415 with the hospital's dialysis technician performing water testing revealed that she is responsible for the mixing of bicarbonate concentrate that is used for the hospital's hemodialysis treatments. The interview revealed the dialysis technician does mix the powder bags of the product "Naturalyte Dry Packs" into the bicarbonate mixing machine. The observation during the staff interview inside of the water treatment area, revealed the hospital uses the "Naturalyte 45X" mix ratio for dialysate proportioning. During the interview, the dialysis technician was unable to describe what the 45X geometric symbol meant or contraindications of mixing another proportioning ratio with the 45X. The interview revealed the dialysis technician did not know that different proportioning types are not compatible with each other. The interview also confirmed that no education was recalled that indicated the training for mixing dialysate proportioning products.

Interview on 01/08/2013 at 1500 with the hospital's hemodialysis director revealed that the dialysis technician should be aware of not mixing ratios related to dialysis proportioning and was probably nervous during the interview. The interview also revealed no specific documented training for the staff that discusses training related to dialysate proportioning contraindications. The interview confirmed the findings.

Based on hospital policy review, the hospital's "Returns and Wastes" report review, and staff interview, the hospital's pharmacy failed to minimize potential scheduled drug diversion in 4 of 20 reviewed emergency department nurses failing to immediately document waste and disposal of a scheduled drug (Nurse#4,5,6,7, Patients #58, 59).

Findings include:

Review on 01/09/2013 of the hospital's policy "Pyxis Medstation Management" (reviewed 11/05/2012) revealed "Wasted Medications (non-reusable)...Controlled drugs that must be wasted require documentation at the Pyxis Medstation by two nurses. Medication must be wasted if a partial dose is given or a whole dose is not administered and the package is not intact. Waste should not be documented until after administration. All wastes require verification by a witness." No other information in the hospital's policies and procedures that referred to minimizing scheduled drug diversion.

1. Review of the hospital's Returns and Wastes" report for thirty days revealed patient #58 on 01/03/2013 was administered the scheduled drug "Fentanyl" 50 mcg (micrograms) intravenously by nurse #4. The documentation from the report revealed that nurse #4 removed a "Fentanyl 100 mcg" dose from the emergency department "Pyxis Medstation" on 01/03/2013 at 1948. Review of the report for the remaining "Fentanyl" 50 mcg was not documented as wasted until 0636 (total of 10 hours and 12 minutes after removing the drug). The review revealed the drug was witnessed as wasted in the sink by nurse #5.

Interview on 01/09/2013 at 1530 with the hospital's emergency department (ED) manager revealed that nurse #4 indicated that he "removed the Fentanyl at 1948, wasted it at 0636 with nurse #5 as witness. Nurse #4 according to the ED manager remembered the patient. He stated he administered the medication, placed it in his pocket to waste, but the patient became critically ill and he forgot the medication was in his pocket." The ED manager stated she spoke to nurse #5 and he stated he recalled watching the waste. The interview confirmed the finding and indicated that the nursing staff should immediately waste the medication.

Interview on 01/10/2013 at 1015 with the hospital's pharmacist revealed that the ED nursing staff should not keep the scheduled medications in their pockets. The interview revealed the witnessing nurses have no way of knowing what they are wasting. The interview confirmed no other policies for reducing risk of diversion could be produced.

2. Review of the hospital's Returns and Wastes" report for thirty days revealed patient #59 on 12/11/2012 was administered the scheduled drug "Fentanyl" 50 mcg (micrograms) intravenously by nurse #6. The documentation from the report revealed that nurse #6 removed a "Fentanyl 100 mcg" dose from the emergency department "Pyxis Medstation" on 12/11/2012 at 1019. Review of the report for the remaining "Fentanyl" 50 mcg was not documented as wasted until 1853 (total of 8 hours and 34 minutes after removing the drug). The review revealed the drug was witnessed as wasted in the sink by nurse #7.

Interview on 01/09/2013 at 1530 with the hospital's emergency department (ED) manager revealed that nurse #6 indicated that she "removed the Fentanyl at 1019." Nurse #4 according to the ED manager, recalled the patient and stated she pulled and administered the medication. She also stated the patient was critically ill. She stated she asked the Team Leader (nurse #7) to watch her waste the medication. She indicated she did this shortly after administering the Fentanyl and later when to pyxis to put the waste in. The Team Leader (nurse #7) did confirm to the ED manager this is what happened. No specific times could be produced for when the scheduled medication could be documented as wasted. The interview confirmed the finding and indicated that the nursing staff should immediately waste the medication and document.

Interview on 01/10/2013 at 1015 with the hospital's pharmacist revealed that the ED nursing staff should document at the time they waste medication. The interview revealed the nurses did not follow the hospital's policy for wasting medication. The interview revealed the witnessing nurses have no way of knowing what they are wasting. The interview confirmed no other policies for reducing risk of diversion could be produced.

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2013, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710

2. The hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709

3. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

Based on observations as referenced in the Life Safety Report of survey completed 01/11/2013, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

A. Main Hospital Building 8th floor near room 6-805
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. There were computers on wheels that were stored in the egress corridor and not in immediate use.
B. 2nd floor surgical suite is not defined and currently has items in the exit egress corridor.
C. There were charting tables in the AV&A area near M3 NA3-066 and 3-082 that would not retract to the up position when tested. (This items was corrected before the end of the survey)

~ cross-refer to Life Safety Code Standard-NFPA, Tag K0072~

B. Main Hospital Building basement
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The mechanical room # 3 has duct detectors installed with out an access door to view the sampling tubes. (This items was corrected before the end of the survey)

~cross-refer to Life Safety Code Standard-NFPA, Tag K0067~

C. Main Hospital Building 1st floor
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The main oxygen distribution room had a mixture of full and empty oxygen cylinders.

~cross-refer to Life Safety Code Standard-NFPA, Tag K0076~

D. Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:

2. There was no solid non slick surface other than grass and soil at the required exit from the OR Suite leading from door1-005 PST to the public way.

~cross-refer to Life Safety Code Standard-NFPA, Tag K0038~

E. Main Hospital Building bed repair shop
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The door to the bed repair shop did not close and latch when tested.
B. Door 3W-087 did not close and latch when tested.

~cross-refer to Life Safety Code Standard-NFPA, Tag K0029~

F. Main Hospital Building 2nd floor
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include: There is a dead end corridor condition ending at door M2W2-040.

~cross-refer to Life Safety Code Standard-NFPA, Tag K0032~

G. Main Hospital Building basement
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The mechanical room # 3 has an access door that does not have self closing spring installed to keep the door from being left in the open position in the 2 hour rated wall. (This items was corrected before the end of the survey)

~cross-refer to Life Safety Code Standard-NFPA, Tag K0012~

H. Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include:
A. There were housekeeping items store in front of electrical panels in the room with door 2N2-058.
B. 3rd floor MICU room with entry at door PST3-038 the medical refrigerator noted as vaccine refrigerator was not verified to be on an emergency circuit. (This items was corrected before the end of the survey)

~cross-refer to Life Safety Code Standard-NFPA, Tag K0147~

Based on observations as referenced in the Life Safety Report of survey completed 01/11/2013, the hospital failed to ensure the safety and well-being of patients by failing to ensure Life Safety from Fire requirements were met.

The findings include:

A. Main Hospital Building Fire alarm system
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The strobe light in the AVNA unit did not activate with activation of the fire alarm system.
B. The strobe light near 1.52-SP1 and door 1C-105 did not activate with activation of the fire alarm system.

~cross-refer Life Safety Code Standard-NFPA, Tag K0052~

B. Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The smoke door at 1-249 did not close with activation of the fire alarm system.
B. The smoke door at 3-NA3-006 did not close with activation of the fire alarm system.

~cross-refer Life Safety Code Standard-NFPA, Tag K0027~

C. Main Hospital Building 2 south
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The smoke wall was incomplete at the Soiled Linen room. (This items was corrected before the end of the survey)

~cross-refer Life Safety Code Standard-NFPA, Tag K0025~

D. Main Hospital Building 3rd floor
Based on the observations and staff interviews during the survey the following Life Safety item was observed as noncompliant, specific findings include: The 3rd floor (AVA) storage area has no sprinkler coverage.

~cross-refer Life Safety Code Standard-NFPA, Tag K0056~

E. Valley Pavilion 4th floor connector and exit egress stairwells
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. There is two different types of locking devices in one path of egress from this location to the nearest exit egress stairwell. North Carolina Special Locking at the connector and Delayed Egress at the exit egress stairwell.
B. There are two different types of locking devices on the three stairwell exits from the 4th floor that currently do not comply with North Carolina Special Locking. The Delayed Egress function does comply with the Life Safety Code.

NOTE: These exit egress doors did release with activation of the fire alarm system.

~cross-refer Life Safety Code Standard-NFPA, Tag K0038~

F. Main Hospital Building
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
1. There were two ranges of motion to exit from the following areas:
A. GI lab storage room
B. Room with door 2N-080
C. Surveyors Conference room
D. Men's bathroom 3-NA Door 3-051 (This items was corrected before the end of the survey)
E. Chapel door 1-112. (This items was corrected before the end of the survey)

3. The door 1-002 in the egress corridor required more than 15 lbs for force to activate the panic hardware. (This items was corrected before the end of the survey)

~cross-refer Life Safety Code Standard-NFPA, Tag K0038~

Based on observations as referenced in the Life Safety Report of survey completed 01/11/2013, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

A. Main Hospital Building sprinkler riser room
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. The tamper alarms for the M1-99 and #9 failed to give a supervisory signal when tested.
B. Tamper alarm for #10 was not able to be tested.

~cross-refer to Life Safety Code Standary-NFPA, Tag K0062~

B. Main Hospital Building loading dock
Based on the observations and staff interviews during the survey the following Life Safety items were observed as noncompliant, specific findings include:
A. There are backflow valves that serve the loading dock that are not electrically supervised.
B. There are sprinkler dry system accelerators that are not electrically supervised at the "Bird Cage".

~cross-refer to Life Safety Code Standary-NFPA, Tag K0061~

Based on hospital policy review, observation, hospital's "Water System" culture reports review, and staff interview, the hospital's infection control officers failed to ensure the medication preparation was performed to prevent potential cross-contamination and that AAMI (Association for the Advancement of Medical Instrumentation) action level culture results for the hospital's hemodialysis water system were repeated according to hospital policy and procedure.

Findings include:

1. Review on 01/08/2013 of the hospital's policy "Infection Control, Isolation Precautions, and Personal Protective Equipment in the Acute Hemodialysis Unit Program" (effective 06/14/2012) revealed "5. Medication preparation and restrictions related to single and multi-dose vials as determined by the CDC and CMS are maintained in the Acute Hemodialysis Unit and during all 1:1 Hemodialysis treatments throughout the healthcare system. These determinations are as follows: a. Medication storage and preparation is done behind the curtain next to station #1 in the designated "clean" medication area."

Observation on 01/08/2013 at 1045 in the hospital's hemodialysis unit revealed a nurse (unidentified)entering patient station #5 while the patient was undergoing hemodialysis treatment. The nurse was observed to place three vials of the medication "Epogen 5000 units" on top of the contaminated top of the hemodialysis machine. Further observation revealed the nurse at 1047 using a syringe, opened the Epogen vials and prepared the medication intravenously for the patient (station #5) by removing medication using a needle for the three vials. The observation revealed the medication vials were placed on the dirty hemodialysis machine and then removed and prepared in the patient's hemodialysis treatment station and not the designated clean hemodialysis medication preparation area.

Interview during the observation on 01/08/2013 at 1048 with the hemodialysis director revealed that the intravenous medication should never be prepared at the patient's bedside and treatment station. The interview confirmed the finding.

2. Review on 01/08/2013 of the hospital's policy "Microbiological Monitoring" (effective 07/31/2009) revealed "Water Results: Test results exceeding the Action Level or Allowable Limits: In the event test results are above the action level, Promptly (within 48 hours) notify the medical director, clinical manager, and regional technical manager/technical operations manager of microbiology test results above action levels. Discuss with the medical director, the creation of an action plan when test results indicate that the allowable limits have been exceeded. Repeat testing must be completed on any post-disinfection samples that are above the action level."

Review on 01/09/2013 of the hospital's "Water System-Spectra" culture reports revealed that a R.O. (reverse osmosis) 1 Permeate colony count was collected on 11/16/2012 at 0935 and returned with action level results of "98.0" cfu/ml (colony forming units/milliliter) on 11/17/2012. Review also revealed for undocumented reason that the same culture was obtained by the hospital's water system staff on 11/16/2012 at 1400 and results returning also on 11/17/2012 as "50" cfu/ml. Both results were action level results for AAMI that required action level at equal to or greater than 50 cfu/ml. Review of the hospital's culture reports further revealed that no documentation was found where the medical director was notified within 48 hours or was repeated until 11/26/2012 at 1015 (total of 8 days later). No documentation was found for the delay in the action level cultures for the water system used for hemodialysis patients.

Interview on 01/09/2013 at 1410 with the hospital's hemodialysis director revealed no reason as to why the action level cultures were not addressed per the hospital's policies and procedures. The interview confirmed the finding.