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Base on observation and interview, the facility failed to maintain equipment in safe operating condition. Findings include:

During the facility tour on 8/26/2010 between 12:00 PM and 2:00 PM it was observed that the chemical dispensing units are attached to mop sink faucets in housekeeping rooms throughout the hospital. This set-up results in shut off valves being located downstream of the built in atmospheric vacuum breaker (AVB) subjecting the AVB to constant pressure which could cause it to fail prematurely. This set up could also result in hot water leaching into the cold water system and vise versa.

Based on interview, the facility failed was unable to demonstrate that appropriate temperature and humidity levels had been maintained in the Operating Room. Findings include:

During an interview with the facilities manager on 8/26/2010 at approximately 1:30 PM the log for the temperature and humidity in the operating room was requested. The facilities manager stated that the automated building system has the capacity to measure temperature and humidity but a tracking log had not been established. As a result, it is unclear if adequate temperature and humidity levels are maintained in the Operating Room.

Based on documents reviewed and interview the facility failed to ensure policies were reviewed at least annually by the group of professional personnel. Findings include:

During review of the facility's policy and procedures there was no documented evidence of review by the group of professional personnel annually. The findings were confirmed during an interview with the Chief Nursing Officer #1 on 8/28 at 11:00am.

Based on records reviewed the facility failed to ensure before discharge each person was evaluated for proper anesthesia recovery by a qualified practitioner for 2 of 2 patient's receiving surgical services. Findings include:

For MR #'s 5 and 7, there was no documented evidence a post anesthesia assessment that included cardiopulmonary status, level of consciousness, follow up care/observations, or complications noted during recovery had been performed by the CRNA or another qualified practitioner. The findings were confirmed with the Chief Nursing Officer #1 on 8/28 at 1:00pm.

The facility failed to ensure that timely notifications were made to the Organ Procurement Organization (OPO) for three of six patients who died at the hospital and that staff nurses were trained per facility policy. Findings include:

Per the facility's Letter of Agreement with their OPO: "Hospital shall notify...by telephone of any individual whose death is imminent or who had died at the Hospital, regardless of whether Hospital believes individual to be a potential donor."

On 8/28/10 at approximately 1030, death records from 08/09-the present date were reviewed with the Chief Nursing Officer. Patient #13's medical record and facility documents contained documentation of late notification of the OPO. Patient #16 died on 3/30/10 at 2122. Patient # 14 died on 2/4/10 at 0210. Documentation of the time that the OPO was called was not noted in the medical record or other facility documents provided for review.

Per facility policy #600-185, part III, "Organ/Tissue Procurement, "All Nursing Department RN's are required to complete the OPO approved course, "Offering the Option of Donation." On 8/28/10 at approximately 1100, the Chief Nursing Officer (CNO) verified that she was unable to produce documentation that all current facility RN's had training in the facility's organ procurement protocol. The CNO noted that there had been some confusion among nurses regarding whom to call at the OPO and how to document contacts.