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Based on medical record reviews and staff interviews, it was determined the facility failed to ensure that the staff followed physician's orders for chemical restraint in 1 of 33 medical records reviewed. This was found in medical record #2.

Findings include:

Nurses failed to follow physicians' orders in administering Propofol to restrict a patient's behavior. MR #2 is a fifty-nine year old patient who was admitted to the facility on 1/31/12 with complaints of shortness of breath, generalized weakness and poor appetite with a productive cough since 1/10/12. The patient's previous medical history was significant for Hypertension, Anxiety, Depression, Chronic Back Pain, GERD, Hepatitis C, Osteoporosis and Asthma/COPD. Upon arrival at 10:45 AM the patient's vital signs were temperature 98.7 F, pulse 112, respiration 20 and B/P 102/52. Oxygen saturation was 86% on room air and the patient had back pain scored at 7/10. The patient's weight was 72 lbs with a height of 5 feet.

The patient was intubated on 2/1/12 at 4:15 PM and placed on a ventilator for respiratory failure. The patient was placed on Morphine 4 mg IV every hour as needed, "Versed 2 mg PRN for agitation and Propofol infusion 1000 mg/100 ml to start at 5mcg/kg/min" for sedation and to restrict the patient's movement. The order stated that Propofol must be administered to achieve a Ramsey score of 3. The orders were written on 2/1/12 at
5:50 PM. The patient was also hypotensive requiring the using of Dopamine IV and she had developed Acute Renal Failure.

According to the nurse's notes, the patient was sedated at Ramsey score "3-4" on 2/1/12 from 8:00 PM - 5:00 AM on 2/2/12. There was no assessment of the Ramsey clinical score from 6:00 AM that day, (2/2/12) through 7:00 AM on 2/4/12. There was only 1 assessment at 8:00 AM on 2/4/12 which showed the score was 4 and no further documentation up to 7:00PM on 2/5/12. From 8:00 PM on 2/6/12 through 7:00 PM on 2/7/12 the Ramsey score was 4. Therefore, the patient's sedation score of 3 was only achieved between 8:00PM on 2/5/12 - 6:00 AM on 2/6/12 and from 8:00 PM on 2/7/12 - 6:00 AM on 2/8/12. Physical (bilateral ) wrists restraints were used during this interval. On 2/7/12 at 8:00 AM the patient opened her eyes to stimulus but the degree or type of stimulus was not documented in the medical record. During the tour of the unit on 2/7/12 at 11:30AM the patient remained sedated at Ramsey 4 with both wrists in physical restrains. Severe (3+ - 4+) edema of both hands was noted at this point. The observation was brought to the attention of the staff on 2/7/12 at approximately 12:00 noon.

During an interview conducted on 2/8/12 at 10:30 AM, the Director of ICU/Telemetry acknowledged the nurse's failure to consistently document the patient's Ramsey score and the nurse's failure to maintain the score at 3. She stated that hourly assessments and documentation of the Ramsey clinical score is required as ordered by the physician and per facility policy. She also stated that the nurses who failed to document the scores were interviewed regarding the findings. Two of the nurses acknowledged the deficient practice. A third nurse stated that the single assessment at 8:00 AM on 2/4/12 with no subsequent documented assessment means there was no change in the patient's Ramsey score of 4 as noted at 8:00 AM that day.

Based on document review, staff interview and observations, the facility did not ensure that hospital was kept in good repair and safe from harm for staff and patients.

Findings include:

1. During observation on 02/08/12 to 02/09/12 between 10:30 AM to 3:45 PM, it was noted that the perimeters and corners of various rooms/floors of the building were dusty and dirty. Examples including but not limited to the following area:

i. Med/Surg room #316, #318, #308 and others had dust and dirt along the perimeters and corners of the room.
ii. Mental Health unit room #202, #214 and others had dust and dirt along the perimeters and corners of the room.
iii. The ICU room #455 had dust and dirt behind the lift system beams.

Furthermore, the above patient care areas also had doors that were in disrepair with splinters, along with the vinyl base covering coming off from the wall to reveal the structure beneath.

2. During observations on 02/16/12 to 02/17/12 between 10:30 AM to 3:45 PM, it was noted that the exhaust ventilation vents and air-conditioning units/heaters in different areas of the facility were very dirty with accumulation of dust and dirt, which leads to environmental contamination. Examples include, but are not limited to:

i. The exhaust vents in the Nursery of Maternity suite.
ii. The exhaust vents in patient room #316, #318 and #308.
iii. The pediatric room/isolation room in the Emergency Department was dirty and dusty as well as the exhaust vent.
iv. The exhaust vent of the Soiled Utilty room in the Mental Health unit was dirty and dusty.

Furthermore in the Mental Health unit, many air-conditioning units/heaters had the filter coming off from the unit on the floor.

3. During the tour of the Operating Rooms on 02/09/12 at 2:30 PM, the following observations were noted:

i. The door of OR #2 did not latch positively /or the door did not completely shut to ensure positive air pressure and prevent cross-contamination from the corridor.
ii. The linen that was on the operating table of OR #2 was noted to be dusty.
iii. The operating table in OR #1 was very dusty and had an abundant amount of tape stuck on it.

4. On 02/09/12 at 12:30 PM during tour of the ED in the Ortho ED room the Cast Cutter was extremely dirty and dusty.

5. On 02/08/12 at 3:30 PM, during the survey of the Maternity unit on the fourth floor, it was noted that when a nurse call bell was tested from a patient room, it did not register in the medication room, clean utility room, soiled utility room and other areas as required by AIA 7.32.G1. The findings were verified with Staff #15 at the time of observation. Furthermore one Soiled Utility room near the Labor & Deliver Bed #2 did not have a duty station/console installed in the room.

6. On 02/09/12 at 1:00 PM during the tour of the Mental Health Unit, it was noted that:

i. The Day room had unsupervised board games stored on top of the table. These board games have small pieces that may cause a choking/suicidal hazard for patients.
ii. The public pay phones installed in the corridor had long cords to the receiver. These long cords may pose a risk of strangulation/harm to the patient or to the staff from an agitated patient.
iii. The shower room opposite the Social Worker office had shower hardware that may possess a looping hazard.

A. Based on observations during survey of the Main Hospital, it was noted that structural components of the facility were not properly protected from fire. Structural steel/steel beams located above the non-fire rated ceiling assembly were not protected to meet requirements for minimum fire rated building construction of Type II 222.

Findings include:

During the survey from 02/08/12 to 02/09/12 between 11:00 AM to 4:00 PM the following observations were made:
1. Multiple areas of structural beams in different parts of the facility were void of proper fire retardant material. For example:

a. The structural beam in the Machine room of the Maternity Unit was missing fire retardant material/spray at two to three places.
b. The structural beam in the room/space behind the sterilizers in the clean sterilization room had multiple places devoid/missing of fire retardant spray/material
c. The main Soiled Linen holding room had areas on the structural beam missing fire retardant spray/material.

Findings were verified with Staff #12 during the tour.

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1


B. Based on observation, the facility failed to keep the Emergency Exit in the Mental Health Department and the corridor serving as an exit access in the Surgical Suite, at least 4 feet wide that was clear and unobstructed.

Findings include:

1. On 02/09/12 at 12:45 PM, during the tour of the Mental Health Department it was noted that the emergency Exit of the Unit was noted blocked by multiple boxes and a steel cabinet.

2. On 02/09/12 at 2:30 PM, during the tor of the Surgical suite it was noted that the egress route by the ORs was not kept clear at a minimum of 4 feet and had abundant amount of equipment stored in the passageway. The requirement of NFPA 101 is " Width of aisles or corridors (clear and unobstructed) serving as exit access is at least 4 feet. Section 19.2.3.3 "

C. Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

1. On 02/09/12 at 3:15 PM, during document review it was noted that the Medical Gas report dated 12/23/11 had deficiencies. Staff #16 did not have any follow-up to those deficiencies.

2. Furthermore, the O2 delivery pressure reading in the maternity suite was 48 PSI. It should be noted that as per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery, is 50 PSI (+5/-0).

Based on observation, staff interview and document review, facility did not ensure that the chemical dispensers in the house keeping closets were maintained for proper function and operation and did not have any mechanism in place to ensure their preventive maintenance were conducted in a timely manner.

Findings include:

1. A tour of the hospital was made on 02/08/12 and 02/09/12 between 11:30AM to 3:00 PM. The following was noted:

i. The J-Fill system in the housekeeping closet on the 3rd floor dedicated for Med/Surg was operational with the chemicals coming out the colors as explained by Staff #13. Staff #17 stated that recently the dispenser was not working for few days and was fixed. Staff #15 was asked to provide the recent report of the repair that was made in-house.

ii. The J-Fill system in the housekeeping closet on the 4th floor dedicated for New Directions was not operational and was tagged as out of service. As per Staff #16 she went to the other department on the 4th floor for chemicals to clean her department. The other J-fill system near the ICU was operational as the chemicals were coming out with the color and smell as indicated by Staff #13. However, Staff #13 was not aware if any action on the non-working J-fill system was taken.

iii. The J-Fill system in the housekeeping closet on the 4th floor dedicated for the Maternity unit was found non-operational. The chemicals that were dispensed from this J-Fill system did not have any color (they were clear) and no smell/fragrance.

As per Staff #20 this J-Fill system was not operational and was producing a clear fluid for the last one to two years. Staff #13 and Staff #14 stated that they were not aware that the J-Fill system was not functioning. Furthermore, Staff #14 did not see a J-fill vendor in the facility for the past year to do any preventive maintenance. Staff #20 stated that she could not use this J-fill system which was dedicated for the Maternity suite. She had to go to other floors to obtain chemicals because the cart cannot leave the Maternity suite. The chemicals observed in her bucket did not have any color or smell.

iv. The J-Fill system in the housekeeping closet on the 2nd floor dedicated for Mental Health was found to be non-operational since the chemicals coming out were not as per the colors and fragrance as explained by Staff #13.

2. Staff #13 further stated that the J-Fill systems in the housekeeping closets are on quarterly maintenance by the vendor and she was also under the impression that the facility takes care of repairs. Staff #13 was asked to provide the inventory of all the J-fill system installed in the facility and their quarterly maintenance report to indicate that they are all current with their inspection and preventive maintenance. Staff #15 was also asked to provide the past year's repair reports on the J-Fill systems.

3. Staff #13 was asked to provide the documents and the contract from the vendor for the J-fill system and the repair logs. She could not provide any records or documentation indicating when the J-fill system dispensers were last inspected. Furthermore, if the contract required quarterly Preventive Maintenance there were no records to prove it was done. Staff #13 also did not have any logs/documentation to indicated staff complaints of dispensers not working in particularly the Maternity suite dispenser and action taken to resolve the issue. Staff #13 also did not have any process to ensure that the strength of the chemicals used is always correct or what to do if it is not.

4. Staff #15 at 1:45 PM, stated that after going through all records, he could not find any repair records for the J-fill system. The facility only does one-time plumping work and does not perform any preventive maintenance or repairs on the equipment.

5. Staff #13 was interviewed regarding the process of cleaning along with the chemicals used. Staff #13 was asked to provide a policy and procedure regarding the different kind of chemicals used for cleaning the patient rooms. Staff #13 provided a training module/education material in lieu of a policy and procedure. One education material was for 'Johnson -Diversy Cleaning Chemicals'. In this material there was a summary for 10 different chemicals to be used in a patient room or toilet. The chemicals stated were Virex, Crew NA, Alpha-HP, Virex Tb, Good Sense, Expose.256, Crew Emeril, Stride, Spitfire and Shineup. As per Staff #13 these 10 items are not always used at the same time. They are used as needed. The Virex 256 is the main chemical used since it is a disinfectant. The remaining chemicals are used as follows:

i. Alpha HP- Cleaner (floor).
ii. Good Sense-Air freshener.
iii. GP Forward-Strong Cleaner (not mentioned in the educational material).
iv. Crew NA- Bathroom/toilet cleaner.
v. Crew Emeril -Porcelain/bathroom cleaner.
vi. Stride- Floor cleaner.
vii. Spitfire- Degreaser.
viii. Virex Tb- For isolation rooms only.

6. A review of the education material revealed that under 'Johnson-Diversey J-Fill Dispensing Systems' that 'metering for proper dilution is controlled in each chemical cartridge. Dilution is always correct'. The material does not indicate how the staff/operator will know when the chemical cartridge is not working for proper dilution. Staff #13 stated that she was not aware of any test strips to measure the dilution, however she stated that the colors, foamy appearance and smell of certain chemicals was a good indicator of proper dilution.

7. A policy was not provided for the color of the different solutions. However as per the interview with Staff #13 the colors of the chemicals coming out of the dispenser should be the following:

i. Virex- Light Blue
ii. Crew- Bluish Green
iii. Good sense- Orange
iv. GP- Green
v. Alpha- yellowish green
vi. Stride-Orangish red

During the tour and inspections of all J-Fill Dispensers there was no evidence of the above mentioned color chemicals coming out of the dispenser.

Based on observation and staff interviews, it was determined that the facility did not ensure that proper humidity levels were provided and monitored in the ORs.

Findings include:

1. On 02/09/12 at 2:00 PM it was noted that the temperature in OR #2 and OR #3 was reading 66.8 *F. As per the facility's policy the temperature and humidity is only checked in the morning between 4-5 AM and then at 7 AM. The facility does not have any other means or way to ensure that the temperature is between 68*F-73*F as required by the AIA, AORN and ASHRAE code.

A review of the facility's policy revealed that the temperature should be between 66*F-70*F. This policy is inaccurate as per the standards of AIA, ASHRAE and AORN.

2. In reviewing the logs for humidity and temperature it was noted that on 02/06/12 the humidity of all 4 ORs were between 16*F-18*F and the facility had no documentation or note indicating that this issue was relayed to the engineering staff or if any corrective action was taken.
These findings were verified with Staff #16 and Staff #15.

Based on observation and staff interview, it was determined that the facility did not ensure a safe environment consistent with recognized infection control practices for prevention of cross contamination. Furthermore, the facility did not ensure the air-pressure in various non-patient care areas were as per industry standards to prevent cross-contamination in the environment.

Findings include:

1. The Pediatric room as per Staff #2 was also the negative pressure air-borne room. As per Staff #16 this room should always be on negative air -pressure. On performing a simple tissue test the room did not exhibit negative air -pressure. Furthermore, the room did not have self-closure on the exit door and the ceiling tiles were not the cleanable tiles. The ceiling tiles exhibited cervices and appeared porous which indicates that they may be able to retain dust and dirt in them.

2. During observation on 02/08/12 to 02/09/12 between 10:30 AM to 3:45 PM, it was noted that the perimeters and corners of various areas of the building were dusty and dirty. Examples including but not limited to area:

i. Dirty floors and corners were noted in the Main Soiled linen Holding room.
ii. Dirty corners with dust and cobweb were noted in the clean linen/laundry room.
iii. Triage room and Fast Track ED room #2 had dirty walls and floors in the Emergency Department.
iv. The area/room behind the Sterilizers in the Central Sterilization/processing room was noted to be very dirty and dusty.
v. The area under the pass-through window in the Central Sterilization/processing room was noted very dusty and dirty with dust lint.

3. During survey of the facility from 02/08/12 to 02/19/12 between 10:30 AM to 3:45 PM, it was noted that many Soiled Utility rooms and Housekeeping closets did not exhibit negative air pressure as they are require by AIA Table 2.
Examples including but not limited to were:

i. Soiled Utility Room of the Maternity unit exhibited positive air pressure.
ii. Housekeeping closet of the OR suite exhibited neutral air pressure.
iii. The Clean Utility room opposite the C-section OR in the maternity suite had neutral air pressure instead of positive air-pressure.
iv. The Decontamination room in the Central Sterilization area exhibited positive air-pressure to the corridor instead of negative air-pressure.
All above findings were verified with Staff #15 and Staff #16 during the tour.

The janitorial closet had 5 clean hand rolls and 2 rolls of tissue as noted at 10:35 AM on 2/7/12.

In a bathroom in the ED core the following items were found:

One 1 liter bag of IV 0.9% NaCl solution.
4 boxes with packages of clean personal items of soap and hand sanitizers.
A box of facial masks.



26934

A. Based on medical records reviews, document reviews and staff interviews, it was determined that the facility failed to ensure that patients received emergency care consistent with prevailing standards of practice. This was found in 2 of 33 medical records reviewed. Medical records #1 and #3.
Findings include:
Reassessments were not performed prior to the patients discharge after they presented to in the emergency department (ED) for emergency care. MR #1 is a fifty-two year old patient who presented to the ED on 12/7/11 at 10:11 PM after she had a grand mal seizure. The patient had a history of Seizure Disorder and had a CVA with deficits in the right upper and right lower extremities. Upon arrival the patient was postictal, confused and lethargic with decreased responsiveness to commands. The patient was given Depakote and Potassium orally for low serum levels. The patient, who lived alone, was discharged at 1:40 AM on 12/8/11 accompanied by her neighbor. There was no documentation in the medical record that the patient's mobility was reassessed prior to discharge by either a physician or a nurse before the patient was discharged from the facility.
The patient was admitted to another acute care facility that next day with persistent weakness and slurred speech. She was discharged from that facility on 12/11/11 after she had returned to her baseline.
Based on interviews conducted on 2/8/12, Staff #1 stated that the patient was able to ambulate with minimal assistance, however there was no documentation to support this or whether any assistive device was provided to the patient.
MR #3 is a thirty-four year old patient who presented to the ED on 2/6/12 at 5:20 PM. The patient told the nurse "I'm looking for a pain management." The patient's previous medical history was significant for Schizo-affective disorder and back surgery x 3. According to the medical practitioner, the patient had chronic back pain secondary to disc disease and complained of lower back pain. The patient had been taking Oxycodone for pain. Physical assessment revealed the patient was alert and oriented and she had severe tenderness at L-S spine and at the para-spinal muscles. Vital signs showed the patient's pulse was 131/minute, B/P was 140/99 and the pain score 9/10. The patient received Toradol 60 mg IM at 5:54 PM and was discharged at 6:00 PM, 6 minutes after the medication was administered. There was no evidence in the medical record that the patient was reassessed to determine the effectiveness of the medication or that her pulse rate was re-checked prior to discharge.

The above findings were confirmed during interview with Staff #1 on 2/8/12.
B. Based on medical record reviews, document reviews and staff interviews, it was determined the facility did not have a policy for police officers involvement or management of patients in the emergency room. This was found in 2 of 33 medical records reviewed. Medical records #5 and #23.

Findings include:

1. Police officers participated in patient care without a policy defining their roles.
MR #5 is a twenty-eight year old patient who presented at the ED at 1:25 AM on 12/11/11 because he had suicidal ideations. The patient had a history of Depression with approximately twenty hospitalizations since the age of 13. The patient had also made 3 suicidal attempts in the past 7 months. The patient was calm upon arrival and security guards were placed at the patient's bedside. The patient remained calm during his ED stay but at 8:18 PM that day he attempted to elope while the security guard went to the nurse's station for water which the patient had requested. The patient was stopped by security and staff before the patient exited the doors. A code was called to alert other staff for assistance. The police was also called. The police arrived at 8:30 PM and the patient was handcuffed by the police. The patient sustained a "small laceration/avulsion to left index finger." This incident was confirmed during staff interviews conducted on 2/7/12 at approximately 2:30 PM.

2. MR # 23 is a forty-six year old patient who arrived in the ED accompanied by officers from the Pennsylvania Police Department on 1/16/12 at 1:05 AM because he had been in a fight with his girlfriend and was "acting out." The triage notes also states the patient "made suicidal statements to the police." The patient was "positive for ETOH" with blood alcohol level of 183. The patient made attempts to elope from the ED on several occasions and was uncooperative with his care. He was monitored by 2 security personnel.

At 2:50 AM the patient exited the ED doors and was "tackled by security" and sustained a skin laceration to the left side of his face. He refused care for the injury and threatened to sue the facility. The Port Jervis Police Department (PJPD) was contacted for assistance as the patient continued to make attempts to leave. Restraints were ordered by the physician until the patient became cooperative. The patient was restrained by the police and then the staff was able to remove his shoes. The police had multiple conversations with the patient and he complied with taking his medications in the police presence. They left the ED at 3:00 AM that morning. The patient who was pending an arrest was released into the custody of the police at 4:30 AM.

The facility's policy does not address the role of police officers in the ED or facility. In addition, there was no policy to address police officers wearing weaponry in the facility.