HospitalInspections.org

Based on review of policy/procedure and interview, it was determined that the facility failed to require that:

1. evacuation drills were completed at least once, every 12 months for 5 of 5 Single Group License (SGL) clinics; Douglas Emergency Dept, Douglas Physical Therapy, Palominas-Hereford-Palominas, Bisbee Physical Therapy and Tombstone Clinic; and

2. smoke detectors were tested monthly in 2 of 5 SGL clinics; Douglas Physical Therapy 4 smoke detectors, and Palominas-Hereford Clinic 13 smoke detectors.

The above deficiencies pose a risk to the health and safety of the patients, staff and visitors if a fire event should occur.

Findings include:

1. Facility policy titled "Fire Safety Management Plan" dated 6/4/2007, revealed: "...It is the policy of Copper Queen Community Hospital to protect, patients, personnel, visitors, and property from fire, smoke and other products of combustion through the design, measurement, assessment, and improvement process. This is accomplished through ongoing monitoring and improvement of the features of fire safety. When features of fire safety are compromised, interim life safety measures are implemented to offset the risk...."

A policy/procedure regarding evacuations drills to be conducted once every 12 months was requested. No policy/procedure was submitted.

Evacuation drill documentation for 5 of 5 SGL Clinics was requested on 10/14/2020, and was not provided.

Employee #4 verified in an interview conducted on 10/14/2020, that they are conducting fire drills quarterly at 5 of 5 SGL clinics, however, the employees have not evacuated in the past 12 months.

2. Facility policy titled "Fire Safety Management Plan" dated 6/4/2007, revealed: "...Maintenance, Testing, Inspections, Records and Reports...A. The requirement for testing, inspecting and maintaining the various components of each fire protection system are extensive...1. The Director of Environmental Services is responsible for inspections, testing, and maintenance of the fire protection system and alterations or additions to the system and for providing access to components of fire protection systems that require inspection, testing, or maintenance. 2. The Director of Environmental Services will establish an inspection, testing, and maintenance program that encompass the relevant areas of NFPA Codes and related regulatory requirements...B. Records and Reports 1. The Director of Environmental Services is responsible for maintaining all documentation and records of inspection testing, and/or maintenance...."

Documentation of monthly smoke detector testing for the last 12 months for the above clinics was requested. No documentation was submitted.

Employee #4 verified in an interview conducted on 10/14/2020, that some of the smoke detectors are linked to the alarm system and some are not, however, there was no documentation of monthly smoke detector testing.

Based on observation, the facility failed to maintain the emergency exit and enclosed stairwell door with a 1.5-hour fire rated door. With the door removed, during a fire event resulting in a smoke filled enviroment ,a patient or staff could fall down the stairs. This could result in injury or death. Failing to maintain fire barriers could allow smoke to enter the stairwell and a fire to spread more rapidly through the two-hour fire barrier and give staff and patients less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 7, Sub-Section 7.2.2.5.1.1. All inside stairs serving as an exit or exit component shall be enclosed in accordance with Section 7.1.3.2 Exits, Sub-Section 7.1.3.2.1. Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1) * The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating.
(3) * The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).

Findings include:

Observations while on tour revealed the fire rated door at the top of the stairwell had been removed by the facility due to damage. The stairwell does not have a safety landing at the top of the stairwell with the door removed, and any person entering the stairwell intentionally or by accident in a smoke filled enviroment could fall down the stairs.

Employee #1 and #4 confirmed during the exit conference on October 13 and 14, 2020 that the door at the top of the stairwell had been removed by the facility.

Based on review of manufacturer's recommendations, facility documents and interview, it was determined that the facility failed to ensure that patients' medication refrigerator temperatures were within specified parameters in 1 SGL; Douglas Emergency Dept, which poses the potential risk that medications given that aren't cooled to specific parameters could be ineffective and harmful.

Findings include:

Review of "CQHC REFRIGERATOR LOG" revealed: "...Record the observed temperature Monday - Friday and your initials. If out of range (i.e. less than 36 F or greater the 46 F, 2-8 C (Celsius), adjust the thermostat and re-read in one hour and record the new temperature. If sill out of range, report to on-site pharmacist...."

"CQHC REFRIGERATOR LOG"

9/2020:

Out of 30 days, 9 temperatures were between 47 F and 49 F, and no action was taken.

10/2020:

Out of 14 days. 4 temperatures were between 49 F and 48 F, and no action was taken.

Employee #55 verified, in an interview conducted on 10/14/2020, at 12:00 pm, that yes the temperatures are out of range and action should have been taken.

Based on review of policy/procedure and interview, it was determined that the facility failed to require that:fire inspections were conducted per the city ordinance for 3 of 5 SGL clinics; Douglas Emergency Department, Douglas Physical Therapy, and Palominas-Hereford Clinic.

Facility policy titled "Fire Safety Management Plan" dated 6/4/2007, revealed: "...Maintenance, Testing, Inspections, Records and Reports...A. The requirement for testing, inspecting and maintaining the various components of each fire protection system are extensive...1. The Director of Environmental Services is responsible for inspections, testing, and maintenance of the fire protection system and alterations or additions to the system and for providing access to components of fire protection systems that require inspection, testing, or maintenance. 2. The Director of Environmental Services will establish an inspection, testing, and maintenance program that encompass the relevant areas of NFPA Codes and related regulatory requirements...B. Records and Reports 1. The Director of Environmental Services is responsible for maintaining all documentation and records of inspection testing, and/or maintenance...."

A copy of the most recent fire inspection reports for 3 of 5 SGL clinics was requested. No documentation was submitted.

Employee #4 verified, in an interview conducted on 10/14/2020, that he/she does not have any documenation of fire inspections being conducted at 3 of 5 SGL clinics.

Based on review of policy and procedure, medical records, and staff interview, it was determined the facility failed to ensure that patients or the patient's representative receives a written copy of their patient rights in five (5) SGL clinics; Douglas ED, Douglas PT, Palominas-Hereford Clinic, Bisbee PT and Tombstone Clinic. This poses the potential risks that patients will not be informed of their patient rights to make an informed decision.

Findings include:

Review of the facility policy "Patient Rights & Responsibilities" (Section 2.03.22, last date modified 02/07/2020) revealed no documentation as to how patients or their representative are to receive their patient rights.

Review of 17 out of 17 medical records revealed that patients #2, #3, #7, #8, #9, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30, had no documented evidence that Patient Rights were provided and/or received by the patient or patient's representative.

Employee #6 who works in the Emergency Department Registration, confirmed in an interview conducted on 10/13/2020 (1313) , that when a patient comes to the Emergency Department registration/triage area, they are required to sign a consent for treatment (unless it is urgent/emergent and then the patient is treated first and signs consent after they are medically stable), and the patient is also given a copy of their patient rights. Employee #6 also confirmed, that the consent for treatment does not include patient rights, and that there is no patient signature required when receiving their patient rights.

Based on review of policy and procedure, observation tour, manufacturer's recommendations and interview, it was determined that the facility failed to ensure that:

1. the Hydrocollator was cleaned every two weeks according to manufacturer's recommendation at one (1) SGL clinic; Douglas PT which poses the potential of cross contamination between patients; and

2. hydrocollator temperatures were with-in recommended guidelines in one 1 SGL clinic; Douglas PT, which poses the potential risk that patients are not receiving adequate treatment with the HotPacs or sustain burns if the HotPacs are too hot; and

Findings include:

1. Review of manufacturer's recommendations "Hydrocollator HEATING UNITS" revealed: "...Care and Cleaning...The tank should always be drained, cleaned, and inspected at minimum intervals of every two weeks...."

Review of the Hydrocollator "Temperature Log" revealed that since 5/7/2020, the hydrocollator had only been cleaned on two occasions.

Employee #54 verified, in an interview conducted on 10/14/2020, at 10:30 am, that the hydrocollator has not been cleaned every two weeks per manufacturer's recommendations.

2. Review of manufacturer's recommendations "Hydrocollator HEATING UNITS" revealed: "...The recommended operating temperature is 160 (degrees) F (Fahrenheit) to 165 F. The temperature of the water should be checked with a thermometer after every adjustment, before using the HotPac...."

Review of the Hydrocollator "Temperature Log" revealed that out of the 14 temperatures taken since 5/7/2020, 13 were between 151 F to 155 F.

Employee #54 verified, in an interview conducted on 10/14/2020, at 10:30 am, that the hydrocollator temperatures are not within manufacturer's guidelines.

Based on review of the facility's medical records, and interviews, it was determined that the facility failed to require that three (3) out of three (3) swing bed patients received their patient rights, and that the physician, and dietary personnel participated in the development and on-going interdisciplinary care planning. These deficient practices poses a risk to the health and safety of the patients, when the patients are not made aware of their rights specific to swing bed requirements, and that the required interdisciplinary plan of care does not include updates from the physician and dietary personnel specific to the patient's healthcare needs.

Findings include:

Policy titled "Admission to Swing-Bed" (#22.03.02; 01/13/2020), revealed: "...to admit to swing-bed status the following must be in place...resident must be given an admission package to include Rights and Responsibilities...."

Policy titled "Care Plan Swing-Bed Resident" (#22/03/11; 01/24/2020), revealed: "...purpose of patient care plans at Copper Queen Hospital is to make a comprehensive assessment of the patient's needs...determine interventions appropriate for those needs...a patient care plan will be completed on all new swing-bed patients...swing-bed coordinator and interdisciplinary team to include...physician, registered nurse, physical, occupational and respiratory therapists, pharmacist...case manager/discharge planner...a comprehensive multidisciplinary care plan will be completed on all swing-bed patients within forty-eight (48) hours of admission...will include goals...desired outcomes...goals...physician will be involved in care planning process...."

Personnel # confirmed during an interview conducted 10/14/2020 (1115), that when needed, s/he fills in for the discharge/case manager, which would include participating in the interdisciplinary care planning for swing-bed patients. Personnel # revealed that different departments/services participates in the interdisciplinary care planning meetings, to include the physician, and that there is no documented evidence of the physician attending. Additionally, Personnel # confirmed, that dietary personnel does not participate in the interdisciplinary care planning meetings.

Personnel # confirmed during an interview conducted 10/14/2020 (1455), that s/he participates in the interdisciplinary care planning for the swing-bed patients, and that a physician participates, but there has been no participation by dietary personnel. Additionally, Personnel # revealed that there is no documented evidence of who attends the interdisciplinary care planning for the swing-bed patients, and that the physician's name is not listed.