HospitalInspections.org

Based on a review of nine open medical records and 10 closed records, it was determined that one record lacked verification that a patient had been informed of her right to appeal her hospital discharge.
Patient no.15 was a 66-year old Medicare recipient admitted to the hospital on January 18, 2012 and discharged on March 5, 2012. No Important Message from Medicare could be found in her medical record.

Based on a review of nine open and 10 closed medical records, it was determined that three closed records contained verbal/telephone orders (VO/TO) that were not authenticated in compliance with this standard.

Patient no. 10 was a 67 year old patient who was in the hospital from February 24 to March 1, 2012. Her physician order sheets contained five VO/TO that were not authenticated by the ordering physician until March 17, 2012.

Patient no. 16 was a 90 year old patient who was in the hospital from February 23 to March 6, 2012. His medical record contained one VO/TO that had not been authenticated as of the time of the review.

Patient no. 17 was a 64 year old patient who was in the hospital from March 5 to March 7, 2012. His medical record contained two VO/TO noted by the RN on March 6, but not authenticated by the physician until March 9, 2012.

Based on the findings of the Life Safety Code survey, it has been determined that the hospital has not maintained the physical plant in accordance with the requirements of the NFPA as evidenced by the deficiencies cited at:

1. K015 - Failure to seal holes and gaps in the ceilings ;
2. K018 - Doors were held open by unapproved hold open devices;
3. K025- Failure to seal holes and penetrations in smoke barrier walls and ceilings;
4. K029 - Failure to maintain strike mechanism on the door in operable condition;
5. K034 - Failure to maintain stairwells free of storage;
6. K038 - Locking mechanism on sterile central supply limited egress;
7. K039 - Failure to maintain corridors used for egress unobstructed and free of storage;
8. K054 - Failure to provide a smoke or heat detector in all corridors where the fire alarm system panels are located;
9. K056 - Failure to have sprinkler systems in certain areas;
10. K062 - Failure to maintain certain sprinkler system components in optimal condition;
11. K069 - Failure to have a properly designed kitchen hood system over cooking surfaces;
12. K076 - Failure to properly store medical gases; and
13. K147 - Failure to maintain various electrical applications.

Based on observation of the main kitchen on April 24, 2012, it was determined that the walk-in refrigeration equipment and food storage shelving was not maintained in good condition.

The findings included:

Observation of the main kitchen on April 24, 2012 revealed that the metal floors of the walk-in refrigeration equipment was rusting and no longer cleanable. In addition, metal wire shelving was found to have its metal coating worn and no longer cleanable.

The condition of the physical plant and the overall hospital environment must be maintained in such a manner that the safety and well-being of patients are assured.