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Tag No.: C0221
AIA, (American institute of Architects) Guidelines for Design and Construction of Health Care Facilities Under the 2006 edition, section 2.1, 8.2.3.4 it states in part:
(3) Semirestricted areas
(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, nonperforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.
(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plan into the semirestricted environment. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.
(4) Restricted areas. Ceiling finishes in restricted areas such as operating rooms shall be monolithic, scrubbable, and capable of withstanding chemicals. Cracks or perforations in these ceilings are not allowed."
Based on tour of the surgical suite on 12/18/13 with Staff C (Senior Director of Surgical Services) it was observed that the facility failed to have the proper ceiling tiles in Central Processing area.
Findings include:
During tour of the surgical suite with Staff C on 12/18/13 it was observed and shown to Staff C that the ceiling tiles throughout the central sterile processing and central sterile storage areas along with the soiled or decontamination room had perforated ceiling tiles that are porous and unable to withstand chemical cleaning. Also it was found that the tiles that were in place failed to be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plane.
Tag No.: C0282
Based on observation and interview the facility failed to ensure that biological's that were unusable were not being used for patient related care in 2 patient care areas and 1 outpatient care area.
Findings include:
During the tour of the ICC (Intermediate Critical Care) care area of the hospital on 12/17/13 the blood glucose testing practice was being reviewed. During this review it was observed that the red control solution being used had been dated for 3/12/13 to reflect the opened date and the green control solution being used had been dated for 8/12/13. This observation was confirmed during interview on 12/17/13 with Staff A, Clinical Nurse III.
During the tour of the outpatient care area identified as "FRH [Franklin Regional Hospital] Internal Medicine" on 12/18/13 the blood glucose testing practice was being reviewed. During this review it was observed that the control solution being used had not been dated to reflect the date opened and associated date of expiration ("90 days after opening").This observation was confirmed during interview on 12/18/13 with Staff B, RN (Registered Nurse).
During tour of the E.D. (Emergency Department) on 12/17/13 the blood glucose testing practice was being reviewed, during this review it was identified that the monitor control solutions that were in use for daily quality checks had been opened but had no identifying date to show when they would expire (90 days from opening by manufacturers instruction). This observation was confirmed by Staff F (E.D Manager).
Tag No.: C0308
Based on observation and interview the facility failed to ensure that all patient information was secure from unauthorized access during the practice of transport of specimens from Franklin Regional hospital to Lakes Region General Hospital.
Findings include:
During tour of the hospital lab area and the respiratory department it was identified that in the lab when specimens were sent over to LRGH (Lakes Region General Hospital) for testing, the process was to call a local cab company which was contracted to act as a courier for the hospital to transport the specimens. This was also the practice for ABG ' s (Arterial Blood Gases) from the respiratory department.
Interview with Staff D (Lab Director) and Staff E (Respiratory Therapist) on 12/18/13 identified that when the specimens were sent by cab, they contained patient names, medical record # 's, and the specific tests being run. Observation of the containers used to send the specimens identified no means for securing the patient information from unauthorized access. The inability to secure this information was confirmed by Staff D and E.