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Based on record review and interview the facility staff failed to provide the Important Message from Medicare (IMM) on discharge for 1 patient (Patient #10) out of 7 patients with Medicare out of a total universe of 19 medical records reviewed.

Findings include:

Record review of policy "Medicare/Medicaid Advantage Notifications" #11490513, last revised 04/2022 under Delivery of Important Message from Medicare (IMM) revealed "registration/admitting department employee or designee will deliver the initial IM ...The follow up IM will be delivered to the patient or representative, personnel by nursing staff. The IM will be delivered as far in advance but no more than 2 days before discharge."

Review of Patient # 10's medical record revealed Patient #10 presented to the Emergency Department and was admitted to the Medical Surgical Unit on 6/07/2022 with increased shortness of breath and severe chronic obstructive pulmonary disease (COPD). Patient #10 was discharged 6/10/2022, The initial IMM was signed by Patient #10 and dated 6/07/2022. There was no follow-up IMM in Patient #10's medical record.

On 7/20/2022 at 3:05 PM during interview of Infection Preventionist (IP) O, IP O confirmed, they could not find the Important Message From Medicare on discharge for Patient #10.

Based on observation, staff interviews, and review of maintenance records between July 19 through July 20, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

Building 01
K321 Hazardous Areas - Enclosure
K351 Sprinkler System - Installation
K712 Fire Drills
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers

Building 02
K321 Hazardous Areas - Enclosure
K500 Building Services - OtherHVAC
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers

Building 03
K132 Multiple Occupancies-Contiguous Non-Health Care Occupancies
K211 Means of Egress - General
K351 Sprinkler System - Installation
K754 Soiled Linen and Trash Containers
K919 Electrical Equipment - Other

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

See K-tags for details of the specific findings.

Based on observation, interview and record review the facility failed to assure proper storage and security for emergency medication and supplies in 2 (Emergency Department, Medical-Surgical department) of 4 emergency code carts observed in a total universe of 4 emergency carts in the facility.

Review of facility policy titled, "Medication Storage, GMHC - 29007" dated 03/2022 revealed, under "Defining Secure Storage: 1. A medication shall be considered secure when stored in a manner that reasonably prevents access by non-employees, as well as employees that do not handle, transport, or store medications..."

Example in the Med-Surg (Medical-Surgical) Department:

On 7/19/2022 at 10:25 AM during a tour of the Medical-Surgical department the emergency code cart was observed to be in an unlocked "closet". The top drawer of the cart contains medication for use during an emergency. The cart is accessed by a numerical code lock located on the front of the cart. The 3 digit code to unlock the cart is visibly written in large print on the top surface of the cart.

In an interview with In-patient Manager C on 7/19/2022 at 10:25 AM when asked how staff would be aware that the cart hasn't been opened Manager C stated, "Good point, they wouldn't know. I agree it's not secure with the code to open it in plain site."


Example in the ED (Emergency Department):

On 7/19/2022 at 1:20 PM during a tour of the ED the emergency code cart was observed in the trauma room. The top drawer of the cart contains medication for use during an emergency. The cart is accessed by a numerical code lock located on the front of the cart. The 3 digit code to unlock the cart is visibly written in large print on the top surface of the cart.

In interview on 7/19/2022 at 1:20 PM with ED Manager B, ED Manager B confirmed that patients could be alone in the room and that the cart could be opened by someone other than nursing since the code to open it is written on it. "I guess we wouldn't know if something had been taken out."

Based on observation, staff interviews, and review of maintenance records between July 19 through July 20, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.

Building 01
K321 Hazardous Areas - Enclosure
K351 Sprinkler System - Installation
K712 Fire Drills
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers

Building 02
K321 Hazardous Areas - Enclosure
K500 Building Services- Other
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers

Building 03
K132 Multiple Occupancies-Contiguous Non-Health Care Occupancies
K211 Means of Egress - General
K351 Sprinkler System - Installation
K754 Soiled Linen and Trash Containers
K919 Electrical Equipment - Other

As a result of these deficiencies, 42 CFR 485.623(d) Standard: Life Safety from fire is NOT met.

See K-tags for details of the specific findings.

Based on record review, interview and observation the facility failed to provide a safe environment for patients free from potential hazards by failing to secure injection and suture needles, failing to properly secure oxygen canisters, failing to properly label and store warmed intravenous fluids, failing to follow policy for the temperature range on the blanket warmer and failing to use multidose medication vials for single patients in 3 (Medical-Surgical Unit, Emergency Department, and the Rehabilitation Department) of 10 patient care departments in a total universe of 10.

Record review of facility policy titled, "Patient Rights and Responsibilities, GMHC - 0040" dated 02/2022 revealed under "Patient Rights and Responsibilities :You have the right to expect this from us...a clean, safe environment..."


Examples on the Medical- Surgical In-patient unit:

On 7/19/2022 at 10:20 AM during a tour of the Med-Surg (Medical-Surgical) department, supplies for initiating IVs (intravenous) were observed in Room 604. Room 604 is an unlocked room on the patient care unit. The supplies included IV needles.

In an interview on 7/19/2022 at 10:25 AM with In-patient Manager C, RN Manager C stated, "Those are supplies that we use for practicing IV starts." When asked if patients would ever ambulate in that hallway RN Manager C stated that it could be possible.

On 7/19/2022 at 10:40 AM a door on the patient care hallway labeled, "Authorized personnel only" was observed to be unlocked. Upon entering it was observed that the room was the medication room. Directly to the left of the door was a large bin labeled, "Needles" that contained injection needles.

In an interview at 10:40 AM with In-patient Manager C, when asked about patient access to the room stated, "I totally agree that the unsecured needles are a safety issue, but the door doesn't lock, I'm not sure what else we can do."


Examples in the Emergency Department:

On 7/19/2022 at 1:00 PM during a tour of the ED (Emergency Department) with ED Manager B a white 4 drawer unlocked cart was observed at the entrance to the department by the patient scale. The second drawer contained boxes of sutures with needles. When asked about the location of the cart with unsecured needles, ED Manager B stated, "I guess we never thought of that."

On 7/19/2022 at 1:10 PM observed in the ED, an oxygen canister, without a gauge, not in a holder, in the dirty utility room. A second oxygen canister, with a gauge, not in a holder, was observed under a cart in the clean supply room.

In an interview on 7/19/2022 at 1:15 PM with ED Manager B when asked about the oxygen canisters stated that she thought that the one in the dirty utility room was empty stating, "I guess I don't know for sure but respiratory therapy usually picks them up from there." When asked about the "storage" of the the oxygen canister under a cart in the supply room ED Manager B stated, "I don't even know how that got there, I didn't know it was there and it certainly shouldn't be."

Record review of facility policy titled "Warming Cabinet" dated 1/15/2021 revealed, "General Instructions: 1. Blankets and fluids will be warmed in separate, dedicated compartments...2. Warming cabinets of any kind will be labeled with appropriate temperature range for the intended content...5. Maximum temperature of blanket warmer is 130 degrees...6. All solutions will have a 'removed by' date marked on container along with staff initials, after 7 days solution will be discarded if not used..."

On 7/19/2022 at 1:30 PM the blanket warmer in the clean utility room of the ED was observed to have an upper and lower compartment. The upper compartment contained both blankets and 3 IV (intravenous bags). Each IV bag was labeled with the date 8/8 - the day of this observation was 7/19/2022. The lower compartment held blankets and the internal thermometer read, "155".

In an interview on 7/19/2022 at 1:30 PM with RN (Registered Nurse) H when asked how long IV solutions can remain in the warmer RN H stated, "I don't know, probably 30 days."

Record review of May and June 2022 "Blanket Warmer Temperatures" daily checklist revealed the following: May had 6 of 31 days without documentation of a check: 5/12/2022, 5/14/2022, 5/15/2022, 5/20/20222, 5/24/2022, 5/25/2022. Of the days where the temperature was documented all were above the 130 degrees as defined in policy. June had 2 of 30 days without documentation: 6/2/2022, 6/17/2022, with all days where the check was documented the recorded temperature was above 130 degrees. There was no label on the warmer or the checklist indicating what the appropriate temperature should be.

On 7/20/2022 at 11:30 AM in an interview with ED Manager B, Manager B confirmed the findings and stated, "Staff need some more education on this."



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Examples in the Rehabilitation Department

Record review of policy "Medication Administration" #11222452, last revised 3/2022, Parenteral Medications #1 Multiple-Dose Containers revealed "to avoid infection risk, multiple-dose containers will be allocated to individual patients for the exclusive use of that patient ... a multiple-dose vial ... is to also label the vial indicating the date of puncture."


On 7/19/2022 at 2:35 PM during observation while touring Rehabilitation Services Department, observed Rehabilitation Services Manager W pull one 5 ml (milliliter) bottle and one 1 milliliter bottle of Dexamethasone Sodium Phosphate bottle out of a locked file cabinet. Both bottles were opened and not labeled with patient name or date opened.

On 7/19/2022 at 2:50 PM during interview with Occupational Therapist (OT) X, OT X stated the medication is used in some of their treatments, the bottles are brought to the patient's room where the medication is drawn up, and the bottles are returned to the file cabinet.

Based on observation and interview the facility failed to remove expired supplies from use in 2 (Emergency Department and Rehabilitation Services Department) of 10 Patient Care areas.

During a tour of the ED (Emergency Department) on 7/19/2022 at 1:00 PM an opened 16 ounce bottle of 3% hydrogen peroxide was observed on a dressing cart at the entrance to the department. The bottle had a date of 6/22/03 written on it.


In an interview on 7/19/2022 at 1:05 PM with ED Manager B , ED Manager B confirmed the date stating, " Oh, my gosh, that is correct. That should not be here. It should be dated with an expiration of 28 days from opening."

On 7/19/2022 at 1:25 PM 42 yellow top blood collection tubes were observed on the shelf that stored blood collection tubes. The yellow top tubes had an expiration date of 2/28/2022.

In an interview 7/19/2022 at 1:25 PM with ED Manager B, ED Manager B stated, "We check for outdates on a monthly basis but it looks like we missed those."


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During a tour of the Rehabilitation Services Department on 7/19/2022 at 2:35 PM an opened 500 ml (milliliter) bottle of 5% Acidic Acid Solution was observed in the file cabinet in the Rehabilitation managers office. There was no date of expiration or date opened written on the bottle.

On 7/19/2022 at 2:35 PM interview with Rehabilitation Manager W, Manager W stated, "I don't know when the bottle of Acidic Acid was opened or when it expires."

Based on Record Review and Interview the facility failed to follow their Pain Assessment policy to re-evaluate the effectiveness of pain relieving medications in the timeframes specified, for 1 of 1 Patients (Patient #6) in a sample of 19 records reviewed. This had the potential to cause increased pain and suffering for Patient #1.

Record review of policy "Pain Assessment" Section 21 - Acute Care, #11193397, last revised 02/2022, under ongoing pain assessment revealed "reassessment timeframe is 30 minutes for ... Intravenous medication ... 60 minutes for ... Intramuscularly medication b. Oral medication."

Patient #6's medical record was reviewed and revealed Patient #6 presented to the Emergency Department 7/11/2022 at 10:11 AM with the diagnosis of severe sepsis (infection in the blood) due to left lower extremity non-purulent cellulitis (skin infection without drainage) and was admitted to the Medical Surgical Department 7/11/2022 at 12:24 PM for intravenous antibiotics and left leg pain. Patient #6's pain was rated on a 1-10 pain scale (ten being the most pain and patient stating up to 4 is an acceptable pain level) and pain medications were ordered on 7/11/2022 at 1:18 PM Tylenol 1,000 mg every 6 hours as needed for mild pain (3 or less), 7/11/2022 at 1:19 PM Flexeril (muscle relaxant) 10 mg 3 times daily as needed for muscle spasms, 7/11/2022 at 1:21 PM Tramadol (Narcotic pain medication) 50 mg tablet every 6 hours as needed for moderate pain (4-6), and 7/11/2022 at 1:22 PM Fentanyl (Narcotic pain medication) 25 mcg (milligrams) every 1 hour as needed for severe pain (7 or greater).

On 7/11/2022 at 4:27 PM Patient #6 rated pain was 7, at 4:29 PM Tramadol was given, pain reassessment at 7:55 PM (1 hour and 28 minutes late) was 10, and intravenous Fentanyl was given at 7:56 PM and reassessed at 8:30 PM (4 minutes late) as 2.

On 7/12/2022 at 12:16 AM Patient #6's pain was 5 and intravenous Fentanyl was given at 12:16 AM, pain reassessment at 1:15 AM (29 minutes late) was 2. Patient # 6's pain was 8 at 7:00 AM and 8 at 7:46 AM and intravenous Fentanyl was given at 7:50 AM, pain reassessment at 8:47 AM (27 minutes late) revealed "interventions declined" and was not rated. At 10:09 AM Patient #6 pain was 4, Tramadol was given, and pain reassessment at 12:13 PM (1 hour and 4 minutes late) was 8. Intravenous Fentanyl was given at 12:13 PM and pain reassessment at 2:00 PM (1 hour and 7 minutes late) was 4. At 6:37 PM intravenous Fentanyl was given, pain reassessment at 7:37 PM (30 minutes late) was 4.

On 7/13/2022 at 2:01 AM Patient #6 rated pain as 8, at 2:01 AM intravenous Fentanyl was given, and at 3:19 AM pain was reassessed (48 minutes late) as 4. At 7:23 PM Patient #6's pain was 6, at 7:41 PM intravenous Fentanyl was given, and Patient #6's pain was reassessed at 8:23 PM (11 minutes late) as 5. At 10:02 PM Patient #6's pain was 9, intravenous Fentanyl was given at 10:02 PM, pain was reassessed at 11:00 PM (27 minutes late) and Patient #6 "appeared to be asleep."

On 7/14/2022 at 4:16 AM Patient #6 rated pain 7 and at 4:27 AM was given intravenous Fentanyl, and pain reassessment done at 5:16 AM (19 minutes late) revealed "appears asleep." At 8:01 AM Patient #6 was given intravenous Fentanyl, and pain reassessment at 9:49 AM (48 minutes late) was 4. At 10:40 AM an order for Roxicodone (narcotic pain medication) 5-10 mg tablets every 4 hours as needed for severe pain (7 or greater) was entered. At 12:31 PM patient rated pain as a 7, was given Roxicodone at 12:31 PM and pain reassessment at 2:32 PM (1 hour late) was 6. At 5:12 PM Roxicodone was given, and pain reassessment at 7:43 PM (1 hour and 21 minutes late) was 8.

On 7/15/2022 at 12:22 AM Patient #6's pain was 7, at 12:22 AM Roxicodone was given, and pain assessment at 1:00 AM (8 minutes late) revealed "appears asleep".

On 7/16/2022 at 1:04 AM Patient #6 rated pain at 8, Roxicodone was given, and pain reassessment at 2:15AM (11 minutes late) was 5. Patient #6 was transferred on 7/16/2022 to the acute hospital where her/his total knee arthroplasty (knee replacement) was performed in February 2021. 2 of 6 reassessments for moderate pain and 15 of 22 pain reassessments for severe pain were completed late during Patient #6's hospitalization.

On 7/20/22 at 9:30 AM during interview with Infection Preventionist (IP) O during review of Patient #6's medical record, when asked when pain reassessments are to be completed, IP O stated "after an hour after giving something" and sooner if an intravenous medication is given. IP O confirmed pain reassessments were not completed according to policy in Patient #6's medical record.

Based on record review and interview the facility failed to obtain a properly executed informed consent form for hospitalization for 2 Patients (Patient #17 and Patient #19) out of 19 records reviewed.

Review of facility policy #11613986, titled "Informed Consent", last revised 04/2022 revealed, "Except in certain emergency situations.....the patient or his or her representative will be provided an adequate explanation of the care plan and will agree to proceed with this plan prior to any procedure or treatment....6. Signing and witnessing Permission Forms:...i. If the adult needs to sign the form(s) and is unable to sign due to physical condition, the patient's mark or, if possible, initials shall be obtained. ....ii. A witness attesting to the genuineness of the patient or patient representative's signature should sign, date and time the form (s)...all forms must be signed, dated and times by patient and witnesses."

Review of Patient #19's medical record revealed a consent for hospitalization that had an illegible scratch present for the signature, no date and no witness signature or date and time were present.

Review of Patient #17's medical record revealed a consent for hospitalization that stated, "Patient unable to sign," Initials of SD (Patient #17 initials are not SD) no date and no time were present.

In an interview on 07/20/2022 at 11:00 AM with Health Information Manager U, stated, "If the patient is unable to sign, normally one person would witness, the Registered Nurse or witness should be signing, not initialing and it should be dated and timed."

Based on observation, record review, and interview, staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention policies of the facility and nationally recognized standards of practice in 4 (Medical-Surgical Unit, Outpatient Infusion Department, Emergency Department, Operating Room) of 10 Patient Care areas, and in the Kitchen.

Record review of facility policy titled, "Reprocessing & Distribution of Supplies to/from Central Supply, GMHC - 32011" dated 3/2022 revealed, under "General Instructions: 1. Each department is responsible for cleaning instruments immediately after use with an appropriate hospital supplied enzymatic cleaner prior to return to CS (central supply). 2. Contaminated instruments will only be transported in a container with a secure lid and biohazard labels."

Examples in the Medical- Surgical department:

On 7/19/2022 at 10:20 AM during a tour of the Med-Surg (Medical- Surgical) department an unlabeled bin was observed on the counter in the dirty utility room. When asked what it was for In-patient Manager C stated, "We put any used instruments in it to go to OR (operating room) for sterilization." When asked about pre-treating the instruments Manager C stated, "We used to have a solution here to soak them in, not sure what happened to it."

On 7/19/2022 at 10:30 AM in an interview with Med-Surg RN (Registered Nurse) D when asked about the process for used instruments RN D stated, "We just put them in that bin in the dirty utility room."

On 7/19/2022 at 10:35 AM in occupied patient room Room 501 a bedpan was observed on the handwashing sink in the room. In-patient Manager C looked at the bedpan and stated, "I can't tell if it is used or not but it probably shouldn't be there."

On 7/19/2022 at 10:40 AM in the Medication Room 4 large dime sized holes were observed in the wall across from the Pixis (automated medication distribution unit). The holes were through the dry wall. When asked about the holes In-patient Manager C stated, "There used to be something there to place used medications in but it got taken down and obviously the holes haven't been patched."

Record review of facility policy titled, "Hand Hygiene, GMHC-26002" dated 3/2022 revealed, "B. Alcohol-based Hand Rub...indication for use: a. before and after direct patient contact...c. After removing sterile or non-sterile gloves d. after contact with patients intact skin e. after contact with objects and equipment in the patient's immediate vicinity...

On 7/20/2022 at 7:45 AM observation on the Med-Surg unit of RN E administering oral and parenteral medications to patient in Room 502 revealed no handwashing at the following events: after glove removal, after working on the computer and then administering an injection, and when leaving the room. In an interview at 8:00 AM with RN E, RN E stated, "I'm sure I missed some handwashing opportunities."

On 7/20/2022 at 8:50 AM observation during Patient Care rounding observed 4 staff members to enter room 502 without washing hands upon entry.

Examples in the Outpatient Infusion Department:

No signage on dirty utility room

Record review of policy "Hazardous Materials & Waste Management Control Plan" #10666607, last revised 05/2019, V. Protection, #4 revealed "Identify by labeling and appropriate signage hazardous materials and wastes as well as the areas where they are used, stored, or disposed of."

On 7/20/2022 at 8:42 AM during tour of Outpatient Infusion Department, observed next to department exit sign, an unlocked dirty utility room. The room contained a sink with a clear bin of unclean instruments on top of the counter, 2 filled large red sharp containers, and 1 stack of empty biohazard containers. There was no sign to identify the area as hazardous.

On 7/20/2022 at 8:58 AM during interview with Registered Nurse (RN) Y, RN Y stated the sharp containers held used needles stating "patient's aren't allowed" in that area, and confirmed the area was not identified as hazardous.

Examples in the ED (Emergency Department):

Record review of the facility policy titled, "Cleaning of Equipment in Emergency Department, GMHC - 24006" dated 02/2022 revealed, "Instrument trays: a. All instruments and trays are washed in the ED using a detergent solution..."

On 7/19/2022 at 1:10 PM observation was made in the dirty utility room of an unlabeled plastic container on the counter and a smaller container filled with a blue solution next to it. When ED Manager B was asked to describe the process for handing dirty equipment ED Manager B stated that, "We pump the precleanse into the smaller container until the instrument is submerged, then it soaks for a while and then is placed in the larger container for OR (operating room) to pick up and sterilize."

Review of the instructions for use on the detergent solution labeled, "Enzymatic Pre-Soak Cleaner" revealed "add 1/2 oz (ounce) or 15 ml (milliliters) to 1 gallon of water. Soak according to hospital protocol then rinse."

On 7/19/2022 at 1:30 PM in an interview with ED Manager B, Manager B stated, "I just confirmed with staff, they just pump that cleaner into the container until the instruments are covered." When asked if they dilute the solution as indicated on the solution bottle Manager B stated, "I guess they don't know that they are supposed to." ED Manager B confirmed that there is not a Biohazard label on the transport container.


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Examples in the Operating Room Suite:

AORN eGuidelines+ copyright 2012-2022 Inc., Guidelines for Perioperative Practice: Design and Maintenance of the Surgical Suite: 2.2.1: The requirements for each zone include the following: All zones: have surfaces on floors, walls, ceilings, and cabinets that are durable, smooth, cleanable, and able to withstand cleaning practices."

During a tour of the Operating Room Suite on 7/20/2022 at 9:00 AM with OR (Operating Room) Registered Nurse (RN) J, observed peeling paint on the wall near the entrance in OR room 2. RN J stated, "Yes, we have placed a work order in to repair this."

A review of the facility policy, titled "Eye Wash Station in the OR, GMHC-32057", dated 2/2022, revealed: "1. Eye Wash stations provide an effective means of treatment when chemical or biologic material come in contact with the eyes. Eye wash stations should be readily available and accessible to all personnel using harmful chemicals."

During a tour of the OR suite on 7/19/2022 at 10:45 AM with Surgical Technician (ST) L, observed a plumbed eyewash station in the endoscopy reprocessing room that had 3 draining tubes from the steris reprocessing machine that drained into the same sink where the eyewash station was located, ST L stated, We don't use this eyewash station because of the potential splash of the chemicals draining into the sink. There is a eyewash station in the OR corridor which is the one we would use."


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Examples in the Kitchen:

Record review of policy "Dress Code - Nutrition Services" #10910978, last revised 04/2019 revealed "All hair is to be covered by the hair restraint. Beard nets must be worn if facial hair is present."

On 7/19/2022 at 9:58 AM during tour of Dietary Department with Dietary Supervisor Z, observed Cook V with black skull cap with pieces of hair noted on back and sides of cap not covered and face mask with facial hair on both sides of face not covered. Also observed Dietary Aide AA with hair tendrils on both sides and back of hair net not covered.

On 7/19/2022 at 9:58 AM during interview with Dietary Supervisor Z, when asked about use of hair nets, Supervisor Z stated "all of their hair should be covered."

Based on record review and interview the facility failed to develop a contingency plan for staff who are not fully vaccinated for COVID 19, in 1 of 1 COVID-19 Vaccination policy.

Findings include:

A review of the facility policy, titled "COVID-19 Vaccination Program", dated "2/18/2022, revealed: "2. Exemptions and requests for reasonable accommodation for employees. A....Those granted an Exemption, Delay, or Reasonable Accommodation my be subject to additional safety and infection control requirement at [Facility name] discretion."

Further review of the policy revealed no evidence of a contingency plan or mitigation strategies for unvaccinated staff.

During an interview on 7/20/2022 at 1:15 PM, when asked does the COVID-19 Vaccination Program address the contingency plan or mitigation strategies for unvaccinated staff, Manager of Manager of Continuous Readiness S stated, "No, it doesn't"

During an interview on 7/20/2022 at 2:00 PM, when asked does the COVID-19 Vaccination Program address the contingency plan or mitigation strategies for unvaccinated staff, Manager of Human Resources Manager T stated, "No."