HospitalInspections.org

Based on observation, interviews and review of documents, the hospital failed to meet compliance with the life safety code (LSC) requirements as cited at K-145 during a revisit survey on 8/15/11 that assures the health and safety of all patients and others who may be present in the building when emergency power would be needed.

The cumulative effect of this continued non-compliant deficient practice may prevent the emergency power supply from being available at the time of a power loss resulting in the hospital's inability to ensure the safety of patients and others.

Findings include:

- The hospital failed to meet compliance with the life safety code (LSC) requirements as cited at K-145 during a revisit survey on 8/15/11 that assures the health and safety of all patients and others who may be present in the building when emergency power is needed.

- The hospital failed to provide preventative maintenance to patient room doors and desk surfaces leaving jagged edges that had the potential to injure patients as evidenced at A-701, CFR 482.41(a).

Based on document review and staff interview the hospital failed to include all patient rights required in their Bill of Rights; specifically the right to have a family member or representative notified promptly of his or her admission to the hospital.

Findings include:

- The hospital policy titled "Patient Rights and Responsibilities", reviewed on 8/16/11, stated "...A hospital must inform each patient, or when appropriate, the patient's representative...of the patient's rights, in advance of furnishing or discontinuing patient care..."

The patient rights reviewed on 8/16/11 at 8:00am, failed to include, "inform patients of their right to have a family member or representative of his/her choice and his/her physician notified of their admission to the hospital."

Administrative staff member H interviewed on 8/16/11 at 8:15am acknowledged the hospital failed to inform patients of the right to have a family member or representative notified promptly of his or her admission to the hospital.

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Based on document review and staff interview the hospital failed to include all patient rights required in their Bill of Rights; specifically the patient's right to confidentiality of their clinical records.

Findings include:

- The hospital policy titled "Patient Rights and Responsibilities", reviewed on 8/16/11, stated "...A hospital must inform each patient,or when appropriate, the patient's representative...of the patient's rights, in advance of furnishing or discontinuing patient care..."

The patient rights reviewed on 8/16/11 at 8:00am, failed to include, "the patient's right to confidentiality of their clinical records.

Administrative staff member H interviewed on 8/16/11 at 8:15am acknowledged the hospital failed to inform patients of the right to confidentiality of their clinical records.
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Based on document review and staff interview the hospital failed to include all patient rights required in their Bill of Rights; specifically the right to access information contained in their medical record within a reasonable time frame.

Findings include:

- The hospital policy titled "Patient Rights and Responsibilities", reviewed on 8/16/11, stated "...A hospital must inform each patient,or when appropriate, the patient's representative...of the patient's rights, in advance of furnishing or discontinuing patient care..."

The patient rights reviewed on 8/16/11 at 8:00am, failed to include, "inform patients of the right to access information contained in his/her clinical records within a reasonable time frame."

Administrative staff member H interviewed on 8/16/11 at 8:15am acknowledged the hospital failed to inform patients of the right to access information contained in their medical record within a reasonable time frame.

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Based on observation, staff interview, and document review the hospital failed to repair damaged doors throughout the hospital for the safety of all patients in 10 of 38 inpatient rooms with doors (Room #'s 5, 6, 7, 202, 205, 207, 208, 211, 317 and 318), 7 of 10 outpatient room doors, and damaged desk surface for 1 of 4 nurses desk.

Findings include:

- The nurses station desk located at the hospital outpatient area observed on 8/15/11 at 3:15pm contained greater than 30 areas of exposed wood which measured between 4 inches high by 3 inches wide to 1 inch long by 1/2 inch wide. This desk also contained an area on the bottom outside (at the foot level of patients) an area of missing Formica with chipped an splintery exposed wood 6 inches wide by 6 inches high.

- The hospital's "Work Order Details Report", dated 12/31/09, reviewed on 8/18/11 at 10:00am directed plant operations staff to conduct preventative maintenance "...check door finish-i.e.. scratches and dents..."

- Observation on the Medical/Surgical Unit on 8/15/11 at approximately 2:45pm am revealed patient room #'s 202, 205, 207, 208, and 211 with wood entryway doors chipped with jagged edges.

Staff A interviewed on 8/15/11 at approximately 2:45pm acknowledged the chipped doors edges on the entryway doors to rooms 202, 205, 207, 208, and 211 and the potential for a patient to be injured by the jagged edges.

- Observation in the Intensive Care Unit on 8/15/11 at 2:35pm am revealed patient room #'s 5, 6, and 7 with wood entryway doors chipped with jagged edges.

Staff G interviewed on 8/15/11 at 2:35pm acknowledged the chipped doors edges on the entry way doors to rooms 5, 6, and 7 and the potential for a patient to be injured by the jagged edges.

- Observation on the Women's Center on 8/18/11 at 12:00pm revealed patient room #'s 317 and 318 with wood entryway doors chipped with jagged edges.

Staff F interviewed on 8/18/11 at approximately 12:00pm acknowledged the chipped door edges on the entryway doors to rooms 317 and 318 and the potential for a patient to be injured by the jagged edges.

- Observation in the Outpatient area on 8/18/11 at 12:05pm revealed patient room #'s 3, 3404, 3412, 3418, 3422, 3423, and 3425 with wood doors chipped with jagged edges.

Staff F interviewed on 8/18/11 at approximately 12:05pm acknowledged the chipped doors edges on the entryway doors to rooms 3, 3404, 3412, 3418, 3422, 3423, and 3425 and the potential for a patient to be injured by the jagged edges.

Based on observations, staff interview and review of manufacturer's instructions, the hospital's infection control officer failed to ensure hospital personnel followed basic infection control practices for 1 of 1 observed cleaning of the operating room.

Findings include:

Review of the manufacturer's guidelines for "Virex 256" disinfectant cleaner instructed staff to allow surfaces to remain wet for 10 minutes to assure disinfection.

- Staff B observed on 8/16/11 between 11:55am and 1:50pm cleaning operating room #3 revealed the following breeches in infection control. Staff B using "Virex 256" cleaning solution, wet wiped the patient table, over head lights, suction cart, IV pole, cardiac monitor, anesthesia machine, anesthesia supply cart, preparation cart, silver cabinet, cautery machine (a machine used to stop bleeding with electrical current), and a patient warming machine. These areas remained wet for a contact time between two to eight minutes not the required 10 minutes for total disinfection. Staff B at 1:45pm using a floor-cleaning machine with "Virex 256" cleaned the operating room floor. The floor-cleaning machine suctioned up the "Virex 256" immediately after application not the required 10 minutes for total disinfection.

Staff B and staff C interviewed on 8/16/11 at 1:50pm acknowledged the "Virex 256" cleaner required a contact time of 10 minutes to achieve disinfection and the surfaces on the equipment in the operating room failed to remain wet for the 10 minutes required for disinfection.

Administrative staff D interviewed on 8/17/11 at 2:30pm acknowledged the hospital failed to have a policy directing staff on how to clean and disinfect the operating room after each use.

Staff E interviewed on 8/18/11 at 8:05am acknowledged the hospital's monitoring tool for cleaning of room lacked the contact time of the facility approved cleaning products to assure disinfection.