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Based on observation, staff interviews, and review of maintenance records between January 27 and January 30, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 33: enclosures around exit stairs with openings to unoccupied rooms;
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and travel was not interruption at stairs that go below the level of exit discharge;
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 67: heating and ventilation components were not in compliance with NFPA 90A;
K 73: obstructed egress path;
K 130: improper alarms for the emergency generator, improper distance between bulk oxygen tank and combustibles; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014.

26711

Based on observation and staff interview, this facility failed to maintain an environment for the safety of patients and staff in 1 of 7 department tours (Radiology) and 2 of 2 staff interviews (Staff A and C). Failure to maintain a safe environment has the potential to affect all patients and staff who enter the department.

Findings include:

A tour of the Radiology department was conducted on 3/19/2014 at 10:45 a.m. accompanied by Coord. B. At this time it was noted that several floor tiles in the Dell and the GE (General Electric; rooms are identified by the brand name of the equipment in them) rooms remained missing revealing a porous surface that is uncleanable and could have the potential to cause falls in patients and/or staff.

In an interview with Mgr. A on 3/19/2014 at 11:30 a.m. A stated that this repair work should have been done by today.

In an interview with Mgr. C on 3/19/2014 at 11:35 a.m., C stated that there was an error in reporting that an extension date was needed to repair the floors because an extension would not have been necessary; however, C had not been to the Radiology department recently to check on the progress of the repairs.

At 4:10 p.m. on 3/19/2014 another tour of the Radiology department was conducted with Mgr. A and only the floor in the Dell room remains un-repaired.

Based on observation, staff interviews, and review of maintenance records between January 27 and January 30, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: corridor walls, or did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 25: improperly constructed and maintained smoke barriers;
K 29: hazardous areas improperly enclosed;
K 33: enclosures around exit stairs with openings to unoccupied rooms;
K 38: egress paths were not clear at all times, doors were lockable in the egress path, and travel was not interruption at stairs that go below the level of exit discharge;
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 67: heating and ventilation components were not in compliance with NFPA 90A;
K 73: obstructed egress path;
K 130: improper alarms for the emergency generator, improper distance between bulk oxygen tank and combustibles; and
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

A verification visit was conducted on March 10, 2014 with photo review conducted on March 18, 2014.

Based on MR review, Medical Staff R&Rs, and staff interview, this facility failed to ensure that telephone orders are properly authenticated by the medical provider with signature, date, and time within a 48-hour period of being written in 4 out of 6 out of a total of 11 MRs reviewed (Pt.s #6, 7, 8, and 9). Failure to have properly authenticated TOs has the potential to affect all patients receiving care in this facility, including the 4 patients present during the date of the survey.

Findings include:

The Medical Staff R&Rs, updated March 2014, were reviewed on 3/19/2014 at 11:45 a.m. On page 13 of the R&R provided, section C, "GENERAL CONDUCT OF CARE," the R&R state in part, "All orders dictated over the telephone shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner or his/her partner shall authenticate such orders within 48 hours. Failure to do so shall be brought to the attention of the executive committee for appropriate action."

A MR review for Pt. #6 was conducted on 3/19/2014 at 2:46 p.m. accompanied by Mgr A who confirmed the following findings: Pt. #6 was admitted on 3/13/2014 and discharged on 3/15/2014. In that time period there are 4 out of 5 TOs not authenticated by the provider within 48 hours.

A MR review for Pt. #7 was conducted on 3/19/2014 at 2:52 p.m. accompanied by Mgr A who confirmed the following findings: Pt. #7 was admitted on 3/15/2014 and discharged on 3/16/2014. There is one TO written by a pharmacist on 3/15/2014 that is not authenticated by the provider and one TO written by an RN on 3/16/2014 that is not authenticated by the provider.

In an interview with Mgr A during this MR review, A stated that TOs written by pharmacists still need to be authenticated by the provider.

A MR review for Pt. #8 was conducted on 3/19/2014 at 2:55 p.m. accompanied by Mgr. A who confirmed the following findings: Pt. #8 was admitted on 3/11/2014 and discharged on 3/18/2014. Between 3/11/2014 and 3/16/2014 there are 10 TOs that are not authenticated by the provider (there are more TOs written after 3/16/2014 that are not authenticated but they did not fall into the 48 hour time period at the time of the MR review).

A MR review for Pt. #9 was conducted on 3/19/2014 at 3:09 p.m. accompanied by Mgr. A who confirmed the following findings: Pt. #9 was admitted on 3/13/2014 and discharged on 3/18/2014. In that time period there are 7 TOs not authenticated by the provider.

In an interview with Mgr. A at 3:40 p.m. on 3/19/2014 following the MR reviews, Mgr. A stated that all of the medical providers have been trained and instructed regarding the need to sign TOs within 48 hours.





32670

Based MR reviews and staff interview this facility failed to maintain a MR that has a properly completed consent to transfer to a higher level acute facility by not listing the individualized risks of the transfer to the patient in 2 of 3 patients transferred (Pt. #4 and 5). Failure to properly complete transfer consents has the potential to affect all patients needing a transfer out of this facility including the 4 patients who required transfers in the sampled time period between 3/15/2014 and 3/19/2014.

Findings include:

A MR review for Pt. #4 was conducted on 3/19/2014 at 2:05 p.m. accompanied by Mgr. A who confirmed the following findings: Pt. #4 came to the ED on 3/17/2014 with complaints of Abdominal pain. Due to the nature of the complaint the provider determined the need for cardiac (heart related) tests to be done and it was determined that Pt. #4 was having heart related issues. The transfer agreement in the MR does not list the individualized risks to the patient that could develop during the transfer to another facility.

A MR review for Pt. #5 was conducted on 3/19/2014 at 2:25 p.m. accompanied by Mgr. A who confirmed the following findings: Pt. #5 came to the ED on 3/17/2014 with complaints of chest pain. It was determined that due to the nature of Pt. #5's complaints a transfer to an acute care facility with a greater ability to treat heart problems was warranted. The transfer agreement in the MR does not list the individualized risks to the patient that could develop during the transfer to another facility.

In an interview with Mgr A on 3/19/2014 at 2:35 p.m. regarding the transfer consents, Mgr A agreed that the individualized risks were not documented on the transfer consents.

26711

Based on MR review, P/P review, and staff interview the facility failed to ensure that pain reassessments were completed per facility expectation in 1 of 2 out of a total of 5 patients who were medicated for pain while inpatients in the facility (Pt #8).

Findings include:

The facility's policy titled, "Pain Assessment, Reassessment and Management," which is undated, was reviewed on 3/19/2014 at 11:40 a.m. The policy states in part that, "The patient will undergo reassessment of pain at least once per shift and within 1 hour of any pain management intervention."


A MR review for Pt. #8 was conducted on 3/19/2014 at 2:55 p.m. accompanied by Mgr. A who confirmed the following findings: Pt. #8 received one Hydrocodone (narcotic pain medication) on 3/12/2014 at 6:08 p.m. for pain of an undocumented severity level. A pain reassessment was documented at 10:16 p.m. on 3/12/2014 and entered as "pt. tol well," (tol-tolerated). This reassessment is almost 3 hours over the expectation per policy, and also has an undocumented severity level for the pain.

Pt. #8 received two Hydrocodone on 3/12/2014 at 9:59 p.m. for pain of an undocumented severity level. A pain reassessment was documented at 10:16 p.m. on 3/12/2014 and instead of a severity level was entered as "pt. tol well."

Pt. #8 received two Hydrocodone on 3/18/2014 at 5:24 a.m. for pain of an undocumented severity level. A pain reassessment was documented at 6:00 a.m. and instead of a severity level, "No adverse reactions," was entered.

In an interview with Mgr. A during the MR review (between 2:55 p.m. and 3:09 p.m. on 3/19/2014) Mgr. A stated the severity levels should be documented and that the reassessment for the 6:08 p.m. dose of Hydrocodone for Pt. #8 was entered at the same time as the reassessment of the dose given at 9:59 p.m.