HospitalInspections.org

Based on observation and interview, it was determined that the facility did not always provide a safe and accessible environment to all of its patients.

Findings were:

Tour of the facility on 4/9/19 revealed the following:

* The patient bathrooms did not have doorways wide enough for wheelchair access.
* There were no patient shower facilities that had wheelchair access.
* The emergency call systems in the restrooms had no pull cord. If a patient fell in the bathroom, he would be unable to call for assistance.
* The CT room had an oxygen tank. There was no oxygen tubing available for patient use. The Radiology Technician told the surveyors that the oxygen tank was checked daily; however, there was no documentation of the daily check nor was there a check list available that listed the duties of the rounding nurse that designated checks of hospital systems.

In an interview with the Administrator on 4/9/19, the above concerns were confirmed.

Based on observation and interview, it was determined that the facility did not always practice effective infection control.

Findings were:

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

Tour of the facility on 4/9/19 revealed the following:

* The trauma room had rust and water damage under the sink. Supplies were stored on top of cabinets, several "trauma boards" were stored against the wall-one notably dirty. It was also noted that the crash cart was not checked daily.
* Several unoccupied patient rooms were inspected. Patient rooms 103 and 104 had open piping where foot pedal valves were housed that were used to operate bed pan washers. These open plumbing valves were dirty and full of dust. The walls through the patient area had water damage as evidenced by puckered and swollen sheetrock. Floor tiles also had raised areas indicating water damage. Shower areas and sinks had copious amounts of rust and several sinks were noted to be dripping.
* Throughout the hospital corrugated shipping boxes were found that housed clean supplies. These boxes are considered dirty as they have been found to house vectors. Storing a clean item with a dirty item could lead to cross contamination.
* Tour of the lab area revealed clean supplies stored under the sink. Floor tiles were missing from the floor making the floor impossible to thoroughly clean.
* The x-ray room had evident water damage along the wall near a pipe where water flowed.
* The medication room housed a very dirty medication cart. The drawers that held patient medications were dirty inside and the top of the cart had paper taped to it. (Tape prevents thorough cleaning.) The biohazard box next to the medication cart was full.

In an interview with the Administrator on 4/9/19, the above infection control concerns were confirmed.

Based on observation and interview, it was determined that the facility did not always adhere to applicable standards of practice when labeling multi use vials of medications.

Findings were:

According to the Joint Commission, 2019 "Multi-dose vials are to be discarded 28 days after first use unless the manufacturer specifies otherwise (shorter or longer). Manufacturers are only required by law to test the effectiveness of the bacteriostatic agent used in the multi-dose vial for a period of 28 days. Manufacturers are allowed by the FDA to provide extended dating in the package insert if they have conducted testing beyond the 28 days."

During a tour of the facility on April 9, 2019, an open vial of Etomidate Injection was found in a locked medication refrigerator in the Emergency Department. The vial was not labeled as to when the vial was opened, nor as to who opened it.

The above finding was acknowledged by the Medication Nurse (Employee # 13) on April 9, 2019.

Based on review of documentation and interview, it was determined that the facility had no current infection control program.

Findings were:

Job Description entitled "Infection Control" stated in part under "Job Knowledge" Knowledge of current trends and techniques in nursing practice. Completion of a core-course in infection control as recognized by the Centers for Disease Control is required within the first year of employment."

The Infection Control Nurse, who had been in that position since December 2018, admitted that she had had no training specific to infection control. During an interview on 4/10/19, this same Nurse could not identify the duties required with that position.

On 4/10/19, the Administrator confirmed that the Infection Control Program at the hospital was currently not operational.