HospitalInspections.org

The Plan of Correction (POC) submitted by the hospital stated the following deficiency would be corrected 12/22/14. At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on surveyors' observations, review of hospital documents and interviews with hospital staff, the hospital failed to ensure the physical plant and environment is constructed, arranged, and maintained to ensure the safety of patients. The hospital failed to:

a. Ensure the hospital was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff. See Tag C-0221;

b. Ensure proper storage of trash and biohazard waste was provided. Refer to Tag C-0223;

c. Maintain clean and sanitary facilities for safety of patients and personnel. See Tag C-0225;

d. Ensure temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226.

See also LSC Tags

The Plan of Correction (POC) submitted by the hospital stated the following deficiency would be corrected 12/22/14. At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on surveyors' observations and interviews with staff, the hospital failed to ensure the hospital was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff.

Findings:

A tour of the hospital was conducted on the afternoon of 01/21/15.

Surgery Department (OR):
There were no:
1. Handwashing sink in the the clean workroom or the decontamination room.
2. Physical barrier between the anesthesia workroom and the central processing room.
3. Physical barrier between central storage and the central processing room.
4. Janitor's closet or soiled holding room.

The administrator of the hospital stated medical gases had not been added to emergency room #3 on the afternoon of 01/21/15.

As of 01/21/15, the hospital has not submitted a functional narrative for the construction of the OR, HVAC system , remodeling of patient room #111 and alarm system for the negative pressure rooms.

The Plan of Correction (POC) submitted by the hospital stated the following deficiency would be corrected 12/22/14. At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on surveyor observations and interviews with staff, the hospital failed to ensure proper storage of trash and biohazard waste was provided.

Findings:

A tour was conducted of the hospital on 01/21/15.

NFPA (National Fire Protection Association) 2000 guidelines 19.7.5.5 requires: "...Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (gallons - 121 Liters) shall be located in a room protected as a hazardous area when not attended."

There were no designated areas/rooms for collection and holding of biohazard waste and trash for pick-up in the surgery (OR) department.

A gray trash (greater than 32 gallons) receptacle was observed in the semi-restricted area of the OR.

The above information was confirmed by the OR manager on the afternoon of 01/21/15.

The Plan of Correction (POC) submitted by the hospital stated the following deficiency would be corrected 12/22/14. At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on observation, hospital document review and staff interview, it was determined the hospital failed to ensure humidity and ventilation was maintained within acceptable standards.

Findings:

A tour was conducted of the hospital on 01/21/15.

There was no monitor for the negative air flow rooms (#116 and 117).

Review of hospital documents, documented negative air flow in the sterile storage room in the surgery (OR) department.

Temperature and humidity monitoring logs for the (OR) documented humidity in the OR ranged between 16-59%. Normal humidity ranges for the OR is 30-60%.

The hospital did not have any contracts with vendors to make the necessary repairs per the POC submitted.

The above information was confirmed by the administrator on the afternoon of 01/21/15.

At the time of the revisit on January 21, 2015, this Condition of Participation was not corrected.
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Based on review of governing body meeting minutes and hospital documents, surveyors' observations, and interviews with hospital staff, the hospital does not ensure the organizational structure of the hospital is effective in providing quality health care in a safe environment. The governing body failed to monitor, evaluate and ensure the services of the hospital. See Tag C- 241 for details and findings.

At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on review of hospital documents, surveyors' observations, and interviews with hospital staff, the governing body does not:

a. ensure that policies governing the hospital's total operation are enforced:
b. ensure quality health care is provided in a safe environment.
c. ensure that all practitioners providing patient care are qualified and have current privileges granted and health histories.

Findings:

The physical environment was not constructed and maintained to ensure a safe and sanitary environment. Refer to Tags 0221, 0223, 0226, and 0278.

There was no evidence of current privileges granted or complete health history for Staff GG the dentist for the Swing Bed program.

Although the Plan of Correction, received at the Department on 12/03/14, documented the deficiencies would be corrected by 12/22/14, physical plant and environment still was non-compliant. Other than ceiling tiles in the surgical area being changed, no correction of the surgery environment had been started. The hospital still did not have negative pressure isolation rooms for patients presenting with airborne infections.

At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to ensure the infection control program developed and monitored hospital-wide practices to ensure a safe and sanitary environment was maintained.

Findings:

1. The surveyors asked for all meeting minutes from the time the recertification survey was conducted, 10/23/14. No infection control committee meeting minutes were presented to the surveyors for review. Staff C told the surveyors that no infection control committee meeting had occurred since the recertification survey.

2. Quality assessment and performance improvement (Quality) meeting minutes for 11/13/14, only contained a statement that infection control data was presented. The meeting minutes did not contain evidence that surveillance data was reviewed, analyzed with corrective actions and follow up. This finding was reviewed on 01/21/15 with Staff C, the person identified as responsible for infection control and Quality.

3. While surveillance of several surgical services processes had been performed, only the ceiling tiles had been changed. The physical environment for this department still contain infection control problems and the hospital continued to perform surgery. Refer to Tags C-221, 223, and 226 for details.

4. The hospital does not have an operational negative pressure patient room, both inpatient and in the emergency room, to isolate airborne infections.

5. The governing body did not ensure the physical environment was constructed and maintained to ensure a safe and sanitary environment.

The Plan of Correction (POC) submitted by the hospital stated the following deficiency would be corrected 12/22/14. At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on review of the quality performance improvement program (QAPI) plan and meeting minutes and interviews with hospital staff, the hospital failed to ensure the quality program evaluated all services provided at the hospital.

Findings:

Review of QAPI, medical staff and governing body meeting minutes since the recertification survey on 10/23/14 did not contain evidence review of services utilized at the hospital was reviewed and analyzed to determine if services were provided appropriate or any addition or deletion of services was needed.

The above information was presented to the administrative staff during the exit interview on the afternoon of 01/21/15.

Based on observation, staff interviews and review of hospital documents, the hospital failed to:

a. Ensure that surgical procedures are performed in a safe manner;

b. Ensure the hospital was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff. See Tag C-0221;

c. Ensure proper storage of trash and biohazard waste was provided. Refer to Tag C-0223;

d. Maintain clean and sanitary facilities for safety of patients and personnel. See Tag C-0225;

e. Ensure temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226.

See also LSC Tags

Findings:

A tour of the surgical department (OR) was conducted on the afternoon of 01/21/15.

The POC submitted by the hospital documented, a functional narrative for the construction of OR and the HVAC system would be completed on 12/2/14.

The administrator was asked if the hospital had submitted a functional narrative to OSDH. The administrator stated no.

Temperature and humidity monitoring logs for the (OR) documented humidity in the OR ranged between 16-59%. Normal humidity ranges for the OR is 30-60%.

The hospital has not made any changes to the OR, with the exception of changing the ceiling tile and removing the furniture from the semi-restricted corridor. This was confirmed by the OR manager on the afternoon 01/21/15.

At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on hospital documents and record review and interviews with hospital staff, the hospital failed to ensure the hospital has an effective quality assessment and performance improvement (Quality) program that collects relevant data, includes all analyzes the data and implements corrective action to ensure the quality and appropriateness of all patient care was furnished.

Findings:

Upon arrival, the surveyors requested all Quality meeting minutes since the recertification survey on 10/23/14.

The only Quality meeting minutes that were provided for review were for 11/13/14. The meeting minutes did not have relevant indicators to identify potential problems and opportunities to improve quality of care for all areas of the hospital. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken. This finding was reviewed with Staff C, the person identified as responsible for Quality on the morning of 01/21/15

The meeting minutes did not contain any documentation that surgical services problems had been reviewed and analyzed corrective actions/plans. The hospital has continued to provide surgical services in the surgical area without the physical plant issues being resolved.

These findings were reviewed with administrative staff at the exit conference on the afternoon of 01/21/15. No additional information was provided.

At the time of the revisit on January 21, 2015, this deficiency was not corrected.
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Based on hospital documents and interviews with hospital staff, the hospital does not ensure that appropriate remedial action is taken to address deficiencies identified through the quality assessment and performance improvement (Quality) program. The only Quality meeting minutes that were provided for review were for 11/13/14. The meeting minutes did not have relevant indicators to identify potential problems and opportunities to improve quality of care for all areas of the hospital. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken. Findings were reviewed with administrative staff on the afternoon of 01/21/15. No additional information was provided.