HospitalInspections.org

Based on observation and interview with staff it was confirmed that the facility failed to maintain the safety of patients by failing to ensure the access to departments are locked and secured during and after regular business hours.

Findings include:

During tour of the facility's departments with staff members on 5/2/12 and 5/3/12 it was found that there were multiple departments that were accessible during all hours of the day and night with no protection for patient and staff safety. These areas are as follows:

1) Obstetrics was toured with Staff A (Unit Manager) on 5/2/12 during which time it was confirmed that several doors onto the unit were not secure and were able to be entered with no notification to the staff. On 5/3/12 Staff B (Director of Engineering and Security) toured the unit and confirmed the finding made on 5/2/12 calling the doors not secured and unable to protect the safety of patents and staff, these doors are as follows, "OB rear door, OB staff door, OB main door" these door were confirmed through observation and interview with Staff A (Unit Manager) on 5/3/12 being doors that have direct access with no security.

Also on 5/3/12 it was found through interview with Staff A that the security bands that are placed on the new borns failed to have band sensors on them so if the band was cut it does not alarm failing to protect the safety of new born's.

2) Radiology department was toured with Staff C (Director of Radiology) on 5/2/12 during which time it was confirmed that several doors onto the unit were not secure and able to be entered with no notification to the staff. On 5/3/12 Staff B toured the unit and confirmed through interview and observation that the finding made on 5/2/12 are doors that are not secured and unable to protect the safety of patents and staff, these doors are as follows "fire door 36, fire door 06, double doors located by ultra sound, radiology changing room, and radiology outside double doors by ultra sound", these door were confirmed with Staff C on 5/3/12 as being doors that have direct access with no security.

3) Emergency department was toured with Staff D (Emergency Department Manager) on 5/2/12 during which time it was confirmed that several doors onto the unit were not secure and able to be entered with no notification to the staff . On 5/3/12 Staff B toured the unit and confirmed through interview and observation that the finding made on 5/2/12 are doors that are not secured and unable to protect the safety of patents and staff, these doors are as follows "Two sets of double doors entering the department from the existing hospital" these doors were confirmed through observation with Staff D on 5/3/12 as being doors that have direct access with no security.

Based on observation and interview the facility failed to secure the materiel's management area that stores needles and syringes from unauthorized personnel.

Findings include:

Observation on tour of the kitchen on 5/1/12 at 9:30 am revealed a corridor on the backside of the kitchen with two separate sectioned off areas one on each side of the kitchen corridor. Each storage area was surrounded by wire fencing and had the ability to be locked. The storage areas were unlocked and needles and syringes were stored in this area and accessible to unauthorized personnel.

Interview on 5/3/12 at 1 p.m. of Staff B, (Director of Engineering and Security), and Staff E, (Director Materiel's Management), confirmed the area was unlocked during the day and is accessible to unauthorized personnel.

Based on record review and interview the facility failed to show documented evidence of informed consent for treatment in the Emergency Department for 3 of 10 Emergency room patients in a standard survey sample of 30. (Resident identifiers are # 3, #4, and #6).

Findings include:

Review of emergency room patient records on 5/3/12 in the a.m. revealed patient records for Resident #3, Resident #4, and Resident #6 did not have written documentation of informed consent for treatment in the Emergency Department.

Interview of Staff F, (Chief Nursing Officer), on 5/3/12 at 1 p.m. confirmed that the patient records for Resident #3, Resident #4, and Resident #6 did not have written documentation of informed consent for treatment in the Emergency Department.