HospitalInspections.org

Based on medical record review, document review and interview, one (1) of 10 medical records reviewed, the facility did not maintain adequate inventory of emergency supplies to ensure patient care needs are met.

This failure may prevent patients from receiving timely treatment during cardiac emergencies.

The facility did not have an effective system in place to monitor the use of Combo Pads on nursing units and ensure adequate supply of the item.

See findings in Tag A0724.

Based on observation, staff interview, the hospital did not maintain its plant in such a manner that the safety and well being of patients and staff are assured.

Findings include:

Emergency Department Psychiatric Holding (ED):
On the morning of 7/12/2018, during a tour of the holding area of the Psychiatric ED, it was observed that the ceiling tiles are from the regular suspension ceiling tiles and the door knobs of the two holding rooms have regular door knobs which impose potential risk of looping for the psychiatric patients who use these rooms.


MRI Suite:
On 7/12/2018 at 3:00 pm, during a tour of the MRI suite it was noted that the Metal chain holding the tag of the fire extinguisher was not an MRI compatible material.

Psychiatric unit - 2 North:
On 7/13/2018 at 11:32 AM, the following were observed during a tour of the Psychiatric unit - 2 North:

1- The soap dispenser and the towel dispenser of the tub room were attached to the wall at a level of approximately five feet from the floor and their shape and the way they are attached to the wall allows for looping around them.

2- The Electric panel located by the nurse station has a latch mechanism that is approximately five feet from the floor. The latch is a potential looping hazard.

3- The cover base of room 209 next to stairwell 3 was loose and detached from the wall.

4- The handles of the cabinet doors of the dining room were of the regular type, and not the psychiatric approved safety type. The regular handles are potential looping hazard.

5- The file cabinets, drawers, door handles, metal paper cutter, wire shelving storage cabinet, wiring of fans, computers and other electric equipment were observed in the activity rooms. All the above referenced items either are looping hazard or can be used by patients as weapon to harm self or others.

6- The door handle of the electric panel on the corridor was affixed to the wall at a level greater than 5 feet from the floor which constitute a looping risk and was not the psychiatric approved type.

7- The door to the nursing station (dwarf door) which is approximately 30 inches in height was not secured. This door is accessible to patients and can be used to gain access to the nursing station where many loose items are stored that can be used by patients as weapons to harm self and others.

Based on observation and staff interview, the facility did comply with applicable provisions of the Life Safety Code of the National Fire Protection Association to prevent injury/death in the event of any fire emergency.

Findings include:
1a- There were no exit signs provided in the treatment area of the Emergency Department to direct the staff to the outside of the area in the event of fire or smoke.
1b- There were no exit signs provided in the CT Scan suite to direct the staff to the outside of the area in the event of fire or smoke.


2. There were no strobes provided in the handicapped bathrooms of the hospital as per NFPA requirement. This observation was identified on the 1st floor of the hospital.
strobes in the ADA (Americans with Disabilities Act) bathrooms are to alert people who are hearing impaired about the Fire alarm signals when activated.

The above finding was identified in the presence of the Facility's Fire Safety Director and was presented to the hospital leaders during the exit conference on 7/17/18.


3. During a tour of the 5th floor of the hospital on 7/12/2018 at 2:00 pm, (Medical Surgical Unit), the electric conduit between the 5th and the 6th floor was open with no seal or fire stop material, which poses a vertical penetration between the two floors.

This observation was made in the presence the facility's staff who acknowledged the finding.


4. During a tour of the Operating Room Suite and other floors of the hospital, the directories of various Emergency Electric Panels, listed many items that does not belong in the specific branch of the Essential Electrical System (EES) and the EES of the hospital does not conform to the requirement of Type 1 EES as per the NFPA 99, 2012 edition. Specifically, The Essential Electrical System of the hospital is not divided into three branches that are separate from each other; The Life Safety Branch, The Critical Branch and the Equipment Branch.
Examples of Items that are listed on the Life Safety Branch contrary to the requirements included but were not limited to:

# ATS 4- LSB:

Basement - 'ELSMERB' (left side) Breaker:
a- Item 13- Corridor lights & elevator lobby.
b- Item 19 - Receptacle in Health Office
c- Item 20 - Receptacle in Health office

Life Safety Branch - Basement - 'ELSMERB' (left side)
a- Item 1- Loop system basement
b- Item 2- Telephone Equipment room
c- Item 3 - Telephone room (cab. Ctr)
d- Item 4- Loop System 4,5,6 floors
e- Item 9- Doctors Call System
f- Item 12- Jacket Heaters
g- Item 13- Jacket Heaters
h- Item 16- Telephone switchboard room receptacle

During an interview with the facility's Engineering and the Director of Safety, they acknowledged the findings and that the three branched of the EES system are not completely separated as per the NFPA 99 requirement.

Based on medical record review, document review and interview, one (1) of 10 medical records, the facility failed to ensure that supplies needed for emergency care of patients were readily available.

This failure may result in patient harm.

Review of medical record for Patient #1 identified a 55-year-old patient who went into cardiac arrest (temporary or permanent cessation of the heartbeat) on 5/22/18 at 5:55 PM and was successfully resuscitated.

Review of document titled "Facility Code Blue CQI" (Post code quality improvement assessment) indicated that there were no defibrillator pads in the code cart and on the unit when Patient #1 was coded on 5/22/18 at 5:55pm.
Interview with Staff H, Staff Nurse in the ICU on 7/16/18 at 11:33am, she stated that she checked the crash cart on 5/22/18 at 7:10am and noticed there were no combo pads. She immediately requested combo pads from Central Supply, but none was delivered.
During interview with Staff A, ED Assistant Nurse Manager, he confirmed there were no combo pads in the ICU during the code. He explained that combo pads are placed on the patient during a code to facilitate timely intervention if the patient were to develop a cardiac rhythm that requires defibrillation. Staff G, Patient Care Technician was sent to the Emergency Department (ED) to get Combo Pads. The combo pads were applied on the patient immediately.

On 7/16/18 at 11:18 am, during interview with Staff G, Patient Care Technician, she stated that she ran down to the ED to get combo pads and it took her approximately 5 minutes to return to the ICU.

During interview with Staff E, Material Logistic Manager, she stated there is a list of items supplied to each unit for which an inventory par (A minimum quantity of a given item that each unit must have) level is maintained. The par level assigned to each item is used to track and maintain adequate supply on each unit. She acknowledged that they ran out of combo pads in Central Supply since 5/18/18, when it was initially requested by ED staff and had not received the shipment of combo pads in the morning of 5/22/18, when it was requested by the ICU staff.

Review of job responsibilities for "Material Logistics" staff dated 8/2017 reveals that staff would perform the following duties:
"Perform data entry for stock/non-stock item; monitor nursing units daily to see what supplies are needed and ensure accurate par levels are maintained and no stock runs out; ensure timely deliveries of supplies throughout the facility ...".

There was no indication that material logistics staff monitored the supply of combo pads on the units and maintained par level of the item as per their job responsibility.

During interview with Staff F, Assistant Director of Logistics on 7/16/18 at 10:36am, he acknowledged that the combo pads were not on the inventory list of items routinely supplies to nursing units. Staff reported the usage of combo pads on each unit have not been tracked to prevent shortages.