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Based on document review and interview, the facility failed to ensure that it complied with 42 CFR 405.1205(c)(1) for 2 of 5 medicare patient medical records (MR) reviewed.

Findings include:

1. Review of 42 CFR 405.1205 (b)(c)(1) indicates the following: "Advance written notice of hospital
discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary ' s rights as a hospital inpatient, including discharge appeal rights. The hospital
must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary ' s admission to the hospital.
(2) Content of the notice. The notice must include the following information: (i) The beneficiary ' s rights as a hospital inpatient including the right to benefits for inpatient services and for post-hospital services in accordance with 1866(a)(1)(M) of the Act.
(ii) The beneficiary's right to request an expedited determination of the discharge decision including a description of the process under § 405.1206, and the availability of other appeals processes if the beneficiary fails to meet the deadline for an expedited determination.
(iii) The circumstances under which a beneficiary will or will not be liable for charges for continued stay in the hospital in accordance with 1866(a)(1)(M) of the Act.
(iv) A beneficiary's right to receive additional detailed information in accordance with § 405.1206(e).
(v) Any other information required
by CMS.
(3) When delivery of the notice is valid.
Delivery of the written notice of rights described in this section is valid if-
(i) The beneficiary (or the beneficiary ' s representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and
(ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section.
(4) If a beneficiary refuses to sign the notice. The hospital may annotate its notice to indicate the refusal, and the date of refusal is considered the date of receipt of the notice.
(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary ' s representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge."

2. Review of patient #16's MR indicated the patient was a Medicare patient and was admitted to the facility on 09-30-11 and was discharged on 10-05-11. Patient #16's MR lacked documentation that the patient was given the Medicare Important Message no more than 2 days prior to discharge.

3. Review of patient #20's MR indicated the patient was a Medicare patient and was admitted to the facility on 08-20-11 and was discharged on 08-26-11. Patient #20's MR lacked documentation that the patient was given the Medicare Important Message no more than 2 days prior to discharge.

4. On 12-05-11 at 1515 hours, staff #48 confirmed that the Medicare Important Message/Rights is given to Medicare patients only during admission and not prior to discharge.

Based on Life Safety Code (LSC) survey, Putnam County Hospital, was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC).

The Putnam County Hospital one story Surgery Center addition was determined to be Type II (111) construction and fully sprinklered. The renovated OB unit, 2 South Oncology wing, and 3 North Administration wings were located in the four story partially sprinklered building of Type II (222) construction. These renovated areas were fully sprinklered. The facility has a fire alarm system with smoke detectors in corridors, patient rooms and offices. The facility has the capacity for 25 patients and had a census of 14 patients at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency (see K 048), failed to maintain 1 of 1 fire alarm systems (see K 051), failed to ensure smoke detectors connected to the fire alarm system in 3 of 12 smoke detectors in the surgery department, were properly separated from an air supply (see K 054), failed to perform weekly sprinkler system fire pump tests (see K 062) and failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity (see K 144).

Based on observation, the facility failed to secure a gas cylinder in the medical gas room.

Findings:

1. On 12-5-11 at 2:00 pm in the presence of employee #A3, it was observed in the Medical Gas Room that there was 1 small carbon dioxide tank gas cylinder unsecured by chain or holder creating an unsafe environment for staff if knocked over and the head is broken off.

Based on record review, observation and interview, the facility failed to provide a complete written plan for the evacuation of 14 of 14 patients in the event of an emergency, failed to maintain 1 of 1 fire alarm systems, failed to ensure smoke detectors connected to the fire alarm system in 3 of 12 smoke detectors in the surgery department, were properly separated from an air supply, failed to perform weekly sprinkler system fire pump tests and failed to ensure 1 of 1 generators serving as the alternate source of power was maintained and capable of operating at full capacity.

Findings:

1. Record review with POD1 on 12/06/11 at 1:30 p.m. indicated the policy and procedure for the evacuation of occupants in the event of an emergency was part of Hospital Regulation 40-2. Pages 10 and 11 of the regulation included an Emergency Call List which was updated June 2011 and listed staff and physicians to be contacted in the event of an emergency requiring evacuation.

2. Interview with POD1, listed as the Safety Officer at the time of record review indicated the list was not current and two of eleven doctors, three of 28 nursing staff and 9 of 11 hospital administrative staff were no longer on staff and many had been gone as long as two years. In addition, pager and other contact numbers were incorrect.

3. Observation with POD1 on 12/06/11 at 4:40 p.m. and 12/07/11 at 11:45 a.m. indicated an adjunct fire alarm control panel (FACP) was located in the surgical entry foyer which was not continuously occupied. The main FACP was located in POD1's office which confirmed at the time of observation, was not continuously occupied. The areas were not electrically supervised by a smoke detector.

4. Review of the Serviceman's Recommendation and Summary Report following the annual Fire Alarm Test and Inspection with POD1 on 12/06/11 at 12:50 p.m. noted "there are six heat detectors in the boiler room that are damaged and need replaced".

5. POD1 said at the time of record review that the heat detectors "still worked" and had not been replaced.

6. Observation with POD1 on 12/07/11 between 11:45 p.m. and 12:15 p.m. indicated three smoke detectors were located 12 inches from air supply vents in the sterile side of the surgery suite.

7. POD1 confirmed the distance measurements and agreed at the time of observations, the air flow could impede the function of the smoke detectors.

8. Review of sprinkler system reports of inspection by the sprinkler contractor on 12/06/11 at 12:45 p.m. with POD1 indicated a fire pump test was done on 09/30/11, however, there was no record of a weekly fire pump test performed in facility preventive maintenance logs.

9. POD1 confirmed at the time of record review, no weekly testing was done.

10. Observation with POD1 on 12/07/11 at 3:20 p.m. indicated no emergency shut off was evident for the emergency generator.

11. POD1 said at the time of observation, the emergency generator was larger than 100 horsepower and there was no emergency stop of any kind.

Based on policy/procedure review, patient record review ands staff interviews the CAH hospital failed to furnish health care services in accordance with appropriate written polices for one of three respiratory patient tests reviewed and for three of seven patient transfusions reviewed.

Findings included:
1. On 12/6/11 between 10:30 a.m. and 12:30 p.m. review of policies and procedures revealed:
a. a procedure labeled "Blood transfusion, Procedure for 100-36E Rev. 7/11" which states, "Check TPR and BP prior to administering for baseline to be used for later comparison. Reactions usually occur in the first 15 minutes of a transfusion....it is necessary for nursing personnel to stay in attendance with the patient. A Blood Transfusion Consent Form must be obtained except in emergent situations...... Take TPR and B/P Record on blood Transfusion Form #4500. Take repeat vital signs 15 minutes into the transfusion and record on Transfusion Record PCH #4500. Each transfusion should be infused in 1 2-2 hrs but not to exceed 4 hours. (?) Because of the possibility of a delayed reaction, vital signs should be monitored before, and after transfusion up to 15 minutes past transfusion and more if needed.(?)"
b. a procedure labeled "Respiratory Care Department Requisitioning Cardiopulmonary Procedures Revised/Reviewed: 08/02; 7/2004, 3/08" which states "Respiratory care procedures are performed only when ordered by a doctor."
2. Review of transfusion patient records and respiratory patient records on 12/6/11 between 12:30 p.m. and 2:30 p.m. revealed:
a. Transfusion CP#T3 did not have the time it was signed out of the laboratory and the post set of vitals which are to be taken 30 minutes after the completion of the transfusion were, as documented, taken 25 minutes before the transfusion was completed.
b. Transfusion CP#T6 did not have a signed consent.
c. Transfusion CP#T7 did not have a signed consent and had a 2 degree temperature change (possible transfusion reaction) at time of 2035 but the transfusion reaction was not called until 2115.
d. Respiratory blood gases CP#R1 did not have a doctor's order for the testing performed.
3. In interviews on 12/6/11 between 12:30 p.m. and 2:30 p.m., staff person CP #6 acknowledged the missing transfusion documentation and staff person CP#7 acknowledged the missing respiratory documentation. to indicate health care services were not furnished in accordance with the appropriate written policies.

Based on observation and interview the facility failed to have a policy/procedure for dispensation of antibiotic medications in the Emergency Department (ED) for one medication reconstituting equipment set and failed to ensure authorized access to drugs by individuals in 1 instance.

Findings include:

1. During the facility tour of the ED on 12-05-11 at 1145 hours the following was observed in the ED medication room; an unlabeled box with an unlabeled plastic container with clear liquid on top of the wall cabinet with connected tubing running down the side of the wall cabinet with a plastic measuring device.

2. On 12-05-11 at 1145 hours staff #42 confirmed that the item listed above in 1. was used to reconstitute antibiotics medications by ED nurses and pharmacy personnel change the equipment.

3. On 12-07-11 at 1355 hours staff #40 confirmed that the facility did not have a policy/procedure for using the medication equipment for reconstituting medications in the ED.

4. On 12-5-12 at 2:15 pm in the presence of employee #A3, while on facility tour, it was observed in the cardiac Rehabilitation area that a hospital employee had the keys and accessed a locked drawer in which was stored 1 vial of 25 nitroglycerin tablets and 10 tablets children's aspirin 81 mg. It was also observed that there was no other hospital staff in the area.

5. On the above date and time, upon interview, the hospital employee having access indicated he/she was an Exercise Specialist. This employee also indicated he/she did not possess a health care provider license.

6. On 12-7-11 at 1:00 pm, hospital staff was requested to provide documentation indicating the Exercise Specialist had authority to access drugs and no documentation was provided prior to exit.



17294

Based on document review, observation and interview, the facility failed to ensure that staff followed established policy/procedure for decontamination of instruments and failed to follow CDC's Guidelines in determining and implementing risk category for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings.

Findings include:

1. Review of policy/procedure 4, Decontamination of Instruments, Utensils and Equipment, indicated the following; "Solution mixed according to manufacturer instructions: Detergents, Germicidal Detergents and Enzyme Solutions."
This policy/procedure was last reviewed/revised on 09-11.

2. Review of Medline Dual Enzymatic detergent manufacturer's recommendations indicated to use 1-2 ounces per gallon of water.

3. On 12-06-11 at 1005 hours, staff #45 was observed cleaning procedure equipment in the soiled workroom. Procedure equipment was observed in a sink sitting in solution.

4. On 12-06-11 at 1005 hours, staff #45 confirmed that he/she estimates how much water is in the sink before adding the Medline Dual Enzymatic detergent solution. It could not be determined if the enzymatic solution was mixed with water according to the manufacturer recommendations.

5. Review of the CDC's Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings indicated the following on page 9:
"Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting. Conduct periodic reassessments (annually, if possible) to ensure proper implementation of the TB infection-control plan."

6. Review of nursing staff #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10's personnel files indicated each had completed questionnaires in the last 12 months to determine tuberculosis risk/status.

7. Requested documentation of Facility TB Risk Assessments from staff #49 on 12-06-11 at 1525 hours and none was provided.

8. On 12-06-11 at 1525 hours, staff #45 confirmed the facility has not done annual risk assessments per CDC's guidelines and the facility does not do annual PPDs on nursing staff.

Based on document review and interview the facility failed to ensure that the patient care policies were reviewed at least annually by a group of professional personnel which included one member who is not a member of the CAH staff.

Findings include:

1. Review of the Patient Care Policy Manual and facility documentation lacked documentation that a physician or nurse practitioner non medical staff member reviewed the Patient Care Policy Manual on the last annual review on 08-05-11.

2. On 12-05-11 at approximately 1450 hours, staff #41 confirmed that the Patient Care Policy Manual is reviewed annually by members of the CAH Medical Staff and the does not include at least 1 physician or nurse practitioner who is not a member of the CAH Staff.

Based on document review the facility failed to ensure that nursing care plans were reviewed per facility policy/procedure for 3 of 7 medical record (MR) care plans reviewed (Patient #1, 10 and 20).

Findings include:

1. Review of policy/procedure 100-28, Charting, indicated the following;
"C. Multidisciplinary Care Plan Form #4886
3. There will be an evaluation of care plan every 24 hours."
This policy/procedure was last reviewed/revised on July 2011.

2. Review of patient #1's MR indicated the patient was admitted to the facility on 11-30-11 and the Care Plan lacked documentation of review on 12-01, 02 and 04-11.

3. Review of patient #10's MR indicated the patient was admitted to the facility on 11-19-11 and the Care Plan lacked documentation of review on 11-20 and 22-11.

4. Review of patient #20's MR indicated the patient was admitted to the facility on 08-20-11 and the Care Plan lacked documentation of review on 08-21, 22, 24 and 25-11.

Based on document review and interview, the facility failed to include 6 contracted services in its quality assessment performance improvement (QAPI) program.

Findings:

1. Review of the facility's QAPI program indicated it did not include the contracted services of blood bank, laboratory, pharmacy, telepsychiatry, teleradiology and transcription.

2. On 12-7-11 at 12 noon, upon interview, employee #A5 indicated there was no documentation of inclusion of the above contracted services in the facility's QAPI program and no documentation was provided prior to exit.

Based on document review and interview the facility failed to ensure that residents are informed that residents have the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement for one facility.

Findings include:

1. Review of the resident's rights document given to residents on admission lacked documentation that the resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

2. On 12-07-11 at 0916 hours, staff #50 & 51 confirmed that the document given to residents on admission lacked documentation that the resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.