HospitalInspections.org

Based on observation, staff interview and policy review, the facility failed to provide the patients with a safe environment. This could affect all ambulatory patients in the facility. The facility census was 50.

Findings include:

1. Review of the policy and procedure for Syringe and Needle Disposal (reviewed and revised January 2018) revealed used syringes and needles are disposed of safely in conformance with applicable laws and safety regulations. Immediately after use, the needle-protective device is engaged. Syringes and needles are placed into puncture resistant, one-way container specifically designed for that purpose.

Observation was made on 06/27/18 at 11:20 AM of Staff B checking a patient's blood sugar at the nursing station. Staff B wiped the patient's finger with an alcohol wipe, punctured the patient's finger with a safety lancet, performed the blood sugar check, picked up the supplies, and threw the alcohol swab and lancet into the trash can at the nursing station. Observation of the nursing station revealed an open area with no door. This area was noted to be accessible to the patients if staff were not in the area.

Review of the Side Button Safety Lancet instructions revealed to dispose of the lancet in a suitable sharps container.

Interview with Staff B on 06/27/18 at 11:30 AM confirmed he/she had thrown the lancet into the nursing station trash. Staff B stated she/he had always thrown the lancets into the trash can.


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2. During tour of the geriatric unit on 06/27/18 from 9:15 AM to 10:15 AM an observation was made of disposable gloves setting on the ledge of the nursing station behind the glass divider that was above the nursing station desk. The glass divider was approximately two feet high and was directly above the counter height desk. The gloves were visible to anyone in the area and patients could reach over the glass and access the gloves. This could result in a safety issue.

Staff D verified in an interview at the time of the tour that the gloves were left on the ledge and could be accessed by patients if they reached over the divider.

Based on medical record review, staff interview and review of the medical bylaws, the facility failed to provide a discharge summary within 30 days for one of 21 discharged patients reviewed (Patient #9). The sample was 31 patients. The census was 50.

Findings include:

Review of the medical record for Patient #9 revealed the patient was admitted on 03/23/18 with the diagnosis of bipolar disorder, unspecified. The medical record was void of a discharge summary. The patient was discharged on 03/27/18.

On 06/27/18 at 2:04 PM interview with Staff A revealed that he/she had contacted the physician and he/she stated that he/she had missed seeing Patient #9 and a discharge summary had not been completed.

Review of the Rules and Regulations of the Medical Staff of Ohio Hospital for Psychiatry, not dated, revealed on page 15 Appendices 7.12.1 revealed that all discharge summaries and other medical record documentation shall be completed within 30 days following the patient's discharge.

Based on documentation review, observation, and interview, the facility failed to ensure doors identified in the exit egress could be readily unlocked by staff at all times (K222). The facility failed to ensure exit discharge was provided with a hard level walking service to the public way (K271). The facility failed to ensure exits were marked appropriately (K293). The facility failed to ensure the identified one hour fire rated walls for the hazardaous areas were free of penetrations and the doors had self closing devices (K321). The facility failed to ensure duct dectors were sensitivity tested at least bi-annually and smoke dectors were functionally tested annually (K345). The facility failed to provide documentation that the wet sprinkler system gauges had been replaced or calibrated at least every five years (K353). The facility failed to ensure the one hour smoke barrier was free of penetrations (K372). The facility failed to ensure the fire/smoke dampers were tested at least every six years as per NFPA 80 and NFPA 105 and the dampers functioned when tested (K500). The facility failed to ensure the remote annuciator panel was located in a manned area (K916).

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically Chapter 19 of the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association 101. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

1. Please see K222 for findings related to the facility failing to ensure exit egress doors could be readily unlocked by staff at all times.

2. Please see K271 for findings related to the facility failing to ensure exit discharge was provided with a hard level walking service to public way.

3. Please see K293 for findings related to the facility failing to ensure exits were marked as required in Chapter 7 of NFPA 101.

4. Please see K321 for findings related to the facility failing to ensure the identified one hour fire rated walls for the hazardous areas were free of penetrations and doors had self closing devices.

5. Please see K345 for findings related to the facility failing to ensure duct detectors were tested for sensitivity at least bi-annually and smoke detectors were functionally tested annually.

6. Please see K353 for findings related to the facility failing to provide documentation the wet sprinkler system gauges had been replaced or calibrated at least every five years.

7. Please see K372 for findings related to the facility failing to ensure the one hour smoke barrier was free of penetrations.

8. Please see K500 for findings related to the facility failing to ensure fire/smoke dampers were tested every six years as per NFPA 80 and NFPA 105 and dampers functioned when tested.

9. Please see K916 for findings related to the facility failing to ensure the remote annunciator panel for the generator of the old building was located in a manned location.