HospitalInspections.org

Based on observation and interview, the facility failed to ensure that each patient's right for confidentiality of his/her medical record (MR) was maintained on 2 of 9 inpatient units.

Findings include:

1. During the facility tour with staff #47 on 03-09-11 at 1000 hours of the 5 East inpatient unit, in the hallway between patient rooms 534 and 535, a laptop was observed to not be logged off, with patient information available and no staff present by the laptop.

2. On 03-09-11 at 1000 hours, staff #47 confirmed that the laptop should have been logged off.

3. During the facility tour with staff #49 on 03-09-11 at 1110 hours of the Acute Rehab inpatient unit, in the hallway between patient rooms 334 and 335, a laptop was observed to not be logged off, with patient information available and no staff present by the laptop.

4. On 03-09-11 at 1110 hours, staff #49 confirmed that the laptop should have been logged off.

5. During the facility tour with staff #49 on 03-09-11 at 1120 hours of the Acute Rehab inpatient unit, in the hallway between patient rooms 350 and 351, a laptop was observed to not be logged off, with patient information available and no staff present by the laptop.

6. On 03-09-11 at 1120 hours, staff #49 confirmed that the laptop should have been logged off.

Based on policy/procedure review, transfusion record review and staff interview, the facility failed to ensure medical staff policies/procedures were followed for two of seven transfusions reviewed.

Findings included:
1. On 3/8/11 between 1:00 p.m. and 3:00 p.m., review of a policy/procedure titled "Blood Components Administration" dated 12/09 indicated:
a. "a signed consent must be obtained"
b. "vital signs are to be taken 15 minutes after the start of the transfusion"
2. Review of seven transfusions records indicated:
a. Transfusion #5, started on 12-01-10 at 02:36, had the 15 minute vitals recorded as being taken at 3:36.
b. Transfusion #7, started on 10-01-10 at 06:54, had no documented signed consent available.
3. In interview on 3/9/11 between 2:00 p.m. and 3:00 p.m., staff person #17 confirmed the above findings.

Based on Life Safety Code (LSC) survey, Reid Hospital & Health Care Services was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code (LSC), Chapter 18, New Health Care Occupancies for the 2008 building, Chapter 19, Existing Health Care Occupancies for the Reid Hospital Wound Care Center built in 1987, and with Chapter 39, Existing Business Occupancies for the Reid Hospital Rehabilitation Services Facility in Richmond, the Reid Rehab Services Nettle Creek Health Care Center in Hagerstown, and the Reid Sleep Lab & Diagnostic Services Facility in Richmond built in 1987.

Reid Hospital & Health Care Services is comprised of the main hospital and attached Outpatient Care Center (OCC). The main hospital is a seven story fully sprinklered building of Type II (222) construction with a basement with the attached outpatient care center, a two story fully sprinklered building of Type II (222) construction with a basement, which has a fire alarm system with smoke detection in the corridors, patient rooms and spaces open to the corridors. The facility has a capacity of 237 and had a census of 161 at the time of this survey. The Reid Hospital Wound Care Center is a one story fully sprinklered building of Type II (222) construction and has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The Reid Hospital Rehabilitation Services Facility is a one story fully sprinklered building; the Reid Rehab Services Nettle Creek Health Care Center and the Reid Sleep Lab & Diagnostic Services Facility are one story nonsprinklered buildings of Type II (222) construction and each facility has a fire alarm system with smoke detection in the corridor.

Based on LSC survey and deficiency found (see CMS 2567L), it was determined that the facility failed to ensure a secondary electrical source of power from battery backup, or an emergency generator set to two hyperbaric chambers (see K 142).

The effect of this systemic problem resulted in the hospital's inability to assure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure 2 of 2 hyperbaric chambers were provided with a secondary source of electrical power. This deficient practice could affect all patients using the hyperbaric chambers located in the Reid Hospital Wound Care Center.

Findings:

1. Observation on 03/09/11 during a tour of the Reid Hospital Wound Care Center with engineering technician # 1 at 2:30 p.m. indicated the two hyperbaric chambers in the facility were wired to a breaker panel in the electrical room. NFPA 99, 19-2.7.2.1

2. Interview with the WCD #1 on 03/09/11 at 2:40 p.m. indicated the hyperbaric chambers are used by burn patients and other patients with various diagnoses.

3. Interview with ET #1 on 03/09/11 at 2:50 p.m. indicated the two hyperbaric chambers are not supplied with either a secondary electrical source of power from battery backup, or an emergency generator set.

Based on document review, the facility failed to ensure a maintenance and testing program for 10 pieces of equipment used for patient treatment.

Findings:

1. On 3-8-11 at 9:50 am, employee #A8 was requested to provide documentation of preventive maintenance (PM) for a refrigerator, dishwasher, microwave and toaster located in the Occupational Therapy area at the Reid Hospital Rehabilitation Services offsite facility. No documentation was provided prior to exit.

2. On 3-8-11 at 11:45 am, employee #A8 was requested to provide documentation of PM for a dishwasher, microwave, stove, clothes washer and dryer located in the hospital's Acute Rehab gym area. No documentation was provided prior to exit.

3. On 3-8-11 at 11`:50 am, employee #A8 was requested to provide documentation of PM for a massage stone heater located in the hospital's second floor Physical Therapy, Occupational Therapy and Speech Therapy area. No documentation was provided prior to exit.

4. On 3-10-11 at 11:15 am, employee #A10 was requested to provide documentation of preventive maintenance (PM) on polysomnography equipment. No documentation was provided prior to exit.

Based on observation and interview, the facility failed to identify 2 conditions to control infections and communicable diseases that could result in diseases of patients and personnel.

Findings:

1. On 3-8-11 at 9:55 am in the presence of employee #A8, it was observed in a Biohazardous Waste Room at the Reid Hospital Rehabilitation Services offsite facility, there was a laminator and 2 carts stored in this room.

2. Upon interview, offsite facility personnel indicated the laminator was used to laminate items taken out of the room into patient care areas. Also upon interview, offsite facility personnel indicated the carts were used to transport items through patient care areas.

3. On 3-8-11 at 12 noon in the presence of employee #A8, it was observed in a hallway accessible to the public outside the surgical suites, 2 biohazard tubs full of biohazardous waste items.

Based on document review, observation and interview, the facility failed to ensure that policies governing surgical care were followed by facility staff in one instance.

Findings include:

1. Review of policy/procedure Reid Hospital Exposure Control Plan indicated the following:
"Personnel Protective Equipment:
Reid Hospital will provide gloves, face shields, masks, eye protection and aprons/isolation gowns at no cost to employees.
Employees shall:
Utilize protective equipment in occupational exposure situations."
This policy/procedure was last reviewed/revised on 12/2009.

2. During the facility tour with staff #43 of the Surgical Services area on 03-08-11 at 0940 hours, the following was observed in operating room #4: a staff member not wearing eye protection while assisting the surgeon during a surgical procedure.

3. On 03-08-11 at 0940 hours, staff #43 confirmed that the staff member was not wearing eye protection and should have been wearing eye protection.