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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" chapter of this code.

The findings include:

K11: Building separation wall was missing and not properly rated.
K12: Class of Construction did not meet non-combustible standards of a Type II (1,1,1)
K34: The facility did provide stairways that did open to unoccupied rooms.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K39: The facility did not ensure corridor doors had the required width.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K130: The facility failed to properly isolate the emergency generator (EPS) in its own rated room and the facility failed to properly maintain the proper head room in the means of egress.
K144: The facility did not test the emergency electrical generator in accordance with the codes, the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator
K145: The facility did not provide a Type I essential electrical system that was properly divided.
The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable system to ensure safety to all occupants, patients and staff of this facility.

Based on tour of the facility and interview with staff, in 2 of 2 interviews (A and D) the facility failed to maintain an environment for the safety of Pts and visitors. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per tour on 8/27/13 at 10:30 AM with CCO A, rooms #111 and 114 have flaking paint with exposed drywall and dents/gouges in the wall creating a porous, non-cleanable surface. The tile wall in the whirlpool room has multiple holes, breaking the integrity of the wall and preventing a cleanable surface. These findings were confirmed during the tour by CCO A., and interview with Dir D on 8/27/13 at approximately 10:35 AM, the rooms 111 and 114 are on a schedule to be patched and painted.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "Existing Healthcare Occupancy" chapter of this code.

The findings include:

K11: Building separation wall was missing and not properly rated.
K12: Class of Construction did not meet non-combustible standards of a Type II (1,1,1)
K34: The facility did provide stairways that did open to unoccupied rooms.
K38: The facility did not provide egress paths at all times, and paths with sufficient headroom.
K39: The facility did not ensure corridor doors had the required width.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K130: The facility failed to properly isolate the emergency generator (EPS) in its own rated room and the facility failed to properly maintain the proper head room in the means of egress.
K144: The facility did not test the emergency electrical generator in accordance with the codes, the facility did not monitor derangement signals at a continuously monitored location and did not provide a remote stop switch for the generator
K145: The facility did not provide a Type I essential electrical system that was properly divided.
The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable system to ensure safety to all occupants, patients and staff of this facility.

Based on tour, observation, review of P&P and interview with staff (B and E) in 1 of 1 staff observation (E) the facility failed to ensure MDV are not accessed in a procedure room for multiple Pts. In 1 of 2 tours the facility failed to ensure spiked IV solutions are labeled when accessed. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 8/27/13 in the PM of facility policy titled Medication Storage an Preparation Areas, dated 9/10, states "All medication should be prepared in the pharmacy when possible, however, it is understood that this condition may not be met at all times. The prep area must be clean and allow sterilization via accepted (alcohol) methods. Any preparation required outside of the pharmacy will patient (sic) specific. If multiple doses for different patients are to be prepared from an applicable multi-dose container, these doses should be prepared in the pharmacy. If this is not possible, only patient specific doses can be prepared at the bedside."

Review on 8/27/13 in the PM of facility policy titled Peripheral Intravenous Therapy-Administration dated 9/12, it does not include labeling the IV tubing when the IV is spiked. This is confirmed in interview with CCO A at approximately 11:15 PM, acknowledging the tubing should be labeled to determine discard date and time.

Per observation on 8/27/13 at 9:30 AM of CRNA E preparing medications for Pt #6 having a colonoscopy, CRNA E, obtained a syringe filled with propofol (sedation medication) from the anesthesia cart in the procedure room. When questioned when and where the syringe was prepared, CRNA E stated it was drawn up when preparing the previous Pts (#7) medications, in the procedure room.

Per tour on 8/27/13 at 9:00 AM with Dir B the medication room in the Ambulatory Surgical Unit has a spiked IV of Lactated Ringers (saline with potassium and chloride added), laying on a paper towel with Pt #8's name written on it. The IV tubing has no label indicating date, time and who spiked the fluid. This is confirmed during tour by Dir B, acknowledging the bag should be labeled.

Based on observation, review of P&P and interview with staff (A), in 2 of 2 observation of staff (F and G) the facility failed to ensure staff cleans procedure rooms after Pts are out of the room, and staff at risk for splash or splatter wear PPE. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 8/27/13 in the PM of facility policy titled Scope Room/Terminal Cleaning, n.d., states 1. "Surgery staff will clean the scope room in between cases." Per interview with CCO A at approximately 11:15 AM on 8/27/13, the policy infers the Pt is out of the room.

Review on 8/27/13 in the PM of facility policy titled Infection Control, Standard Precautions, n.d., states "Mask, face shield eye protection, Protect eye, nose, mouth and mucous membranes from exposure to sprays or splashes of blood, body fluids, secretions and excretions; Apply appropriate protection prior to performing such activities."

Per observation on 8/27/13 at 9:30 AM CST F wiped down the scope equipment after a colonoscopy procedure while Pt #7 is still present in the procedure room.

Per observation on 8/27/13 at 9:50 AM MD G did not have on a mask or eye protection when performing a colonoscopy procedure on Pt #6.

The above observations were discussed with CCO A and Dir B at approximately 10:00 AM, both acknowledging MD G should wear PPE and the room should not be cleaned until after the Pt is out of the room.

Based on MR review, review of P&P and interview with staff, in 4 of 4 MRs requiring a CP (1, 2, 3 and 4) out of a total of 5 MRs reviewed, the facility failed to ensure the CP is individualized to Pt needs, includes measurable goals and interventions that are applicable to the Pts. This deficiency directly affects 4 Pts treated at the facility and potentially affects all Pts treated at the facility.

Findings include:

Review on 8/28/13 in the PM of facility policy titled Patient Care Planning, dated 11/12, states under Implementation II.B.2 "Clinical Practice Guidelines (CPG)-Care Plan Problems and/or Needs-these can be based on a medical diagnosis, related symptom or human response relevant to the hospitalization....3. Goals-May be patient specific, education related, and/or designated to prevent and manage complications. 4. Interventions-Used to assist the patient and/or family in progressing toward their goals and achieving therapeutic outcomes."

Per interview with CCO A on 8/27/13 during MR review between 12:30 PM and 2:20 PM, CCO A acknowledged CPs are not always individualized, including goals that are not measurable, and interventions appropriate to the Pt.

Pt #1's MR review on 8/27/13 at 12:30 PM revealed Pt #1 was admitted on 8/24/13 for a primary diagnosis of Hyponatremia (low sodium in blood). There are 5 Nursing CP problems including 1) Physical Mobility, Impaired with a goal of "Enhanced Mobility Skills, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Infection, Risk/Actual with a goal of "Infection Prevention/Resolution/Control, Patient will demonstrate the desired outcomes." 3) Coping, Compromised Family with a goal Effective Family Coping, Patient will demonstrate desired outcomes." These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #2's MR review on 8/27/13 at 12:55 PM revealed Pt #2 was admitted on 8/25/13 for a primary diagnosis of Paraparises (partial paralysis) and breast cancer. There are 4 Nursing CP problems including 1) Pressure Ulcer Risk with a goal of "Skin Integrity, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Urine Elimination, Impaired with a goals "Effective Urinary Elimination, Patient will demonstrate desired outcomes"; "Effective Containment of Urine, Patient will demonstrate the desired out comes"; "Reduced Incontinence Episodes, Patient will demonstrate the desired out comes". These goals are not measurable to determine Pt meeting the goals at or prior to discharge. Pt #2 reported pain levels of 5 to 10 out of 10 requiring multiple doses of narcotics between 8/25/13 and MR review on 8/27/13. There is no CP for Pain Management. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #3's MR review on 8/27/13 at 1:35 PM revealed Pt #3 was admitted on 8/23/13 for a primary diagnosis of Appendicitis. There are 3 Nursing CP problems including Appendicitis/Appendectomy with a goal "Signs and symptoms of listed potential problems will be absent or manageable." Pt #3 has received multiple doses of pain medication since admission, there is no CP for Pain Management. These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Pt #4's MR review on 8/27/13 at 2:10 PM revealed Pt #4 was admitted on 8/23/13 for a primary diagnosis of confusion and weakness. There are 4 Nursing CP problems including 1) Pressure Ulcer Risk with a goal of "Skin Integrity, Patient will demonstrate the desired outcomes" and goal "Enhanced Functionality Ability, Patient will demonstrate the desired outcomes." 2) Confusion, Chronic/Acute with a goal "Cognitive Ability, Patient will demonstrate desired outcomes"; "Functional Ability, Patient will demonstrate the desired out comes" and "Restorative Sleep/Rest, Patient will demonstrate the desired out comes". These goals are not measurable to determine Pt meeting the goals at or prior to discharge. The interventions listed for the problems included all possible interventions and are not specific to the Pt needs. This is confirmed in interview with CCO A and Dir C during MR review.

Based on MR review, review of P&P and interview with staff in 3 of 4 MRs with pain medication provided (2, 3 and 4) the facility failed to ensure staff is completing a reassessment following administering pain medication to determine effectiveness. And in 1 of 1 ED MRs (5) out of a total of 5 MRs reviewed the facility failed to ensure transfer documents include complete documentation of risk of transfer. This deficiency directly affects 3 Pts treated at the facility, and potentially affects all Pts treated at the facility.

Findings include:

Review on 8/27/13 in the PM of facility policy titled Pain Management-Hospital & ER, dated 7/31/13, states under B. Ongoing Pain Assessment-Refers to any pain assessment and all reassessments. Reassessment is defined as pain assessment after an intervention. 7. "Reassessment intervals following intervention is recommended to occur: Intravenous medication-30 minutes, Intramuscular medication-60 minutes, Oral medication-60 minutes, Non-pharmalogical intervention-60 minutes." Under C. Pain Assessment in Emergency 3. "Reassessment of existing pain occurs via 'ED Narrator'. Complete the 'Pain Assessment' section within ED Narrator no later than 30 minutes post IV medication administration (more often if indicated by emergency condition)."

Pt #2's MR review on 8/27/13 at 12:30 PM revealed Pt #2 received oral morphine (narcotic) on 8/27/13 at 7:50 AM for pain rated at 8 out of 10. There is no reassessment within 1 hour documented to determine any relief of pain, per policy. This is confirmed during MR review with CCO A and Dir C, acknowledging staff should document the reassessment.

Pt #3's MR review on 8/27/13 at 1:35 PM revealed Pt #3 received IV Dilaudid (narcotic) on 8/23/13 at 9:53 PM in the ED for pain rated at 8 out of 10. There is no reassessment within 30 minutes documented to determine any relief of pain, per policy. This is confirmed during MR review with CCO A and Dir C, acknowledging staff should document the reassessment.

Pt #4's MR review on 8/27/13 at 2:10 PM revealed Pt #4 received oral Tylenol (non-narcotic pain medication) for pain located in Pt #4's head. There is no reassessment within 1 hour documented to determine any relief of pain, per policy. This is confirmed during MR review with CCO A and Dir C, acknowledging staff should document the reassessment.

Pt #5's MR review on 8/27/13 at 2:20 PM revealed Pt #5 obtained a fractured leg from a bicycle crash on 8/25/13. The Patient Request/Refusal/Consent to Transfer completed on 8/25/13 states under 4. Provider Certification, Risks a list of risks, with boxes to be checked, that include Death, Loss of function, Physical deterioration, Psychological deterioration, Transportation risks: all transfers have the inherent risks of traffic delays; accident during transport; inclement weather; rough terrain; air turbulence; and the limitations of equipment and personnel present in the vehicle, Other. The box checked is "Physical deterioration". There is a blank line for specifics that is not completed. This is confirmed during MR review with CCO A and Dir C, acknowledging the MD should have completed specific physical deterioration in the provided space.

Based on MR review, review of P&P and interview with staff, in 1 of 1 MR requiring anesthesia services (3), the facility failed to ensure the post-anesthesia note is comprehensive including:Cardiopulmonary status, Level of consciousness, observations, follow up and/or complications. This deficiency potentially affects all surgical Pts treated at the facility.

Findings include:

Review on 8/27/13 in the PM of facility policy titled Standard of Anesthesia Practice, n.d., states under #6 "Complete, in an accurate and timely manner, all documentation of pertinent information on the on the patient's medical record. Per interview with CCO A on 8/27/13 at approximately 4:15 PM the policy does not address specific data to be documented.

Pt #3's MR review on 8/27/13 at 1:35 PM revealed Pt #3 had an appendectomy on 8/23/13 under General Anesthesia. The Post Anesthetic Note dated 8/24/13 at 1:00 AM has yes or no check boxes for N/V (nausea/vomiting), Recall and Parethesia from positioning. There is a line drawn through the "no" boxes. This does not constitute a complete post anesthesia note that includes cardiopulmonary status (set of vital signs), level of consciousness (awake, alert, lethargic, etc.), observation, follow up and/or complications. This is confirmed in interview with COO A and Dir C during the MR review, acknowledging there is no specific information related to recovery from anesthesia.