HospitalInspections.org

Bringing transparency to federal inspections

500 BURLINGTON ROAD

JACKSON, OH 45640

No Description Available

Tag No.: C0220

Based on observation, record review, and interview, during the life safety code inspection, it was determined the facility failed to maintain a clean environment and ensure it was maintained in a manner safe from fire. The facility failed to ensure air vents were free from dust (C225), failed to ensure a storage cabinet was located less than 18 inches from sprinkler head, fire alarm devices were repaired, corridor doors closed completely, penetrations in the three hour barrier and smoke barrier were closed , smoke dampers were functional and failed to ensure operation of medical gas shut off valves in the event of an emergency (C231). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patient safety. The facility census was 11 patients.

Findings include:

See C225, C231.

No Description Available

Tag No.: C0225

Based on observation and interview, the facility failed to ensure the air vents were free from dust. This has the potential to affect all patients, staff, and visitors. The facility census was 11 patients.

Findings include:

On 01/15/14 at 1:45 P.M. a tour was conducted of the second floor with Staff 1A and 1B.

Observation revealed the walls of the conduit to the return air vents in the bathrooms of rooms 210, 208, 215, and intensive care unit room 3 were coated with copious amounts of dust.

On 01/15/14 at 1:45 P.M. in an interview, Staff 1A confirmed the observation.

No Description Available

Tag No.: C0231

Based on observation, interview, and record review, it was determined the facility was not maintained in a manner safe from fire. This has the potential to affect all patients, staff, and visitors. The facility had a census of 11 patients.

Findings include:

1. Observation on 01/14/14 at 2:04 PM revealed a storage cabinet that contained information technology located less than 18 inches from a sprinkler head. Please refer to Life Safety Code findings at K62 for further detail.

2. Observation on 01/15/14 at 9:21 AM revealed not all corridor doors closed to the mechanical space in the northern most corridor. Please refer to Life Safety Code findings at K18.

3. Observation on 01/15/14 at 11:18 AM revealed penetrations in the three hour barrier that is part of the back wall of the men's bathroom and the physician's on call room between the facility and the medical office building. Please refer to to Life Safety Code findings at K11.

4. Observation on 01/15/14 at 9:28 AM revealed penetrations in a storage equipment room on the north wing of the first floor, a supply room near the storage equipment room and the room near the center stairwell located in otherwise rated barriers. Please refer to to Life Safety Code findings at K25.

5. Review on 01/15/14 of the facility's November 2013 fire alarm inspection report revealed a lack of evidence the smoke dampers were functional. Please refer to to Life Safety Code findings at K67.

6. Review on 01/15/14 of the facility's November 2013 fire alarm inspection report revealed a failure to fix failed alarm devices discovered in November 2013. Please refer to Life Safety Code findings at K52.

7. Interview on 01/14/14 at 2:10 PM with Staff 1F and interview at 3:35 PM with Staff 1D revealed neither staff member knew the location of medication gas shut off valves. Please refer to Life Safety Code findings at K76.

No Description Available

Tag No.: C0270

Based on observation, review of patient care policies, dishwasher temperature logs, maintenance records, manufacturer guidelines and staff interviews the facility failed to
ensure dietary services were provided in a safe and sanitary manner. The facility failed to take alternate action for a dishwasher with a broken wash water temperature gauge that had been broken for over 101 days and failed to provide a policy regarding how to log the wash water temperatures in the event of a broken gauge that had been broken. (C 279) The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients are not at risk for food borne illnesses.

Findings include:

Please refer to C 279.

No Description Available

Tag No.: C0279

Based on observation, dishwasher temperature logs, maintenance records, manufacturer guidelines and staff interviews the facility failed to ensure the broken gauge on the dishwasher wash cycle was repaired and failed to ensure a policy was in place to direct staff how to log the wash water temperature in the event of a broken gauge or policy to direct staff on procedure when dishwasher not working. This had the potential to affect all patients served meals from the kitchen. The facility census was 11 patients.


Findings include:


Review of the facility dishwasher temperature logs during the kitchen tour on 01/14/14 at 4:15 PM revealed the wash temperatures readings were documented between 134 and 130 degrees Fahrenheit (F) from January 01, 2014 through January 16, 2014. The final rinse temperature readings were documented between 180 and 185 degrees F.

Further review of the dishwasher temperature logs from October through December 2013 revealed the wash temperatures were consistently documented between 130 and 140 degrees F. There was a note on the top of the October through December 2013 logs that the wash temperature gauge was broken.


An interview on 01/15/14 at 11:00 AM with Staff F, Dietary Manager, at the time of the observation confirmed the above findings and revealed the dishwasher wash cycle temperature gauge was not functioning and had been on order per the maintenance department since October 7, 2013. Staff F further stated that the water temperature was being monitored by the maintenance department and staff had been recording the temperature for the wash cycle by looking at the non functioning gauge.

Observation on 01/15/14 at 11:00 AM of the dishwasher temperature gauges confirmed a broken wash temperature gauge and the reading on the rinse gauge revealed the water temperature was 160 degrees F at the start of wash.


On 01/15/14 at 11:00 AM Staff G, Director of Nutrition Services, revealed through interview the dishwasher was of single tank construction so the temperature from the rinse gauge could be used to check the wash water temperature.

Review of the manufacturer guidelines on 01/16/14 revealed the minimum wash temperature was 160 degrees F and minimum rinse water temperature was 180 degrees F. The guidelines do not address instructions to follow when the wash temperature gauge is broken.

Review of a work authorization form dated 10/07/13 revealed the dishwater water heater was supplying 180 degree water to the dishwasher but a thermometer was not reading correctly. The work order indicated the thermometer was ordered on 10/07/13.

An interview on 01/16/14 at 8:15 AM with Staff H, maintenance staff, revealed the part had been ordered by the contracted repair company. This situation with the dishwasher has persisted from October 7, 2013 until the time of survey exited on January 16, 2014, or 101days.


An interview with Staff G on 01/16/14 at 9:50 AM confirmed staff failed to ensure the wash temperature reached the required 160 degrees F. Staff G further stated that staff had been documenting a temperature reading taken from the broken wash gauge. A policy regarding how to log the wash water temperature in the event of a broken gauge was requested.

Staff G stated the facility did not have a specific policy and procedure to address monitoring the dishwasher temperatures, but staff were to use the daily log and follow the minimum temperatures noted on the log and the dials on the dishwasher. There was no evidence of a policy for the staff to follow when the dishwasher was not working and no evidence of education of the dietary staff regarding the use of the broken water temperature gauge for the wash cycle.

No Description Available

Tag No.: C0302

Based on record review, policy review, and staff interview, the hospital failed to maintain a complete emergency record of a transferred patient. This affected one patient (#21) of 4 emergency records reviewed. A total of 37 patient records were reviewed. The hospital's active census was 11.

Findings include:

Review of Patient #21's medical record on 01/15/14 revealed the patient arrived in the emergency room on 01/13/14 at 12:56 PM. The triage nurse indicated Patient #21's chief complaint was anxiety and situational crisis. The physician's examination revealed Patient #21 was depressed and had suicidal thoughts. On 01/13/14 at 5:00 PM, the physician indicated the patient was transferred to a behavioral health center's inpatient crisis unit.

Review of Patientt #21's medical record revealed no additional documentation regarding this transfer.

The hospital's policy on "Transfer of Patient to Other Facility" indicated a telephone report was to be given to receiving facility, the inter-hospital transfer form was to be completed and copies of pertinent medical records was to be sent.

On 01/16/14 at 11:20 AM, Staff C confirmed the transfer form was not in the medical record and there was no additional documentation about communication to the receiving facility in the medical record. Staff C revealed Patient #21 came to emergency room after an evaluation was completed at an outpatient behavioral health center. The behavioral health center had Patient #21 come to emergency room for a medical clearance, before he/she was transferred to the inpatient behavioral health center.

On 01/16/14 at 12:00 PM, Staff C indicated he/she called the receiving behavioral health center. The behavioral health center sent a copy of the transfer form completed at the emergency room to the hospital. Staff C indicated the behavioral health center's evaluation was done prior to Patient #21's arrival in the emergency room but was not provided to the physician and nursing staff providing the emergency care for Patient #21. Staff C indicated the hospital was unable to locate the original transfer form for Patient #21.

No Description Available

Tag No.: C0304

Based on record review, policy review, and staff interview, the facility failed to ensure a general informed consent for treatment was obtained for one (Patient #1) of three records reviewed of patients transferring from another facility in a sample of 37 records reviewed. The facility census was 11.

Findings include:

Patient #1's medical record was reviewed on 01/14/14 and revealed an admission date of 01/11/14 with a diagnosis of extension of cerebrovascular accident. Review of the record revealed a "Patient General Consent" without patient or authorized representative signature. The record further contained the Medicare rights information without patient or authorized representative signature.

These findings were confirmed by Staff B on 01/14/14 at 1:20 PM and revealed the patient came from another hospital and failed to go through registration.

An interview with Staff B on 01/14/14 at 1:30 PM revealed Patient #1 was not cognitively able to sign consents, but the son, who was power of attorney, visited twice daily.

An interview on 01/16/14 at 11:30 AM with Staff E revealed Patient #1 was admitted from another facility by ambulance and the emergency transportation did not take the patient through registration. When notified of the admission from nursing the registration staff sent the admission consent forms to the unit and failed to go to the unit to obtain consent from the patient/authorized representative as per facility policy. Staff E further revealed the facility did not have a process to monitor if consents were signed.
Review of the facility's "Consent Policy and Procedure 5.02" revealed patient registration will obtain permission for treatment: a general consent form signed by or on behalf of every patient at the time of admission.

No Description Available

Tag No.: C0306

Based on record review, staff interview, and review of facility Policy and Procedures and Medical Staff Rules and Regulations the facility failed to ensure medical records contained a physician order for an assisted breathing device for one (Patient #10) of three records reviewed with that equipment, and properly authenticated telephone orders for one (Patient # 29) of one record review with telepone orders in a sample of 37 patient records reviewed. The facility census was 11.

Findings include:

1. Review of the medical record for Patient #10 completed on 01/15/14 reveled an admission date of 01/14/14 and diagnoses of influenza and pneumonia. The record revealed a nursing assessment the patient used a home BiPAP ( bi-level positive airway pressure) machine and respiratory therapy notes dated 01/14/14 that the patient was set up with a full face mask BiPAP machine at 9:30 PM. Review of the record failed to reveal a physician order for BiPAP.

An interview with Staff I on 01/16/14 at 8:40 AM revealed the Respiratory therapist went to the unit and set up a hospital BiPAP machine for the patient using the setting self reported by the patient. Staff I further stated the facility policy was to obtain a physician order prior to initiation of any BiPAP therapy and the therapist who set up the machine failed to check for the physician order.

An interview with Staff B on 01/15/14 at 2:00 PM confirmed the above findings.

An interview with Staff A on 01/16/14 at 10:00 AM revealed that physicians would be expected to follow the Medical Staff Rules and Regulations regarding patient visits and that a progress note was the documentation of a visit with the patient.

Review of the facility non-invasive positive pressure ventilation policy and procedure revised on 01/2013 revealed BiPAP use and settings are per physician order only.

2. Medical record review completed on 01/15/14 for Patient #29 revealed an admission and discharge dated of 11/13/13 to 12/02/13 for swing bed status from another facility. Review of the physician admission orders indicated they were given by telephone order on 11/13/13 and authenticated by the physician on 12/04/13. The physician orders revealed additional telephone orders given on 11/13/13, 11/16/13, 11/17/13, 11/18/13 and 11/27/13 which were all authenticated on 12/04/13. In addition the telephone orders sheets were not marked as having been read back to the physician.

An interview with Staff B on 01/15/14 at 2:00 PM confirmed the above findings that the physician authenticated the above verbal orders after the discharge date of the patient.

An interview with Staff A on 01/16/14 at 10:00 AM revealed the authentication of verbal orders should take place as soon as possible.

Review of the facility's "Policy and Procedure for Verbal Orders" on 01/16/14 revealed verbal orders must be written down as received and read back to the physician and be confirmed as correct by the physician at that time. The physician authenticates the order as soon as practicable and reasonable.

No Description Available

Tag No.: C0360

Based on record review, staff interview and review of the Medical Staff Rules and Regulations the facility failed to ensure required bi-weekly physician progress note documentation for one (Patient #29) of four swing bed patient records reviewed. A total of 37 patient records were reviewed. The facility census was 11 patients.

Findings include:

Medical record review completed on 01/15/14 for Patient # 29 revealed an admission and discharge date of 11/13/13 to 12/02/13 for swing bed status from another facility. Review of the physician admission orders indicated the orders were given by telephone order. The record contained a history and physical dated 11/14/13. Review of physician progress notes revealed physician visits from the admitting physician on 11/21/13 and 11/24/13 for a total of two visits in a 20 day day period. The physician orders indicated physician presence on additional days but no progress notes to correspond to those dates.

Interview with Staff A on 1/16/14 at 10:00 AM revealed the expectation was the physician would document progress notes per each visit per the Medical Staff Rules and Regulations.

Review of the facility Medical Staff Rules and Regulations (last reviewed 02/01/13) on 01/16/14 revealed the attending practitioner is responsible to write timely, pertinent progress notes on all inpatient records to include two to three times a week for swing bed patients and as necessary for a change in condition.