HospitalInspections.org

Based on findings from document review and interview, as of the date of this survey, an analysis of data collected from adverse occurrence reports for the 3rd and 4th quarters of 2013 had not been provided to the hospital-wide quality assessment performance improvement (QAPI) committee.Findings include:
-- Minutes reviewed for the September 2013 meeting of the hospital-wide QAPI committee, called Quality Operations I, contained a report of an analysis of the adverse occurrence reports filed by hospital staff during the 2nd quarter of 2013. Minutes reviewed for subsequent meetings of the Quality Operations I committee to date lacked any further reports of analyses of adverse occurrence reports. -- During interview with the Director of Performance Improvement at 2:30 pm on 4/16/14, he/she confirmed that reports of analyses of the 3rd and 4th quarter collections of adverse occurrence reports should have already been provided to the Quality Operations I committee but were not.

Based on findings from observation and staff interview, the hospital's medical records (MRs) that were waiting to be scanned into the electronic medical record system and then destroyed were not stored in a secure area.

Findings include:

-- Tour of the basement of the hospital's "Old CPEP" building on 4/14/14 at 3:45 pm with the Operations Manager revealed a locked room which contained multiple boxes of MRs waiting to be scanned. Also observed were multiple paint cans and supplies. When queried the Operations Manager indicated the room was shared with the "facilities staff."

-- Per interview with the Director of Facilities Services on 4/15/14 at 2:00 pm, the MRs stored in the basement are to be destroyed but the area is currently accessible to Facility Services staff and is used as a locksmith shop.

Based on findings from observation and interview, three sprinkler heads in corridor G-2 of the hospital were not installed in accordance with NFPA 13 (1999) as referenced in NFPA 101 (2000).

Findings include:

--Per observation on 4/15/14 at 9:22 am, three sprinklers in corridor G-2 were installed 2-3 inches above piping that traversed the entire corridor. NFPA 13 states there are to be no obstructions within 12 inches below the sprinkler head deflector.

--The Director of Facilities Services who was present at the time the above observations were made indicated he/she concurred with this finding and that the sprinkler heads would be relocated.

Based on findings from observation and interview, the wardrobe units in the psychiatric unit were not constructed in a manner that would prevent a patient from self-harm.

Findings include:

--Per observation on 4/14/14 at 10:55 am, the wardrobe in room 3609 of the psychiatric unit was bolted to the wall while the doors were connected to the sides of the wardrobe using piano hinges. As presented in the Office of Mental Health document titled "Patient Safety Standards, Materials and System Guidelines" (1/31/14), wardrobes with doors will pose a potential ligature risk.

-- During interview on 4/14/14 at 10:55 am, the Director of Facilities Services indicated that the closets in other rooms of the unit were similar to those of room 3609 (i.e., they were bolted to the wall), and agreed that they represented a ligature hazard. He/She also stated that the wardrobe units were identified as a risk to patients based on a recent risk assessment conducted by the Hospital and they were going to be replaced.

Based on findings from document review and interview, in 1 of 10 medical records (MRs) reviewed (Patient A), the hospital failed to ensure that the discharge planning evaluation performed for the patient included assessments of his abilities to perform activities of daily living (ADLs) and to obtain medications ordered after discharge.

Findings include:

--Per review of Patient A's MR, he was admitted to the hospital on 03/11/14 with swelling of the lower extremity. He had undergone below the knee amputation in 02/2014 and was admitted from a skilled nursing facility (SNF) where he had been undergoing rehabilitation.

On 3/12/14, Case Manager (CM) #1 documented the following: The durable medical equipment used by the patient included a commode, walker and electric wheelchair; the SNF was notified of the patient's admission but he did not have a "bed hold" as the facility declined to accept him back. Patient A reported that he had not been participating in therapy at the SNF and social work services at the facility were attempting to assist him with finding a place to live.

On 3/14/14, CM #1 documented that arrangements were made to obtain the patient's belongings and wheelchair from the SNF and bring them to the hospital.

On 3/14/14, Social Worker (SW) #1 documented that the patient was not a candidate for rehabilitation and did not presently require long term care placement, and that the patient was informed that unless he had a friend or family member willing to let him stay with them, he would be discharged to the Civic Center to be processed for the shelter system.

On 3/17/14, CM #1 documented that the patient had met with SW #1 the previous week to discuss options regarding where he would go upon discharge and that the patient stated he would be going to the Civic Center to find assistance with temporary living arrangements until permanent residence could be obtained.

Patient A was discharged to the Civic Center on 3/17/14 via medical transport and wheelchair.

There is no documentation that the evaluation of the patient's discharge planning needs included an assessment of the patient's ability to perform ADLs and how the patient, once discharged to the Civic Center, would obtain medications ordered for him after discharge.

--During interview on 4/17/14 at 12:45 pm, CM #1 acknowledged the findings above.

Based on findings from document review and interview, 4 of 13 surgical patient medical records (MRs) reviewed (Patients B, C, D, E), each lacked a review and update to the history and physical (H & P) that had been completed within the 30 days prior to the procedure.

Findings include:

--Per MR review, Patient B had a surgical procedure done on 3/26/14. The MR lacked documentation that the H & P dated 3/21/14 was reviewed and updated within 24 hours prior to the procedure

Per MR review, Patient C had a surgical procedure done on 4/15/14. The MR lacked documentation that the H & P was reviewed and updated within 24 hours prior to the procedure

Per MR review, Patient D had a surgical procedure done on 4/14/14. The MR lacked documentation that the H & P dated 4/9/14 was reviewed and updated within 24 hours prior to the procedure

Per MR review, Patient E had a surgical procedure done on 4/10/14. The MR lacked documentation that the H & P dated 4/7/14 was reviewed and updated within 24 hours prior to the procedure

--The above findings were acknowledged on 4/16/14 at 4:00 pm during the survey exit conference.