HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed 03/15/2012, the hospital's leadership failed to have an effective governing body to ensure a safe environment for patients, staff, and visitors.

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 policy and procedure review, medical record review and staff interview the staff failed to monitor a patient in behavioral restraints per the hospital policy in 1 of 3 patients in behavioral restraints reviewed ((#27).

The findings include:

Review of hospital policy "H-PC-600-01 RESTRAINT, SECLUSION and ISOLATION TIME-OUT" last revised 8/2011 revealed "C. ON-GOING ASSESSMENT, CARE AND DOCUMENTATION FOR THE PATIENT RESTRAINED FOR VIOLENT OR SELF-DESTRUCTIVE BEHAVIOR...1. a. A staff member who is trained and competent will perform assessments at the initiation of restraint and seclusion and every 15 minutes thereafter".

Medical record review of patient #27 revealed a 23 year old presenting to the Emergency Department on 1/21/2012 for overdose and ETOH abuse. Record review revealed a physician's order on 1/21/2012 for restraints for "Violent/Self-Destructive Behavior: Record review revealed the patient was placed in four point soft restraints with a sitter at the bedside at 0550. Record review revealed the restraints were removed at 0927. Record review revealed no documentation of assessment or monitor of the patient every 15 minutes.

Interview with the Clinical care Coordinator on 3/13/2012 at 1535 revealed there was no documentation of the patient being monitored every 15 minutes while in restraints for violent behavior. The interview revealed the sitter should have documented assessment of the patient. The interview revealed it is the nurse's responsibility to ensure the patient is monitored and documented per the hospital policy. The interview revealed the policy is for every 15 minuted documentation of the patient while in behavioral restraints.

Based on review of endoscope reprocessor manufacturer's guidelines, hospital policy, observation during tour and staff interview, the hospital 's endoscopy staff failed to monitor and track endoscope reprocessing per the manufacturer's guidelines.

The findings include:

Review of the endoscope reprocessing manufacturer's guidelines, dated 1999, revealed, "...Disinfect TIME: The disinfect TIME is the length of time that the endoscope is exposed to the disinfectant and should be set according to the disinfectant manufacturer's recommendations, or according to the facility's protocol...".

Review of the hospital's policy, "Endoscopic Reprocessor", reviewed 01/2012, revealed, "POLICY: Endoscopy staff will follow written guidelines to govern the proper use of the Automated Endoscopic Reprocessor. PURPOSE: To ensure proper use of the Reprocessor and optimal high level disinfection for all endoscopes. PROCEDURE: ...X. ...C. Stages included are: wash for 6 minutes, rinse for 5 minutes, disinfect for 12 minutes, second rinse 2 minutes and air for 1 minute. XI. Each use of the reprocesor must be monitored for effectiveness of the sterilization process. ...".

Observation during tour of the endoscopy unit on 03/14/12 at 0900 revealed 2 endoscope automated reprocessors. Observation revealed a control panel on the right front of each reprocessor with a dial that could be moved to a wash/disinfect cycle, a wash only cycle and a disinfect only cycle. Observation further revealed a roll of printed paper tape rolled up and secured with a paper clip. Review of the paper tape revealed a space to document the scope I.D. (Identification) followed with a print out of the total wash time, rinse time, total disinfect time, rinse time, air time and total cycle time. Review revealed no documentation that the print out was reviewed to ensure effectiveness of the sterilization process.

Interview on 03/14/2012 at 0915 with the endoscopy unit coordinator revealed the processing technicians look at the control panel that indicates the cycle is finished. Interview revealed, " we are not looking at every print out to check cycle times. We do check the Cidex (high-level disinfectant used in the reprocessor) for effectiveness but we're not monitoring the times". Interview further revealed the technicians may look at them but are not initialing or dating that the cycle was reviewed for effectiveness of the process.

Based on policy review, medical record reviews and staff interviews the dialysis staff failed document assessment/monitoring of the patient's vascular access site during hemodialysis in 2 of 3 hemodialysis patients reviewed (#39, 32).

The finding include:

Review of policy "7-05-03" last revised September 2010 revealed "INTRADIALYTIC TREATMENT MONITORING...Treatment checks should be completed every 15 minutes not to exceed 30 minutes unless otherwise ordered by the physician...2. At a minimum, obtain and document the following:...Vascular access status and line connections".

1. Medical record review of patient #39 revealed during hemodialysis treatment on 3/13/2012 the vascular access site was not documented as assessed from 1553 until 1630. Record review did not reveal any documentation why the access site monitoring exceeded 30 minutes.

2. Medical record review of patient #32 revealed during hemodialysis treatment on 2/26/2012 the vascular access site was not documented as assessed from 1955 until 2040. Record review did not reveal any documentation why the access site monitoring exceeded 30 minutes.

Interview with administrative staff on 3/14/2012 at 1415 revealed the vascular access site was not monitored every 15 minutes and did exceed 30 minutes for pateint #39 and #32. The interview did not reveal why the nurse did not document assessing the vascular access site per the hospital policy.

Based on policy and procedure review, HIV lookback file review and staff interview the Laboratory staff failed to notify the attending physician, failed to document in the patient's medical record and failed to ensure patient notification contained required elements when the American Red Cross notified the hospital that a patient had been administered Potentially infectious Human Immunodeficiency Virus (HIV) blood in 1 of 1 HIV lookback patients reviewed (#35).

The findings include:

Review of facility policy "Notification to recipients of blood products when (name of hospital) is notified of products that pose potential risk of HIV or HCV transmission adopted 6/10/11" revealed "Upon notification that certain blood products pose potential increased risk of HIV or HCV transmission, (name of hospital) must notify recipients of such blood products within 12 weeks...The date of the end of the 12 week notification period which is then documented on the lookback Log. Medical records will also receive documentation to add to the patient's medical record...3. Notifications by (name of hospital) to attending physicians and recipients verbal Notifications Blood Bank personnel will promptly notify the attending physician at the time the products were given, by phone...Written Notification The completed letter, signed by the Laboratory Medical Director, is sent to the attending physician certified mail..The patient form letter is appropriate completed and signed by the Laboratory Medical Director and mailed to the patient...The patient letter provides sufficient guidance to the recipient regarding pursuing testing and counseling".

HIV lookback file review revealed patient #35 revealed documentation fro the American Red Cross to the lab on 10/25/2011 for Notification Lookback for patient #35. Further review revealed a second notification from the American Red Cross dated 11/04/2011. File review revealed a letter to patient #35 dated 11/2/2011 informing the patient of "the donor of this component now has tested repeatedly for the HIV antibody" and to contact his physician for any questions or desire for counseling. File review revealed no further documentation regarding the Lookback process.


Interview with the Laboratory Director and the HIM director on 3/15/2012 at 0915 revealed there was no documentation in patient #35's medical record regarding the HIV lookback notification. The interview revealed there was no documentation of notification of the attending physician regarding the HIV lookback for patient #35. The interview revealed the written letter to the patient did not contain a basic explanation of the need for HIV testing and counseling, did not contain written information so that an informed decision can be made about whether to obtain testing and counseling and did not contain
a list of programs or places where the person can obtain HIV or HCV testing and counseling, including any requirements or restrictions the program may impose.

Based on observations as referenced in the Life Safety Report of Survey completed 03/15/2012, the hospital failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

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: Maintenance of Physical Plant - Standard Tag A0701.

2. 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.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.

3. The hospital failed to ensure the facilities were designed and maintained in accordance with Federal, State and local laws, regulations, and guidelines to ensure patient safety.

~cross-refer to 482.41(c) Physical Environment: Facilities - Standard Tag A0722.

4. The hospital failed to ensure the a manual shut-down switch for the air handling systems.

~cross-refer to 482.41(c)(4) Physical Environment: Ventilation, Light, Temperature Controls - Standard Tag A0726.

Based on observations as referenced in the Life Safety Report of Survey completed 03/15/2012, 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 1:

Based on observation, on March 13, 2012 at approximately 7:30am onward, the electrical system is noncompliant due to the following:

1. ground-fault interrupter receptacle did not function in men's toilet - located at visitor's entrance.

2. two portable space heaters are connected to the same twenty amp branch circuit in the laboratory area.

3. circuit breaker CL2L4 did not interrupt power to the countertop receptacle in the laboratory area - circuit directory in panelboard must correspond to devices served.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 147.

Building 2:

Based on observation, on March 14, 2012 at approximately 7:30am onward, the medical gas distribution system is noncompliant due to the following:

1. oxygen tanks are not individually secured at the manifold system.

2. there is no canopy or other enclosure to protect the cylinders from extremes of weather.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 076.

Building 3:

Based on observation, on March 14, 2012 at approximately 7:30am onward, the medical gas distribution system is noncompliant due to the following:

1. oxygen tanks are not individually secured at the manifold system.

2. there is no canopy or other enclosure to protect the cylinders from extremes of weather.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 076.

Building 6:

1. Based on observation, on March 13, 2012 at approximately 7:30am onward, there is no electrical supervision of main sprinkler control valves located in above ground valve box.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 061.

Based on observations as referenced in the Life Safety Report of survey completed 03/15/2012, 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.

The findings include:

Building 1:

1. Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an unsealed penetration in the smoke barrier located above cross corridor doors near room 227(2C).

~cross refer to NFPA 101 Life Safety Code Standard - Tag K025.

2. Based on observation, on March 13, 2012 at approximately 7:30am onward, there is an incomplete fire rated enclosure for storage room greater than one hundred square feet in the laboratory area. The door is not minimum forty-five minute rated with listed hardware.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K029.

3. Based on observation, on March 14, 2012 at approximately 7:30am onward, the means of egress components are incomplete in the following areas:

A. Exit discharge to loading dock, rear entrance to IT, is equipped with momentary off switch and no master release switch for electromagnetic locking arrangement.

B. Loading dock exit discharge at kitchen - no guardrails are provided between egress path and edge of loading dock.

C. Entry leaving view area - no sensor above access controlled egress doors.(near labor and delivery)

D. Stair #9 - delayed egress lock did not function with continuous pressure applied for three seconds to the latch release device. Lock did release with activation of the facility fire alarm system by detection devices.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K032.

4. Based on observation, on March 13, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K038.

5. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no sprinkler in slave monitoring area located in old telemetry - pod 2A.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K056.

6. Based on observation, on March 13, 2012 at approximately 7:30am onward, sprinkler system components are noncompliant in the following areas:

A. Laboratory - debris and dust accumulation on heat sensitive element of sprinklers

B. 2A slave monitoring area - debris and dust accumulation on heat sensitive element of sprinklers

C. Lower level - high and low pressure switch valve is not electrically supervised. (in shop)

D. Lower level - high and low pressure switch valve is not supervised.( in equipment room)

E . 3B phone room - sprinkler is obstructed by fluorescent light fixture.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K062.

7. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no baffle or separation provided between deep fryers and gas range. Located in main kitchen area under the range hood fire suppression system.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K069.

8. Based on observation, on March 13, 2012 at approximately 7:30am onward, there are high temperature, exposed element, portable heaters used in laboratory office.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K070.

9. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is storage in the means of egress corridor in the IT department - located on lower level.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K072.

Building 2:

1. Based on observation, on March 14, 2012 at approximately 7:30am onward, storage room areas are incomplete due to the following:

A. holes between corrugated steel decking and wall partition, and primary steel structural member is not protected from fire exposure; storage room is greater than one hundred square feet.(located near entry to medical arts at lower level of hospital)

B. no self-closing device on door to storage room - suite 1300.

C. no self-closing device on trash storage room door - near Cancer Center water heater room

~cross refer to NFPA 101 Life Safety Code Standard - Tag K029.

Building 2:

1. Based on observation, on March 14, 2012 at approximately 7:30am onward, exit access doors throughout the facility are equipped with deadbolt locks in addition to other latching devices; such arrangements create greater than a single motion of the hand to exit areas. Latching hardware on referenced doors exceeds forty-eight inch maximum height above finished floor.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K038.

2. Based on observation, on March 14, 2012 at approximately 7:30am onward, there are no sprinklers in the following spaces:

A. water heater closet - located in suite 1000.

B. electrical equipment room - near new linear accelerator.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K056.

Building 3:

1. Based on observation, on March 14, 2012 at approximately 7:30am onward, the hyperbaric unit is not enclosed with a minimum one hour barrier - doors in existing fire door frames are not minimum B-one hour fire doors with listed self-closing and latching hardware.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K029.

Building 6:

1. Based on observation, on March 14, 2012 at approximately 7:00am onward, there is no tenant separation barrier of a minimum one hour fire resistance rating between the ambulatory health care center and the upper level unaffiliated tenant area. The floor/ceiling assembly is nonrated due to the chosen construction assembly.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K011.

2. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no heat in the provided in the above ground valve box serving the main sprinkler control valves - the heat source must be connected to the emergency power system.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K062.

Based on observations as referenced in the Life Safety Report of Survey completed 03/15/2012, the hospital failed to ensure the facilities were designed and maintained in accordance with Federal, State and local laws, regulations, and guidelines to ensure patient safety.

The findings include:

Building 1:

1. Based on observation, on March 13, 2012 at approximately 7:30am onward, the facility is noncompliant due to the following:

A. Accutech system for the infant security system is connected to the Life Safety Branch of the EES(Essential Electrical System). This system is not permitted to be connected to the Life Safety Branch panel EL4E.

B. There is no low fuel level indicator when the main fuel tanks reach a three hour operating capacity. The signal must register at the generator annunciator panel located in the security area.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 145.

2. Based on observation, on March 13, 2012 at approximately 7:30am onward, the electrical system is noncompliant due to the following:

A. ground-fault interrupter receptacle did not function in men's toilet - located at visitor's entrance.

B. two portable space heaters are connected to the same twenty amp branch circuit in the laboratory area.

C. circuit breaker CL2L4 did not interrupt power to the countertop receptacle in the laboratory area - circuit directory in panelboard must correspond to devices served.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 147.

Building 6:

1. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no low fuel level alarm registered at the generator annunciator panel.

~cross refer to NFPA 101 Life Safety Code Standard- Tag K 145.

2. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no audible alarm for loss of normal power to the fire alarm control panel.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K051.

Based on observations as referenced in the Life Safety Report of Survey completed 03/15/2012, the hospital failed to ensure a manual shut-down switch for the air handling systems.

The findings include:

Building 3:

1. Based on observation, on March 14, 2012 at approximately 7:30am onward, there is no manual shut-down switch within the hospital based facility for the air handling systems serving the building.

~cross refer to NFPA 101 Life Safety Code Standard - Tag K067.