HospitalInspections.org

West Virginia Licensure Rule CSR 64-12-5

5.1.b.1 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The relevant sections of the 2001 edition of The Guidelines for Design and Construction of Hospitals and Health Care Facilities as recognized by the American Institute of Architects Academy of Architecture for Health with assistance from the United States Department of Health and Human Resources shall be used as planning standards;

5.1.b.2 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The National Fire Protection Association codes and standards relevant to Health Care Facilities including the National Electric Code and the 2002 Edition of N.F.P.A. 99 Standard for Health Care Facilities;

5.4.a Additions and renovations or alterations of any hospital which are begun after the effective date of this rule shall comply with the General and Psychiatric Hospital sections, as applicable, of the latest edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities.

5.4.d The hospital shall submit to the Director for review, complete construction drawings and specifications for any hospital construction project which alters a floor plan, impacts life safety or requires approval under W. Va. Code §16-2D-1 et seq. prior to beginning work on the project. An architect and/or engineer registered to practice in West Virginia, shall prepare and sign the drawings and specifications including architectural, life safety, structural, mechanical and electrical drawings and specifications. Minor renovations which alter floor plans may not require the services of an architect and a full set of drawings. However, an actual as built drawing is required for the specific area to be renovated. The approval of minor renovations shall be determined by the Secretary.

This Standard is not Met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to met all standards for licensing established by The Office of Health Facility Licensure and Certification (OHFLAC) for the state of West Virginia and in accordance with (West Virginia Licensure Rule CSR 64-12-5, 5.1.b.1, 5.1.b.2, 5.4.a, and 5.4.d ) for renovations and additions to the hospital. This failure has the potential to adversely affect the care of all patients treated in the renovated rooms.

Findings include:

1. During tour of the hospital on 06/28/11 at approximately 10:00 a.m., the following renovation and alteration of the hospital's original building construction was observed:

a. Hospital patient rooms 10 and 11 were converted into endoscopy procedure rooms. Also, these rooms were used for scope reprocessing. An interview with the plant operations director on this same date at approximately 10:30 a.m. revealed that the renovations of these rooms were performed by plant operations staff. Also, this interview revealed there was no documentation available to indicate that construction renovation plans were submitted to the OHFLAC for approval. Therefore, the renovation of these two (2) rooms for endoscopy services has not been approved by the authority having jurisdiction (OHFLAC).

Based on observation, staff interview and documentation review during the survey conducted 06/27/11 to 06/29/11, it was determined the hospital failed to maintain the environment and all equipment to ensure the safety of the patients, staff and public. This determination was based on the volume of life safety code deficiencies issued to the hospital for non-compliance with the 2000 edition of the life safety code and deficiencies generated related to maintaining the physical environment, Therefore, this Condition is not met. Refer to physical environment deficiencies identified as tag numbers C153, C221, C222 and C223. Also, life safety code deficiencies identified as tag numbers K018, K038, K062, K069 and K077.

Based on observation it was determined the hospital failed to maintain the physical plant in a manner to protect patients that are transported to the magnetic resonance imaging (MRI) trailer unit during inclement weather.

Findings include:

1. On 06/28/11 at approximately 9:00 a.m., an MRI trailer was observed located near the front of the hospital. At this time, there was no sheltered access route to protect patients from the elements of weather during transport.

Based on observation and documentation review it was determined the hospital failed to provide a preventative maintenance program that ensured all patient care equipment is maintained in safe operating condition.

Findings include:

1. On 06/29/11 at approximately 10:00 a.m., a tour of the hospital emergency room was conducted. At this time, a mobile blood pressure machine ( Biomed 37541) was observed to have a safety inspection sticker dated 05/13/08. Review of the facility preventative maintenance equipment log on this same date at approximately 11:00 a.m. showed no evidence that this piece of equipment had a preventative maintenance safety check during the previous twelve (12) month period.

Based on observation it was determined the hospital failed to store all biohazardous medical waste in a secure location.

Findings include:

1. On 06/29/11 at approximately 10:00 a.m., an inspection of the soiled utility room located on the patient care unit was conducted. At this time, biohazardous medical waste storage was observed in this unsecured room. Biohazardous medical waste storage must be in a secure location with access by only trained authorized personnel.

Based on document review and staff interview, it was determined the CAH failed to develop numerous department/service policies with the advice of a group of professional personnel. This has the potential to adversely affect patient care.

Findings include:

1. A review of the following policies revealed none had been developed/reviewed by a group of professional personnel: Housekeeping, Infection Control for Housekeeping, Nursing, Emergency Department, Medical Records, Swing Bed, Laboratory, Dietary, Radiology, Surgical Services and Pharmacy.

2. The Chief Clinical Officer and the Emergency Department/Surgery Director were jointly interviewed in the afternoon of 6/29/11. Both agreed the policies for the departments/services listed above have not been developed/reviewed by a group of professional personnel.

Based on document review and staff interview, it was determined the CAH failed to review annually numerous department/service policies by the group of professional personnel. This has the potential to adversely affect patient care.

Findings include:

1. A review of the following policies revealed some have been reviewed in 2011 and some in previous years (however, none have been annually reviewed by the group of professional personnel): Housekeeping, Infection Control for Housekeeping, Nursing; Emergency Department, Medical Records, Swing Bed, Laboratory, Dietary, Radiology, Surgical Services and Pharmacy.

2. The Chief Clinical Officer and the Emergency Department/Surgery Director were jointly interviewed in the afternoon of 6/29/11. Both agreed all of the policies for the departments/services listed above have not been reviewed by the group of professional personnel.

Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff follows Medical Staff By-Laws & Rules and Regulations by not completing the required history and physical assessments (H&P) in two (2) of two (2) open swing bed medical records (Patient #12 and 13) reviewed. This has the potential to negatively impact all patient care by not providing required information for continuity of care.

Findings include:

1. Boone Memorial Hospital (BMH) Medical Staff By-Laws & Rules and Regulations, last revised 2/2011, page 35, state in part "...2. A complete admission history and physical examination (H&P) shall be completed and entered into the Medical Record within 24 hours of admission...If a complete H&P has been performed and recorded within thirty (30) days prior to the patient's admission to the hospital, a reasonably durable, legible copy of these reports may be used in the patient's hospital medical record provided any changes that may have occurred are recorded in the Medical Record at the time of admission and these reports were recorded by a member of the Medical Staff. In such instances, an interval admission note that includes all additions to the H&P must always be recorded..."

2. Review of the medical record for Patient #12 revealed the patient was admitted to the facility 6/7/11 from a tertiary care facility for swing bed services. There was no documented evidence of an H&P performed by a member of BMH medical staff on the medical record.

3. Review of the medical record for Patient #13 revealed the patient was admitted to the facility 6/25/11 from a tertiary care facility for swing bed services. There was no documented evidence of an H&P performed by a member of BMH medical staff on the medical record.

4. During an interview with the Charge Nurse (CN) in the morning of 6/29/11, the medical records were reviewed and the CN agreed with the findings.

5. During a telephone interview with the Director of Medical Records (DMR) in the morning of 6/29/11, the DMR stated the facility always uses the Discharge Summary and H&P from the referring facility if the patient was a direct admit for swing bed services.

Based on medical record review and staff interview, the hospital failed to ensure the nursing staff appropriately notes-off the hand-written physician orders in two (2) of two (2) open swing bed medical records (Patients #12 and 13) reviewed. This has the potential to negatively impact all patient care by not providing an accurate timeline of when orders were received and care provided.

Findings include:

1. Review of the medical record for Patient #12 revealed admission orders written on 6/7/11 with a Registered Nurse's signature in the middle of the page and a time of 1845, with no date. Unable to determine what the signature and time is for.

2. Written orders on 6/9/11 at 1900 were noted-off without a date or time.

3. Telephone orders on 6/8/11 written by the nurse without a time, then noted-off without a date or time.

4. Written orders on 6/9/11 were noted-off without a date.

5. Verbal orders on 6/9/11 at 1340 with no documented evidence of being noted-off by a nurse.

6. Occupational Therapy orders on 6/9/11 at 1600 were noted-off without a date or time.

7. Telephone orders written on 6/11/11 without a time and noted-off without a date or time.

8. Telephone orders written on 6/17/11 without a time.

9. Verbal orders written on 6/25/11 at 1254 were noted-off without a date or time.

10. Telephone orders written on 6/25/11 at 1600 were noted-off without a date or time.

11. Verbal orders written on 6/26/11 at 1600 were noted-off without a date or time.

12. Review of the medical record for Patient #13 revealed written orders on 6/27/11 at 1840 were noted-off without a time.

13. During an interview with the Charge Nurse (CN) in the morning of 6/29/11, the medical records were reviewed and the CN agreed with the above findings.

A. Based on observations, document review and staff interview, the hospital failed to maintain adequate facilities for decontaminating and cleaning endoscopic procedure scopes and also failed to ensure the operating room staff followed the cleaning solution manufacturer's recommendations regarding instructions for use. This has the potential to negatively impact all endoscopic surgical patient care by causing hospital acquired infections due to inadequately cleaned equipment.

Findings include:

1. During a tour of Boone Memorial Hospital's (BMH) two (2) endoscopic procedure rooms (rooms 10 and 11) in the afternoon of 6/27/11, it was determined the staff are cleaning, decontaminating, drying and storing the endoscopes in the procedure rooms. The scopes are stored in a metal cabinet in the individual rooms. The cabinets are metal with chipping paint and not very clean. During this tour, the Surgery Director (SD) stated the hospital had converted two (2) patient rooms into these procedure rooms.

2. During observations in the morning of 6/28/11, the surveyor observed an endoscope soaking in the disinfecting solution, an endoscope lying on a towel on the counter drying, while a patient was being taken into the same procedure room for an endoscopy.

3. BMH uses CIDEX OPA Solution for disinfecting endoscopes. CIDEX OPA instructions for use state in part "...CIDEX OPA Solution is a high level disinfectant for reprocessing heat sensitive medical devices, for which sterilization is not suitable, and when used according to the Directions for Use. Manual Processing: High Level Disinfectant at a minimum of 68 degrees F (Farenheit). CIDEX OPA Solution is a high level disinfectant when used or reused, according to the Directions for Use, at or above its Minimum Effective Concentration (MEC) as determined by CIDEX OPA Solution Test Strips..."

4. The log being kept regarding changing of the CIDEX OPA and whether the solution MEC passed or failed was up-to-date, however, there was no documented evidence of the temperature of the solution being monitored per the manufacturer's directions for use. During an interview with the SD and surgery tech during the tour in the afternoon of 6/27/11, both stated no knowledge of the requirement to monitor the temperature of the solution.


B. Based on observation and staff interview, the hospital failed to ensure the staff maintained a clean environment in the surgery/recovery area. This has the potential to negatively impact all surgical patients by placing them at high risk for infection.

Findings include:

1. BMH has a surgery/recovery area that is sometimes used as a procedure room and sometimes used as recovery room. This room houses the patient carts/beds used to transport the patients to and from the endoscopy procedure rooms. The endoscopy is also performed while the patient remains on this same cart/bed.

2. During a tour of the surgery/recovery room in the afternoon of 6/27/11, upon entering the surgery/recovery room the surveyors found thick layers of dust and dirt on all high areas and low areas, multiple papers taped to the walls, privacy curtains hanging between the patient beds, the bottom of the patient carts were covered with black dirt and dust. During this tour, the SD and surgery tech were notified of the adhesive on the walls and dust and dirt. Housekeeping was notified to clean.

3. During observations of the surgery/recovery room in the afternoon of 6/28/11, it was noted the adhesive had been removed from the walls and the ceiling light had been cleaned; however, the thick layers of dust and dirt remained on the rest of the high and low areas and the patient carts were still filthy.

4. During these observations, the SD and housekeeping director were both interviewed with examples shown of the dirt and they agreed with the findings.



C. Based on document review, medical record review and staff interview, the hospital failed to ensure the medical staff completes a History and Physical (H&P) in two (2) of two (2) surgery patient medical records (Patient #1, 2) reviewed. This has the potential to negatively impact all surgical patient care by not providing adequate information for continuity of care.

Findings include:

1. Boone Memorial Hospital (BMH) Medical Staff By-Laws & Rules and Regulations, last revised 2/2011, page 35, state in part "...3. When H&P's are not recorded before and operation or any potentially hazardous diagnostic procedure, the procedure shall be cancelled, unless the attending practitioner states in writing that such delay would be detrimental to the patient..."

2. Review of the medical record for Patient #1 revealed the patient underwent a surgical procedure with no documented evidence of a H&P.

3. Review of the medical record for Patient #2 revealed the patient underwent a surgical procedure with no documented evidence of a H&P.

4. During an interview with the SD in the afternoon of 6/28/11 the medical records were reviewed and the SD agreed with the above findings.


D. Based on medical record review and staff interview, the hospital failed to ensure the medical staff obtains a proper informed consent prior to surgical procedures in two (2) of two (2) surgery medical records reviewed. This has the potential to negatively impact all patient care by patients not having full understanding of what he/she is consenting.

Findings include:

1. Review of the medical record for Patient #1 revealed the patient signed a surgical consent with no documented evidence the responsible physician obtained the consent.

2. Review of the medical record for Patient #2 revealed the patient signed a surgical consent with no documented evidence the responsible physician obtained the consent.

3. During an interview with the SD in the afternoon of 6/28/11, the medical records were reviewed and the SD agreed with the findings.