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Based on observations as referenced in the Life Safety Report of survey completed on 02/07/2013, 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 review of the hospital's policy and procedure, medical records and staff interview, the hospital failed to monitor a restrained patient per hospital policy for 2 of 2 sampled emergency services patients that were restrained (Patients #27 and #28).

The findings include:

Review of the hospital's policy, "Restraints", revised 03/16/2012, revealed, "... RESTRAINTS FOR THE MANAGEMENT OF VIOLENT SELF-DESTRUCTIVE BEHAVIOR: ... ASSESSMENT/CARE ...3. The NA (Nursing Assistant) /RN (Registered Nurse) will perform the following approximately every 15 minutes as appropriate for the: Verify the correct application of the restraint. Check for signs of injury associated with restraint. Offer the patient nourishment/fluids. Verify distal pulses in the restrained limb, movement and sensation are intact. Provide for the patients hygiene and elimination needs. Observe patient behavior. 4. The RN will assess the patient approximately every 15 minutes for: Continued need for restraint. ... RESTRAINT DOCUMENTATION: Nursing documentation of restraint initiation and ongoing assessments are completed concurrently in a timely manner as close to the time of occurrence as possible. Documentation of restraints for management of violent or self destructive behavior is on the 24 hour flow sheet (Addendum 4). Documentation of restraints for safety is on the emergency department flow record or the restraint interventions in the inpatient electronic medical record. ...". Further policy review revealed an Addendum 4, "Restraints for Management of Self Destructive or Violent Behavior 24 Hour Flow Sheet". Review of the 24 Hour Flow Sheet revealed columns labeled time, code and initial. Further review revealed codes for observation codes 01-07 and patient care codes P1-P8.

1. Closed medical record review of Patient #27 revealed a 28 year-old male who presented to the hospital's emergency department on 11/18/2012 at 2151 with altered mental status and alcohol abuse. Record review revealed a physician's order for "restraints for management of self-destructive or violent behavior" dated 11/17/2012 at 2225. Further review revealed 4-point soft limb restraints were ordered and applied. Record review revealed no documentation the patient was observed to verify the correct application of the restraint, checked for signs of injury associated with restraint, offered nourishment/fluids, verified distal pulses in the restrained limb, movement and sensation were intact, provided hygiene and elimination needs and observation of behavior every 15 minutes after the restraints were applied until Patient #21 was admitted to ICU (Intensive Care Unit) at 0100 (3 hours, 9 minutes). Record review revealed no documented evidence of a 24 -hour restraint flow sheet nor documented evidence on the emergency department flow record while Patient #27 was in the emergency department.

Interview on 02/07/2013 at 1045 with administrative emergency department staff revealed the restraint monitoring flow sheet was not completed while Patient #27 was restrained on 11/18/2012. Interview further confirmed the nursing staff failed to monitor the patient every 15 minutes while in restraints. Interview confirmed the nursing staff failed to follow the hospital's policy for monitoring restrained patients.

2. Closed medical record of Patient #28 revealed a 77 year-old female who presented to the hospital's emergency department on 12/04/2012 at 1220 after having a seizure. Record review revealed a physician's order for "restraints for management of self-destructive or violent behavior" dated 12/04/2012 at 1300, with a renewed order for restraints at 1700. Further review revealed 4-point soft limb restraints were ordered and applied. Record review revealed no documentation the patient was observed to verify the correct application of the restraint, checked for signs of injury associated with restraint, offered nourishment/fluids, verified distal pulses in the restrained limb, movement and sensation were intact, provided hygiene and elimination needs and observation of behavior every 15 minutes until the restraints were removed at 1854 (6 hours, 54 minutes). Record review revealed no documented evidence of a 24 -hour restraint flow sheet nor documented evidence on the emergency department flow record while Patient #28 was in the emergency department.

Interview on 02/07/2013 at 1045 with administrative emergency department staff revealed the restraint monitoring flow sheet was not completed while Patient #28 was restrained on 12/04/2012. Interview further confirmed the nursing staff failed to monitor the patient every 15 minutes while in restraints. Interview confirmed the nursing staff failed to follow the hospital's policy for monitoring restrained patients.

Based on the hospital's policy review, "Water Quality Monitoring (Audit Tool)" review, the hospital's "Microbiological Reports" review, and staff interview, the hospital failed to ensure that program data submitted for review of the hospital's hemodialysis treatment water quality and remedial actions reflected accurate information for the hospital's Quality Improvement Organization to ensure safe water for hemodialysis patients on the hospital census.

Findings include:

Review on 02/05/2013 of the hospital's adopted policy "Microbiological Monitoring: Portable Reverse Osmosis and Deionization Water Purification Systems for Inpatient Services" (effective 02/29/2012) revealed "Ensure microbiological monitoring data is presented and reviewed at the monthly QAI (Quality Assessment and Performance Improvement) meeting."

Review on 02/06/2013 of the hospital's "Water Quality Monitoring" audit tool submitted by the hospital's contracting hemodialysis service provider for the reporting year of (2012 January-December) revealed that "Microbiological results were within normal limits with no disinfection (remedial action) required." The review of the documentation revealed from January-December that 100% of data reflected no disinfection or action levels were required in the data submitted to the hospital's Quality Improvement Organization.

Review on 02/06/2013 of the hospital's microbiology reports from the hospital's hemodialysis contracted staff revealed that disinfection was required for the portable reverse osmosis (RO) machine water samples as part of action level results for the culture levels elevated. Documentation reports of the microbiological culture reports revealed that disinfection was completed for the portable reverse osmosis machine water samples as follows:

~10/22/2012 disinfection of Portable RO machine #1278939 water sample completed after action level reports on 10/18/2012.

~09/14/2012 disinfection of Portable RO machine #12842 water sample completed after action level reports on 09/14/2012.

~06/29/2012 disinfection of Portable RO machine #12842 water sample with no documentation of date for action level culture reports.

The review revealed no documentation that the hospital's Quality Improvement Organization was aware that disinfection was completed by the contracted hemodialysis staff on the Portable RO machines used for hemodialysis patients. The program data used in reports indicated that microbiological cultures were all 100% met without any disinfection needed. The hospital's Quality Improvement Organization presented program data that did not reflect the documented remedial actions taken by the hospital's hemodialysis water treatment staff.

Interview on 02/06/2013 at 1105 with the hospital's contracted water treatment technician in hemodialysis revealed that the hospital's "Water Quality Monitoring" audit tool was not accurate in stating that no disinfection was performed at the hospital during the reporting year of 2012 on Portable RO machine water samples.

Interview 02/06/2013 at 1350 with the hospital's administrative staff revealed that the hospital did recognize the concerns of inaccurate program data in their reports, but could not produce any new documentation that indicated the hospital was aware of the inaccurate data. The interview confirmed the finding that the presented documentation was not accurate and did not reflect that disinfection of the portable RO machines were being completed after culture actions were required.

Based on hospital policy review, medical record review, and staff interview, the hospital's nursing staff administered a medication without a documented physician order in 1 of 10 sampled emergency department (ED) patients (Patient #8).

Findings include:

Review of the hospital's policy and procedure "Medication Administration Principles" (revised 10/26/20110) revealed "Medication Orders: Medications are to be administered upon orders of a qualified physician, podiatrist, dentist, or other practitioner duly licensed or authorized to prescribe by the State of North Carolina and who has been approved as a member of the medical staff of (Hospital Name). All orders for medication shall be written into the medical record of the patient."

A closed medical record review on 02/07/2013 for patient #8 revealed the patient presented to the hospital's ED on 02/05/2013 with a chief complaint of "sickle cell crisis." Review of the record revealed the patient was administered two (2) doses of the medication "Zofran 8 milligrams" (anti-nausea and vomiting medication) on 02/05/2013 at 0653 and again at 0720. Review of the patient's medical record revealed that there was only one (1) physician order to administer the medication "Zofran" and that was at 0645. No second physician order was found anywhere in the patient's medical record for the administration of the second dose of "Zofran."

Interview on 02/07/2013 at 1100 with the hospital's Director of Emergency Services revealed that no second order could be found for the administration of the medication "Zofran" to the patient. The interview revealed "A physician may have told the nurse, but there is no written order." The interview confirmed the finding.

Based on policy and procedure review, observation and staff interview the facility failed to ensure patient's medical records were secured in 1 of 5 outpatient areas (Outpatient Rehabilitation).

Findings include:

Review of the hospital's policy and procedure Information Management, Security, and Confidentiality, dated 07/30/2001, revealed ".......when in use within the facility, medical records shall be kept in secure areas at all times and shall not be left unattended in areas accessible to unauthorized individuals."

Observation during tour on 02/06/2013 at 1410 of the outpatient rehabilitation center (Buidling 04) revealed patients' medical records containing confidential health information were visibly stored on open shelves in the employee work station of the registration clerks office. Observation revealed the door leading into the registration clerks office did not have a locking mechanism on the door. Observation revealed the main entry door leading into the outpatient rehabiliation department was secured with a key lock mechanism.

Interview on 02/06/2013 at 1410, during the tour, with the outpatient rehabiliation department director revealed the patients' medical records are stored on the open shelves and remain on the open shelves at all times. Further interview revealed the door into the area where the medical records are stored can not be locked. Further interview revealed the outpatient rehabilitation staff are present during the normal operating hours of 0730 - 1630. After 1630 the housekeeping staff has access to the department and the area where the medical records are stored. Interview confirmed unauthorized personnel, housekeeping staff, have access to the patient's medical records confirming a confidentiality and security issue.

Based on observations as referenced in the Life Safety Report of survey completed 02/07/2013, 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 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

2. The hospital failed to ensure emergency lighting was provided in emergency egress corriders.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702

3. 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

4. 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 (a)(1)(2)(3) Physical Environment Standard Tag A-

Based on observations as referenced in the Life Safety Report of survey completed 02/07/2013, 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:

Building 01
1. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward, of the Main Hospital Building, the following Life Safety items were observed as noncompliant, specific findings include:

a. 5th floor, clean utility/ oxygen storage room had no signage noting the full and empty oxygen cylinders. (This item was corrected before the end of the survey)

b. 5th floor, clean utility/ oxygen storage room had free standing oxygen cylinder not in a proper stand in the space.

c. 2nd floor. Respiratory room had oxygen storage without proper signage noting such storage.

d. liquid oxygen storage outside, The "H" cylinders at the bulk liquid oxygen area were not protected from rusting as the cylinders at that location were not off the ground.

e. The "H" cylinders at the bulk liquid oxygen are were not protected from extremes of weather as they did not have a cover to the cylinder valves from extremes of weather.

f. 1st floor, The OR equipment room had a mixture of full and empty oxygen cylinders mixed in the same enclosure.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K 0076

Based on observations as referenced in the Life Safety Report of survey completed 02/07/2013, the hospital failed to ensure emergency lighting was provided in emergency egress corriders.

The findings Include:

Building 02
1. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward, of the Hematology Oncology and Pain Clinic Building, the following Life Safety items were observed as noncompliant, specific findings include:

a. Hospital based area, Hematology Oncology and Pain Clinic Building, the egress emergency lighting for the hospital based area is not complete in the corridor.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0046

Building 03
2. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward, of the Wound Healing Clinic, the following Life Safety items were observed as noncompliant, specific findings include:

a. Wound Healing Clinic, the egress emergency lighting for the hospital based area is not complete in the corridor.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K 0046

Building 04
3. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward of the Outpatient Rehabiliation Buidling the following Life Safety items were observed as noncompliant, specific findings include:

a. Hospital based area; the egress emergency lighting for the hospital based area is not complete in the corridor.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K 0046

Based on observations and staff interviews as referenced in the Life Safey report of survey completed on February 7, 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:

Building 01
1. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward of the Main Hospital Buidling the following Life Safety items were observed as noncompliant, specific findings include:

a. The office located next to freezer #2 has unsealed penetrations in the rated walls wall that were not sealed in order to maintain the require rating of the room.

b. In the steam room located in Same Day Surgery the rated wall on the right side as you enter the room had unsealed areas and does not maintain the required fire resistance rating of the area.

c. The electrical chase in CT Room #1 was not sealed in order to maintain the required fire resistance rating of the area.

d. 2nd floor, the surgery services educators office is a one hour protected space, and the doors to the space has a gap greater than 1/8th of an inch between the door and the inactive leaf next to the door.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0012

2. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. The loading dock. The loading dock area did not have fall protection installed when trucks are not in place loading or unloading items. The path of egress lead persons to the loading dock for egress from the building.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0032

3. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. The generator annunciation panel did not have monitoring of the safety indications and shutdowns at a work site readily observable by personnel. The emergency power system annunciation was at the engineering department with the proper indications and shutdowns but that area is not manned in the overnight shift of the hospital.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0145

Based on observations as referenced in the Life Safety Report of survey completed 02/07/2013, 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:

Building 01
1. Based on the observations and staff interviews during the survey on February 5-7, 2013 at approximately 0800 onward of the main hospital building the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, the corridor doors located on the hall in front of main pharmacy were found blocked open with construction crates preventing the doors from closing.

b. 2nd floor, the neuroscience nurse practitioner office had an impediment to closing the door as the door was wedged open.

c. 1st floor, the anesthesia storage room door did not close and latch when tested.

d. 1st floor, the anesthesia office door did not close and latch when tested

e. 1st floor, the pathology/ lab door did not close and latch when tested.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0018

2. Based on the observations and staff interviews during the survey on February 5-7, 2013 at approximately 0800 onward of the main hospital building the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, Pre-Op Suite #8 was incomplete as it was seen on the Life Safety Plan drawings. The Pre-Op suite did not have cross-corridor smoke doors installed in order to separate the suite from the exit corridor next to Cath Lab.

b. Basement, the materials management double doors at that location did not close smoke tight as the astragal for the door prevented the door from closing smoke tight.

c. 3rd floor, there were unsealed penetrations in the rated smoke wall at the employees brake room looking to the patient room. (This item was corrected before the end of the survey)

d. 2nd floor, there were unsealed penetrations in the rated smoke wall at the nurses managers office at the back corner wall looking at the mechanical room.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0027

3. Based on the observations and staff interviews during the survey on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, The storage room located on the right side of the Cath Lab hall next to the exit door to the main corridor was not equipped with a self closing device.

b. basement, The Operating Room (OR) Equipment Storage Room in the basement was blocked preventing the door from closing.

c. 1st floor, The corridor door to vendor storage in the basement was wedged open preventing the door from closing.

d. 1st floor, dietary dry storage area had impediments to the door closing as there was a jacket covering the latching mechanism.

e. basement, the large linen room in the basement had its door wedged open preventing the door from closing.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0029

4. Based on the observations and staff interviews during the survey on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, exit egress corridor was blocked from the respiratory therapy office toward the ICU area.

b. 1st floor exit egress corridor near the pharmacy was under construction and lead to a dead end corridor (this item was corrected before the end of the survey)

c. 1st floor, emergency room registration, the staff at this location was not familiar with the door release master switch at the special locking doors in that area.

d. 1st floor, emergency room registration, the master door release switch at this location did not release the special locking doors in that area. (This item was corrected before the end of the survey)

e. 1st floor, emergency room registration, the master door release switch at this location was not properly identified.

f. 1st floor administration, the door release mechanism in the vicinity of the special locking door at administration leading into emergency room registration did not release the door when tested. (This item was corrected before the end of the survey)

g. 1st floor administration, the special locking doors at this location leading to the emergency department registration area did not release with activation of an automatic fire alarm system when tested. (This item was corrected before the end of the survey)

h. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to the emergency department registration from administration.

i. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to administration from the emergency department.

j. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to same day surgery from mammography.

k. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to X-Ray from the MRI area.

l. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to X-Ray to the emergency department.

m. 1st floor, the facility has a combination of North Carolina Special Locking systems and Access Controlled Egress Doors which are incomplete at doors leading to the B1 elevator from the CSR area.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0038

5. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, Exit directional sign is incomplete from the corridor between Suite 5 & 7 at the main corridor junction.

b. 1st floor, Exit directional signage is incomplete from the respiratory therapy office toward the ICU area.

c. 1st floor, the area leading from X-Ray to the emergency department has an exit directional sign that leads persons into the emergency department suit. The facility can not lead persons into a suit for egress.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0047

6. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. Fire Alarm Control Panel, the facility did not have item "c" from the North Carolina Special Locking Arrangements 1003.3.1.8.5. A wiring diagram and system components location map shall be provided under glass adjacent to the fire alarm panel.

b. 1st floor, there was no strobe activation in the hallway that includes the Family Chapel with activation.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0052

7. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st floor, dietary dry storage closet has solid shelves in that space that does not allow the sprinkler head in that space to cover that area.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0056

8. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. Documentation review, the facility could not show documentation that the 5 year obstruction test was preformed.

b. Basement, the small dry pipe sprinkler system did not have its fire alarm switch electrically supervised.

c. 3rd floor, the third floor tamper alarm on the sprinkler system in the stairwell did not give a supervisory signal when tested.

d. 2nd floor, the electrical room near the nurse ' s station has a sprinkler head in the space that had paint on the heat sensitive element.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0062

9. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. 1st Floor, The corridor door separating the lobby from Pre-Op did not close smoke tight. There was an excessive gap between the double doors greater than 1/8 of an inch.

b. 1st Floor, 1st floor, Equipment not in use was found stored in the corridor near the Cath lab.

c. 1st floor, Equipment not in use was found stored in the corridor near the Cath lab.

d. 1st floor, There were beds and other equipment found stored in the exit corridor that were not in use at the Pre-Post OP area.

e. 1st floor, There were beds and other equipment stored in the exit corridor that wee not in use near the Radiology area.

f. 4th floor, the wall computer stations (Enovate) did not retract automatically after being opened at the station near room 4208. This condition leaves an impediment into the egress corridor all devices must be checked for this operation.

g. 3rd floor, the wall computer stations (Enovate) did not retract automatically after being opened at the station near room 3224. This condition leaves an impediment into the egress corridor all devices must be checked for this operation.

h. 4th floor the NC/TV room door did not open into the egress corridor 180 degrees flat to the adjacent wall nor was equipped with a door closure to return the door to the closed position after being opened.

i. 1st floor, There were items stored in the exit egress corridor that were not in use on the radiology corridor.

j. 1st floor, There were items stored in the exit egress corridor that were not in use on the OR back hallway.

k. 2nd floor, the wall mounted cabinet did not retract after placed in the down position near room 2228.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0072

10. Based on the observations and staff interviews during the survey on February 5 - 7, 2013 at approximately 0800 onward the following Life Safety items were observed as noncompliant, specific findings include:

a. The Smoke Dampers located in the smoke wall at the 5th floor did not close upon activation of the fire alarm by smoke head. (This items was corrected before the end of the survey)

b. The Smoke Dampers located in the smoke wall at the 4th floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)

c. The Smoke Dampers located in the smoke wall at the 3rd floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)

d. The Smoke Dampers located in the smoke wall at the 2nd floor did not close upon activation of the fire alarm by smoke head. . (This items was corrected before the end of the survey)

~cross-refer to Life Safety Code Standard- NFPA 101, TAg K 0104

Building 02

11. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward of the pain clinic building the following Life Safety items were observed as noncompliant, specific findings include:

a. The pain clinic secondary exit egress had impediments to exiting in the path of egress. (Large boxes) (This item was corrected before the end of the survey)

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0072

Building 03

12. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward of the Wound Healing Building the following Life Safety items were observed as noncompliant, specific findings include:

a. The hospital based area; the canopy is not currently sprinklered. The separation for that canopy and the hospital based area was not verified.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0056

13. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward of the Wound Healing Building the following Life Safety items were observed as noncompliant, specific findings include:

a. Hospital based area; the back flow preventer in the hot box near the post indicator valve does not have the valves electronically supervised.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0062

Building 04

14. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward of the Outpatient Rehab Building the following Life Safety items were observed as noncompliant, specific findings include:

a. The hospital based area; the door to the waiting room was prevented from closing by a kick down installed on the door.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0018

15. Based on the observations and staff interviews during the survey tour on February 5-7, 2013 at approximately 0800 onward of the Outpatient Rehab Building the following Life Safety items were observed as noncompliant, specific findings include:

a. The hospital based area, the large storage/ linen room is greater than 100 square feet and is not a one hour protected space.

b. The hospital based area; the large gift shop storage room is greater than 100 square feet and is not a one hour protected space.

~cross-refer to Life Safety Code Standard- NFPA 101, Tag K 0029

Based on hospital policy review, "Occupational Safety and Health Administration (OSHA) Regulations (Standards-29 CFR-Bloodborne Pathogens Appendix A" review, record reviews, observation, and staff interview, the hospital's infection control officer failed to ensure that standard infection precautions were maintained by a nurse failing to change contaminated gloves during access of a patient's catheter in 1 of 1 observed hemodialysis patients having access of a catheter (Patient #34, Nurse #4); failing to ensure a nurse wore a personal protective equipment (PPE) mask over her nose during vascular access termination in 1 of 1 observed hemodialysis patients being disconnected from treatment (Patient #46, Nurse #4); failing to ensure a nurse and physician cleaned and disinfected their stethoscopes after patient contact to prevent cross contamination (Nurse #4, Physician #1); failing to prevent food was consumed inside of a patient care area (Physician #2), and failing to ensure the control of the spread of infection by a staff nurse failing to perform hand hygiene after patient contact for one of three observed medication (Nurse #1, Patient #42).
Findings include:

1. Review of the hospital's adopted policy and procedure "Personal Protective Equipment Policy" (effective 01/04/2012) revealed "Change gloves and practice hygiene between each patient and/or station to prevent cross-contamination.

Review of the hospital's policy and procedure "Standard Precautions and Transmission-Based Precautions (revised 10/24/2012) revealed "Standard Precautions require that blood, all body fluids, secretions and excretions, mucous membranes and non-intact skin of all patients be treated as potentially infectious. Specifically, Standard Precautions include: routine hand hygiene, appropriate use of masks, eye and face shields, routine cleaning or disposal of care equipment, safe injection practices, wearing face mask when placing a catheter or injecting material into the spinal or epidural space, disposal of linen at point of use, consistent and correct glove use, strict adherence to occupational safety requirements."

Observation of care in the hemodialysis unit on 02/06/2013 at 1335 through 1341 for patient #34 revealed the patient had a spermaceti access site for his hemodialysis treatment. Observation of the patient's initiation of hemodialysis treatment by Nurse #4 revealed the nurse placed a pair of clean gloves on for withdrawing initial blood and heparin from the catheter. Observation revealed that after removing two syringes of blood waste, the nurse left the patient station (bed) and took the two syringes for disposal in the sharps container that was located approximately 10 feet away from patient station. The observation then revealed the nurse went back to the patient's hemodialysis machine and began touching the machine's control panel to enter data with same gloves on. Observation further revealed the nurse without removing or changing gloves, then resumed touching the patient's spermaceti (catheter) for initiation of the patient's hemodialysis treatment. The observation revealed the nurse failed to prevent potential cross contamination of the patient's spermaceti.

Interview on 02/06/2013 at 1355 with Nurse #4 revealed she did not change gloves after leaving the patient station and after touching the dialysis machine. The interview revealed "I did not think of changing gloves, but I understand not contaminating patient spermaceti." The interview confirmed the finding.

2. Review of the "Occupational Safety and Health Administration (OSHA) Regulations (Standards-29 CFR-Bloodborne Pathogens Appendix A) presented as adopted from the hospital's "Bloodborne Pathogen Exposure Control Plan" from the hospital on 02/06/2013 revealed "Masks, Eye Protection, and Face Shields. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated."

Observation of care in the hemodialysis unit on 02/06/2013 at 1140 through 1150 for patient #46 revealed Nurse #4 discontinuing the patient's hemodialysis treatment. Observation revealed the nurse was wearing PPE that included gown, gloves, and mask while the patient's vascular access (catheter) was being disconnected. Observation revealed the nurse was wearing her mask under her nose with the nostril's exposed and not covered.

Interview on 02/06/2013 at 1205 with Nurse #4 revealed she was not wearing her mask over her entire nose and she did not think about it. The interview confirmed the finding.

3. Review of the hospital's adopted policy and procedure "Cleaning and Disinfection of the Stethoscope" (effective 01/04/2012) revealed "The purpose of this policy is to provide instruction for use and cleaning of the stethoscope to prevent possible cross contamination between patients. All reusable instruments and equipment will be thoroughly cleaned and disinfected prior to use on a patient. Follow the steps of stethoscope should be wiped with either 70% isopropyl alcohol wipe or cloth dampened with 1:100 hypochlorite solution after each use to clean the stethoscope after use on each patient."

Observation of care in the hemodialysis unit on 02/06/2013 at 1337 through 1341 revealed that Nurse #4 and Physician #1 both used their stethoscopes to listen to heart and breath sounds for patient #34 during his initial assessment of hemodialysis treatment. Observation revealed both the nurse and the physician touched the direct skin of the patient with their stethoscopes. The observation revealed that neither the nurse or the physician cleaned or disinfected their stethoscopes after using it on the patient. The nurse placed her stethoscope on the patient's bedside table and the physician placed his stethoscope around his neck. No cleaning or disinfection were noted for the stethoscopes the entire observation.

Interview on 02/06/2013 at 1355 with Nurse #4 revealed she did not clean her stethoscope as required in the policy and procedure for hemodialysis. The interview confirmed the finding.

4. Review of the hospital's policy "Patient Care, Infection Control for" (revised 02/02/2013) revealed "3. No eating ot drinking is allowed in the patient care areas to include the nurse;s stations on all units."

Review of the "Occupational Safety and Health Administration (OSHA) Regulations (Standards-29 CFR-Bloodborne Pathogens Appendix A) presented as adopted from the hospital's "Bloodborne Pathogen Exposure Control Plan" on 02/06/2013 revealed "Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work area where there is a reasonable likelihood of occupational exposure."

Observation in the emergency department on 02/05/2013 at 1452 revealed a physician (Physician #2) inside of the patient care area of the work station eating a a "granola bar." The observation of the area revealed desks where the physicians document their care and located beside of a hand washing sink and biohazard waste containers. The observation revealed the physician was sitting at the desk and talking to another physician. She then removed the granola bar from a bag, and began to eat. The physician stated "I know I should not be eating here, but I am starved." The observation revealed the emergency department administrative staff were present but did not make any statements about food in the area.

Interview on 02/05/2013 at 1530 with the hospital's Director of Emergency Services revealed that no food or drink should be in the patient care areas. The interview confirmed the finding.



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Review of hospital policy titled, Hand Hygiene (latest revision 10/24/2012), revealed "...POLICY: INDICATIONS FOR HAND HYGIENE: Hand Hygiene is performed on ungloved hands with hospital-approved hand sanitizer, foam, or gel, Water and soap at sinks located throughout the hospital... Performance of hand hygiene is measured at many basic and important patient care moments ... b. After Patient Interaction is practically-defined as Hand hygiene immediately after or at the time of exiting a patient room (inpatient room) ..."
5. Medical record review for patient #42 revealed a 43 year old male admitted to hospital on 02/02/2013 for complaint of abdominal pain, nausea and vomiting. Record review revealed patient had a history of ESRD (End Stage Renal Disease) and malignant hypertension. Record review revealed patient was prescribed Renvela (medication used to control of serum phosphorus in patients with chronic kidney disease on dialysis) 800 mg (milligrams), po (by mouth) with meals; scheduled for 0800, 1200, and 1700.
Observation of medication administration pass to patient #42 on 02/05/2013 at 1412 revealed the Registered Nurse (RN #1) assigned to patient #42 placed Renvela (800 mg) tablets into a paper medication cup. RN #1 touched patient ' s wrist and arm band to scan bar code. RN #1 placed medication cup on patient's meal tray. Patient touched medication cup to take tablets out of cup and returned medication cup to meal tray. Staff nurse picked up medication cup; cup disposed. RN #1 returned to computer keyboard, picked up medication bin and bar-code scanner; RN #1 exited the patient ' s room without performing hand hygiene. Hand hygiene gel dispensers were observed mounted to wall inside and outside patient's room. RN #1 entered medication room where medication "Pyxis" was located to return bin, scanner, and patient's discontinued medications. RN #1 failed to perform hand hygiene upon entry into medication room. Hand hygiene gel dispenser was observed outside of medication room.
Interview with 4th floor nurse manager on 02/05/2013 at 1425 revealed RN #1 should have perform hand hygiene following patient contact to administer medication.
Interview with hospital's Infection Control Practitioner on 02/07/2013 at 1420 revealed "the expectation is to 'Purell' in and out" when staff has patient contact."

Based on review of the hospital's medical staff rules and regulations, medical record review and staff interview, the hospital failed to ensure an operative report was written or dictated by the surgeon immediately following surgery for 1 of 5 inpatient surgery patients (#22).

The findings include:

Review of the hospital's medical staff rules and regulations, revised 08/28/2009, revealed, "...E. Medical Records...4. Operative reports shall include a description of the findings, the technical procedures used, the specimens removed, the pre- and post-operative diagnoses, and the name of the surgeon and any assistants. Operative reports shall be written (or dictated) immediately following surgery...and the report promptly signed by the surgeon and made a part of the Patient's current medical record. ...".

Open medical record review on 02/06/2013 of Patient #22 revealed a 61 year-old female admitted with severe osteoarthritis of the right hip and right total hip arthroplasty on 02/05/2013. Record review revealed no documentation of an operative report written or dictated immediately following surgery. Record review revealed a form, "Post-Operative/Post-Procedure Note", that was not completed or signed by the surgeon.

Interview on 02/06/2013 at 1045 with administrative staff revealed an immediate operative report was not completed by the surgeon after Patient #22's right total hip arthroplasty on 02/05/2013. Interview further revealed the surgeon did not follow the medical staff's rules and regulations regarding immediate operative reports.