HospitalInspections.org

Based on inspection reports, review of humidity records, observation and staff interview the facility failed to meet the condition for physical environment in the area of life safety code. The total facility census is seven patients.
Findings include:
See Life Safety Code (LSC) citations as follows:
K62 The facility failed to perform required quarterly inspections and tests of the sprinkler system, and to ensure that the annual inspection and test of the sprinkler system was performed within one year of the previous test.
K29 The facility failed to protect the laboratory with a one hour fire-rated barrier and 3/4 hour doors on closers.
K76 The facility failed to ensure that the pulmonary function laboratory, which contained stored medical gases greater than 288 cubic feet but less than 3000 cubic feet, was protected in accordance with NFPA 99.

K78 The facility failed to maintain relative humidity (RH) equal to or greater than 35 per cent in two of two operating rooms during the months of January and February, 2010.

K144 The facility failed to record weekly inspections of the generator as required by NFPA 99.

Based on interview, observation, and clinical record review, the facility failed to ensure the nursing care delivered to Patient #12 ensured the patient was not lying on a side that had skin impairment. The total facility census was seven patients.

Findings:

The clinical record review for Patient #12 was completed on 02/24/10. The clinical record review revealed the 92-year-old patient was admitted to the facility on 02/23/10 with a diagnosis of failure to thrive, cellulitis to the right foot, decreased oral intake, and debility. The review revealed a history and physical dictated on 02/23/10 that stated the patient was blind in both eyes and suffered a stroke.

The clinical record review revealed the patient was assessed as being at moderate risk for skin impairment on 02/23/10. A nursing note dated 02/23/10 at 1:35 P.M. that stated the patient had a two centimeter round open area draining yellow fluid and surrounded with six centimeters of reddened skin on the left hip. The note stated the wound was three millimeters deep.

The clinical record review revealed a problem statement dated 02/23/10 at 11:34 P.M. that stated the patient had an alteration in skin integrity and the goal was have the wounds healed. The intervention listed was to have the patient turned every two hours.

Review of the facilities wound care protocol for wounds reviewed on 02/24/10 stated to treat wounds was to relieve pressure. On 02/24/10 at 9:55 A.M., the surveyor observed the patient in bed lying on her left hip. On 02/24/10 at 9:55 A.M., the surveyor interviewed Nurse G who confirmed the patient was lying on her left hip and that she would be turned every two hours, including on the left hip.

On 02/24/10 at 2:15 P.M. in an interview with Staff A, stated that if a patient has a wound on a hip, then the patient should not lie on that hip.

Based on review of personnel files and staff interview the facility failed to provide nursing care in the area of assessment of patients in the emergency department to determine the urgency of such treatment. The facility served 10,901 patients in the emergency department from January 2009 to December 2009.

Findings include:

Tour of the emergency room on 2/23/2010 at 2:30 PM revealed 10 emergency beds with three nurses on duty. Interview of staff F at that time revealed patients seeking emergency room care are assessed by the registration staff outside the emergency department. Further interview of staff F revealed the registration staff are not medical personnel but, have been trained to triage patients. Review of the personnel files of three registration staff signed on admission forms for 5 patients seeking emergency care revealed a form called "Triage Educational Checklist Admitting/Registration" This checklist described seven groups of symptoms that require immediate attention. The following symptoms are as listed:
1. Chest pain
2. Lacerations
3. Fever in children
4. Overdose from pill/drugs
5. Assault/abuse or rape victims
6. Head injury
7. Women in labor

Review of personnel files of staff K, L, and M revealed the staff's signatures on the Triage Education Lists for staff K on 12/04/09, staff L on 11/30/09 and staff M on 3/19/03.

The "Triage Education Checklist" does not include other patient symptoms that could result in a patient's undesirable outcomes or the need for immediate medical intervention. Interview of staff F on 2/23/2010 at 2:45 PM revealed he/she felt triage should be completed by a registered nurse. Interview of staff A on 2/23/2010 at 2:45 PM confirmed registered nurses should be doing triage but there is no staff assigned to this duty.

Based on interview and clinical record review the facility failed to ensure Patient #12 did not receive a medication to which she was allergic. The total facility census was seven patients.

Findings:

The clinical record review for Patient #12 was completed on 02/24/10. The clinical record review revealed the 92-year-old patient was admitted to the facility on 02/23/10 with a diagnosis of failure to thrive, cellulitis to the right foot, decreased oral intake, and debility. The review revealed a history and physical dictated on 02/23/10 that stated the patient was blind in both eyes and had had a stroke.

The clinical record review revealed a nursing note dated 02/23/10 at 11:21 A.M. that stated the patient was assessed as confused and disoriented.

The clinical record review revealed a physician's order dated 2/23/10 at 12:10 P.M. that stated to give the patient a penicillin-based antibiotic by intravenous route every six hours.

The clinical record review revealed a nursing note dated 02/23/10 at 1:35 P.M. that stated the patient had a two centimeter round open area draining yellow fluid and surrounded with six centimeters of reddened skin. The note stated the wound was three millimeters deep.

Review of the patient's medication administration record revealed the patient was allergic to penicillin and was given the aforementioned penicillin-based antibiotic on 02/23/10 at 1:22 P.M. and 7:10 P.M. and on 02/24/10 at 1:36 A.M. and 7:41 A.M.

Review of the patient's physician orders did not reveal an order to give the penicillin-based antibiotic although the patient was allergic to penicillin.

On 02/24/10 at 11:15 A.M. in an interview with the Quality Improvement Nurse Executive (Staff Z) confirmed the documentation of the medication administration record. In an interview, she said the nursing staff probably continued to give it because the patient was not having a reaction.

On 02/24/10 at 11:15 A.M. in an interview with Nursing Staff Y, she confirmed there wasn't a physician's order to give the penicillin-based antibiotic although the patient was allergic to penicillin.

On 02/24/10 at 11:15 A.M. in an interview with Staff Nurse G, she confirmed she gave the penicillin-based antibiotic although the patient was allergic to penicillin because she was told it was okay to give because the patient was tolerating it.

On 02/24/10 at 11:15 A.M. in an interview, the Pharmacy Manager (Staff X) stated an order needed to be obtained to continue to give the penicillin-based antibiotic.

Based on review of the facility's quality assurance committee meeting minutes, food temperature logs, test tray policy, test tray results, observation and interview the facility failed to meet the condition of quality assurance review. The total facility census was seven.

Findings include:

Review of the facility's Improving Organizational Performance (i.e., the facility's quality assurance committee) committee meeting minutes for 2009 revealed it met quarterly on 03/26/09, 06/04/09, 09/03/09, and 12/03/09. The review revealed Staff W attended once on 12/03/09 and was absent at all other meetings. The review revealed the following disciplines did not contribute to the facility's quality assurance process as evidenced by their absence in the quality assurance committee meeting minutes. Those disciplines are dietary, pharmacy, and anesthesia.

Review of the facility's policy entitled "Test Tray Evaluation" (effective 11/09) stated a total of three test trays are to be conducted. Review of the facility's test tray results that were completed on 02/24/10 revealed two test trays were done: One for breakfast on 02/15/10 and 02/17/10.

Review of the facility's food temperature log from 01/01/10 to 02/12/10 was completed on 02/24/10 and did not reveal that cold foods were tested for coldness.

On 02/23/10 at 11:15 A.M., the surveyor toured patient care area food pantry with Staff H and Staff I. The surveyor observed a refrigerator/freezer unit. The surveyor did not observe where the temperature of the freezer was monitored.

On 02/23/10 at 11:15 A.M. in an interview with the Staff H and Staff I, they stated there wasn't any record of monitoring the freezer's temperature. They stated dietary staff have not asked patients or distributed questionnaires to measure patient satisfaction with the food. They also stated there is no current activity to validate that their current process delivers the right food in the right form to the right patient.

On 02/23/10 at 1:30 P.M. in an interview the Staff H stated if patients complain about the food, then Staff A, would tell her.

On 02/23/10 at 1:45 P.M. in an interview, Staff S stated she does keep track of complaints about the food, and said there have been six complaints in the past year.

Review of the facility's organizational chart was completed on 02/24/10. The review revealed dietary does not report to either the Director of Customer Service or Director of Nursing Services, but occupational therapy

On 02/24/10 at 2:44 P.M. in an interview, Staff J stated she did not attend or contribute to the facility's quality assurance committee.

On 02/24/10 at 3:30 P.M. in an interview, the Quality Improvement Nurse Executive confirmed the facility's pharmacist had not attended the facility's quality assurance committee meetings. She did not dispute that the committee meeting minutes did not indicate medication errors were discussed for 2009.