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Based on observations and interviews with key personnel, it was determined that the facility failed to ensure that the facilities, supplies, and equipment were maintained at an acceptable level of safety and quality.

Findings Include:

1. On December 19, 2016, at 2:45 PM during a tour of the facility conducted with the Director of Plant Operations (DPO) and the Director of Environmental Services (DES), multiple cardboard boxes of supplies were observed stored on the floor, in various places throughout the laboratory. This created a hindrance to effectively clean the floor, as there is a potential for the cardboard to absorb moisture, which would create a habitat for microorganisms to grow. These findings were confirmed at the time of the observations with the DPO, the DES, and the Site Supervisor of the laboratory.

2. On December 19, 2016, from 9:00 AM to 1:00 PM, during a tour of the facility conducted with the Director of Plant Operations (DPO) and the Director of Environmental Services (DES), the following observations were made:


A. A rusty lower shelf and rusty wheel casters, which create uncleanable surfaces that are not easily sanitized were observed on a cart by the door of the Decontamination Room.

B. Multiple boxes were observed stored on the floor of the Linen Storage Room. This created a hindrance to effectively clean the floor, as there is a potential for the cardboard to absorb moisture, which would create a habitat for microorganisms to grow.

C. Two stained ceiling tiles were observed in the Linen Storage Room, indicating past water leakage and creating a habitat for mold growth.

D. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in Medical/Surgical Unit (MSU) Patient Room (PR) 128, on the upper surfaces of the wall hung lamp in the bathroom area.

E. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 127, on the upper surfaces of the wall hung lamp in the bathroom area.

F. Nine stained ceiling tiles were observed in MSU PR 143 indicating past water leakage and creating a habitat for mold growth.

G. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 123, on the upper surfaces of the wall hung lamp in the bathroom area.

H. Three stained ceiling tiles were observed in the MSU Soiled Utility Room indicating past water leakage and creating a habitat for mold growth.

I. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 132, on the upper surfaces of the wall hung lamp in the bathroom area.

J. The bottom of the wooden door frame in the doorway of the Overflow Blood Draw Room was observed to be broken and missing an approximately 3 inch piece of cove base. This created uncleanable surfaces which cannot be easily sanitized.

K. The patient table in X-Ray Room 2 had a partial puncture hole near the foot of the table, creating an uncleanable surface which cannot be easily sanitized.

L. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in Special Care Unit (SCU) PR 101, on the upper surfaces of the cabinet.

M. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 102, on the upper surfaces of the television.

N. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 103, on the upper surfaces of the television.

O. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 104, on the upper surfaces of the television and the cabinet.

P. On intravenous (IV) pole with a rusty base, creating an uncleanable surface which cannot be easily sanitized was observed in the Emergency Department alcove.

These findings were confirmed at the time of the observations with the DPO and/or the DES.

Based on observation and interviews with key personnel, it was determined that the facility failed to assure that Operating Room humidity was at least 35 percent (or 20 percent if the facility elected to use the CMS categorical waiver), and air exchanges were maintained at adopted standards.


Findings include:


1. On December 19, 2016 at 2:45 PM, the Operating Room (OR) air handling screen was observed on the computer monitor in the office of the Director of Plant Operations (DPO). OR #1 was observed to be operating at between 14.5 - 16.5 air changes per hour. There was no reading for OR #2 or OR #3. The DPO stated that OR #3 was not currently being used as an OR. He confirmed that they were not currently monitoring the air changes in OR #2.


2. On December 18, 2016 at 11:30 AM, in an interview with the Senior Director of Surgical and Ancillary Service (SDSAS), he stated that the air handling system had been budgeted for replacement in the OR renovation project, but the mechanical improvements to the OR were not completed at the time of the other renovations, and were placed on hold due to the costs. There currently is no contract to have these mechanical improvements completed for the OR air handling system.


3. In an email provided by the SDSAS, dated December 20, 2016, from an architect, that was addressed to the DPO, read, "... As I understand it, within the surgical suite, OR1 and 2 do not meet the minimum humidity levels and in addition OR1 does not met the current requirement of 20 air changes per hour."


4. On December 20, 2016 at 2:05 PM the OR temperature and humidity logs for the last 6 months were received and reviewed. The humidity range listed on the recording forms was between 30% - 60%. OR #2 records from June 1, 2016 through December 20, 2016 listed 27 of 99 recorded humidity levels, including 9 of the last 9 levels recorded, to be below 30 percent. OR #1 records from June 1, 2016 through December 20, 2016 listed 30 of 114 recorded humidity levels, including 11 of the last 12 levels recorded, to be below 30 percent. The "Action" column on these logs indicated that no action was ever taken when the humidity levels were below 30 percent. The copies of the work orders provided did not reveal any adjustments being made for the low humidity levels.


5. On December 20, 2016 at 2:25 PM the DPO stated that they did not have a waiver in place in regards to the operating room humidity levels.


6. On December 20, 2016 at 3:00 PM the DPO stated that high humidity levels could be controlled in the OR by manipulating the temperature and air changes, but they had no process for raising the humidity if it was too low.

Based on patient interviews and a review of medical records and hospital procedures, the hospital failed to provide evidence of properly executed informed consents for 2 of 7 inpatient medical records and 1 of 1 discharge record reviewed. As a result, the three medical records were determined to be incomplete. (Patient M and Patient N)

The findings include:

A review of the medical record for Patient N revealed that the consent form, dated 12/16/16 at 1:15 PM, had "Verbal Consent" hand written on the signature line. Two signatures of staff were on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

On December 20, 2016 at approximately 12:30 PM, the surveyor interviewed Patient N. The patient stated that he/she did not recall being offered the consent to sign. The patient further reported, "I was pretty sick and my family member was with me. No, I don't think I signed it, but I think my family member would have." The consent form did not contain the family member's signature.

A review of the medical record for Patient M revealed that the consent form, dated 12/17/16 at 11:21 AM, had "Verbal Consent" hand written on the signature line. Two signatures of staff were on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

On December 20, 2016 at approximately 12:20 PM, the surveyor interviewed Patient M. The patient stated that he/she did not recall being offered the consent to sign. The patient further reported, "No, they never asked me to sign it. It's what they always do."

A review of the discharge record for Patient M admitted on September 18 2016, revealed that the consent form, dated 12/17/16 at 11:21 AM, had "Verbal Consent" hand written on the signature line. Only one staff signature was on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

Two hospital procedures for obtaining general and informed consent were reviewed. The procedure for obtaining informed consent indicated that a competent adult has the right to informed consent and the procedure for obtaining general consent indicated that a patient's adult relative can sign the consent form if the patient is unable to give written or verbal consent due to incapacitation.

Based on an interview, a review of medical records and hospital policy, the hospital failed to document that patients were provided with the required notice informing them of their right to receive visitors, including any clinical restrictions or reasonable limitations imposed by the hospital. The failure to document that the required notice was given was found in 9 out of 15 medical records. (Patient records: O, Q, VV, WW, XX, YY, ZZ, AAA and BBB).

The finding includes:

On December 20, 2016, the surveyor reviewed 15 medical records. The required notice for informing patients of their visitation rights was not found in 9 out of 15 medical records. A review of the hospital's patient visitation policy, indicated that the patient medical record must contain documentation that the required notice was provided to the patient or, if appropriate, the patient's support person.

This finding was confirmed with the informatics nurse on December 20, 2016 at approximately 2:15 PM.

Based on observations and interviews with key personnel, it was determined that the facility failed to ensure that the facilities, supplies, and equipment were maintained at an acceptable level of safety and quality.

Findings Include:

1. On December 19, 2016, at 2:45 PM during a tour of the facility conducted with the Director of Plant Operations (DPO) and the Director of Environmental Services (DES), multiple cardboard boxes of supplies were observed stored on the floor, in various places throughout the laboratory. This created a hindrance to effectively clean the floor, as there is a potential for the cardboard to absorb moisture, which would create a habitat for microorganisms to grow. These findings were confirmed at the time of the observations with the DPO, the DES, and the Site Supervisor of the laboratory.

2. On December 19, 2016, from 9:00 AM to 1:00 PM, during a tour of the facility conducted with the Director of Plant Operations (DPO) and the Director of Environmental Services (DES), the following observations were made:


A. A rusty lower shelf and rusty wheel casters, which create uncleanable surfaces that are not easily sanitized were observed on a cart by the door of the Decontamination Room.

B. Multiple boxes were observed stored on the floor of the Linen Storage Room. This created a hindrance to effectively clean the floor, as there is a potential for the cardboard to absorb moisture, which would create a habitat for microorganisms to grow.

C. Two stained ceiling tiles were observed in the Linen Storage Room, indicating past water leakage and creating a habitat for mold growth.

D. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in Medical/Surgical Unit (MSU) Patient Room (PR) 128, on the upper surfaces of the wall hung lamp in the bathroom area.

E. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 127, on the upper surfaces of the wall hung lamp in the bathroom area.

F. Nine stained ceiling tiles were observed in MSU PR 143 indicating past water leakage and creating a habitat for mold growth.

G. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 123, on the upper surfaces of the wall hung lamp in the bathroom area.

H. Three stained ceiling tiles were observed in the MSU Soiled Utility Room indicating past water leakage and creating a habitat for mold growth.

I. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in MSU PR 132, on the upper surfaces of the wall hung lamp in the bathroom area.

J. The bottom of the wooden door frame in the doorway of the Overflow Blood Draw Room was observed to be broken and missing an approximately 3 inch piece of cove base. This created uncleanable surfaces which cannot be easily sanitized.

K. The patient table in X-Ray Room 2 had a partial puncture hole near the foot of the table, creating an uncleanable surface which cannot be easily sanitized.

L. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in Special Care Unit (SCU) PR 101, on the upper surfaces of the cabinet.

M. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 102, on the upper surfaces of the television.

N. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 103, on the upper surfaces of the television.

O. Significant accumulation of dust, indicating uncleaned and unsanitized surfaces were observed in SCU PR 104, on the upper surfaces of the television and the cabinet.

P. On intravenous (IV) pole with a rusty base, creating an uncleanable surface which cannot be easily sanitized was observed in the Emergency Department alcove.

These findings were confirmed at the time of the observations with the DPO and/or the DES.

Based on observation and interviews with key personnel, it was determined that the facility failed to assure that Operating Room humidity was at least 35 percent (or 20 percent if the facility elected to use the CMS categorical waiver), and air exchanges were maintained at adopted standards.


Findings include:


1. On December 19, 2016 at 2:45 PM, the Operating Room (OR) air handling screen was observed on the computer monitor in the office of the Director of Plant Operations (DPO). OR #1 was observed to be operating at between 14.5 - 16.5 air changes per hour. There was no reading for OR #2 or OR #3. The DPO stated that OR #3 was not currently being used as an OR. He confirmed that they were not currently monitoring the air changes in OR #2.


2. On December 18, 2016 at 11:30 AM, in an interview with the Senior Director of Surgical and Ancillary Service (SDSAS), he stated that the air handling system had been budgeted for replacement in the OR renovation project, but the mechanical improvements to the OR were not completed at the time of the other renovations, and were placed on hold due to the costs. There currently is no contract to have these mechanical improvements completed for the OR air handling system.


3. In an email provided by the SDSAS, dated December 20, 2016, from an architect, that was addressed to the DPO, read, "... As I understand it, within the surgical suite, OR1 and 2 do not meet the minimum humidity levels and in addition OR1 does not met the current requirement of 20 air changes per hour."


4. On December 20, 2016 at 2:05 PM the OR temperature and humidity logs for the last 6 months were received and reviewed. The humidity range listed on the recording forms was between 30% - 60%. OR #2 records from June 1, 2016 through December 20, 2016 listed 27 of 99 recorded humidity levels, including 9 of the last 9 levels recorded, to be below 30 percent. OR #1 records from June 1, 2016 through December 20, 2016 listed 30 of 114 recorded humidity levels, including 11 of the last 12 levels recorded, to be below 30 percent. The "Action" column on these logs indicated that no action was ever taken when the humidity levels were below 30 percent. The copies of the work orders provided did not reveal any adjustments being made for the low humidity levels.


5. On December 20, 2016 at 2:25 PM the DPO stated that they did not have a waiver in place in regards to the operating room humidity levels.


6. On December 20, 2016 at 3:00 PM the DPO stated that high humidity levels could be controlled in the OR by manipulating the temperature and air changes, but they had no process for raising the humidity if it was too low.

Based on patient interviews and a review of medical records and hospital procedures, the hospital failed to provide evidence of properly executed informed consents for 2 of 7 inpatient medical records and 1 of 1 discharge record reviewed. As a result, the three medical records were determined to be incomplete. (Patient M and Patient N)

The findings include:

A review of the medical record for Patient N revealed that the consent form, dated 12/16/16 at 1:15 PM, had "Verbal Consent" hand written on the signature line. Two signatures of staff were on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

On December 20, 2016 at approximately 12:30 PM, the surveyor interviewed Patient N. The patient stated that he/she did not recall being offered the consent to sign. The patient further reported, "I was pretty sick and my family member was with me. No, I don't think I signed it, but I think my family member would have." The consent form did not contain the family member's signature.

A review of the medical record for Patient M revealed that the consent form, dated 12/17/16 at 11:21 AM, had "Verbal Consent" hand written on the signature line. Two signatures of staff were on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

On December 20, 2016 at approximately 12:20 PM, the surveyor interviewed Patient M. The patient stated that he/she did not recall being offered the consent to sign. The patient further reported, "No, they never asked me to sign it. It's what they always do."

A review of the discharge record for Patient M admitted on September 18 2016, revealed that the consent form, dated 12/17/16 at 11:21 AM, had "Verbal Consent" hand written on the signature line. Only one staff signature was on the "Witness Signature" line. There was no evidence that the patient was incapacitated or unable to sign the consent form during the admission process.

Two hospital procedures for obtaining general and informed consent were reviewed. The procedure for obtaining informed consent indicated that a competent adult has the right to informed consent and the procedure for obtaining general consent indicated that a patient's adult relative can sign the consent form if the patient is unable to give written or verbal consent due to incapacitation.

Based on an interview, a review of medical records and hospital policy, the hospital failed to document that patients were provided with the required notice informing them of their right to receive visitors, including any clinical restrictions or reasonable limitations imposed by the hospital. The failure to document that the required notice was given was found in 9 out of 15 medical records. (Patient records: O, Q, VV, WW, XX, YY, ZZ, AAA and BBB).

The finding includes:

On December 20, 2016, the surveyor reviewed 15 medical records. The required notice for informing patients of their visitation rights was not found in 9 out of 15 medical records. A review of the hospital's patient visitation policy, indicated that the patient medical record must contain documentation that the required notice was provided to the patient or, if appropriate, the patient's support person.

This finding was confirmed with the informatics nurse on December 20, 2016 at approximately 2:15 PM.