HospitalInspections.org

Based on document review and interview, the facility did not utilize its Quality Assurance and Performance Improvement program to ensure that all safety events were analyzed to identify opportunities for improved patient outcome and safety.

Findings include:

The facility's policy titled "Safety Event Reporting and Investigation," which was last reviewed March 2016, states "all safety event reports will be subject to a thorough and credible investigation."


Review of a sample of safety events (incident) of patients that sustained injury revealed the facility did not conduct an investigation for one (1) of three (3) incidents where a patient sustained injuries. Example included but not limited to:
An incident report dated 10/31/17 revealed a patient "restraint-injury potentially caused by restraint use." There was no documentation of the type of injury or that an investigation was conducted.

Review of a sample of seven (7) incidents of delay in treatment, dated October 1, 2017 to October 8, 2017 revealed:
On 10/1/17 - a delay in physician response to a patient's condition.
On 10/5/17, 10/6/17 and 10/8/17 - delays in treatment- no EKG order in the ED and EKG was not read for two (2) patients by cardiologist.
On 10/8/17 - delay in treatment for a stroke workup.
There was no investigation or analysis of these events.

Review of a sample of 22 incident reports from June 2017 to November 2017 revealed equipment malfunction in areas including but not limited to the; operating rooms, intensive care unit and radiology department. Examples included but not limited to:
On 6/1/17 - an equipment malfunction during a case in the operating room.
On 6/21/17 - an equipment malfunction of a ventilator in the intensive care unit (ICU).
On 6/22/17 - a machine malfunction during a hemodialysis treatment.
There was no documented investigation or analysis of these events.

Review of a sample of five (5) falls from May 2017 to October 2017 revealed:
On 5/22/17 a patient fell from a bed in the pediatric unit.
On 9/20/17 a patient was found sitting upright on the floor in the ICU.
On 10/22/17 a patient fell from a bed and was found on the floor lying in bloody stool.
The root cause of the falls and corrective measures taken was not documented.

During interview with Staff C, Director of Quality, on 12/15/17 at 3:30 PM, she acknowledged the findings.

Based on observation, document review and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

During a tour of the Emergency Department (ED) on 12/11/2017, at approximately 11:30AM, the following were identified:
Rooms were observed without identification signage to indicate the function of the rooms. Examples included but were not limited to:
a. The plain X- Ray room of the ED.
b. The storage in the Annex of the ED.
c. The soiled utility room of the Annex of the ED.
d. All the rooms of the Annex building of the ED.

The soiled utility room in the minor care area of the ED was found to have a positive air flow, instead of the required negative air flow for this type of room.

Two linen carts measuring (2 FT x 3 FT x 5 FT each) were stored in the corridor by the front of patient rooms #1 and #2 of the expansion building of the ED. This is a potential risk of infections as well as for fire safety.

The soiled utility room of the Expansion area of the ED was found to have a positive air flow instead of the required negative air flow for this type of room.



During a tour of the pharmacy on 12/11/2017, at approximately 2:20 PM, the following were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Preparedness Coordinator; and the Director of the pharmacy, who acknowledged the findings.

Some of the ceiling tiles of the intravenous (IV) preparation room of the pharmacy were not from the cleanable or washable type that are required for this room to prevent the transmission of infection.

There were gaps between ceiling tiles which allows for the buildup of germs and dust and it hinders the proper cleaning of the ceiling tiles.

The split ductless air conditioner unit on the IV preparation room of the pharmacy had supply openings which impairs proper cleaning or washing of this unit. This is a potential of transmission of infection.



During a tour of the first floor of the hospital on 12/12/2017, at approximately 10:5AM, the following were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Preparedness Coordinator; and the Director of the pharmacy, who acknowledged the findings.

a. The receiving area of the loading duct on the first floor did not have an illuminated exit sign.
b. The gas manifold storage room on the first floor did not have an illuminated exit sign.
c. The dry food storage room was found to have boxes stored very close to the ceiling tiles, without the 18 inch space required between the stored items and the ceiling.
d. The elevator machine room did not have coverage by the sprinkler system.


During a tour of the facility on the morning of 12/13/2017, at approximately 11:30AM, the following were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Preparedness Coordinator; and the Director of the pharmacy, who acknowledged the findings.

The one hour fire rated wall above the entrance door of the Neonatal Intensive Care Unit (NICU) was found to have some penetrations that were not sealed by a firestop.

The clean utility room of the Orthopedic Unit exhibited negative air pressure instead of a positive air pressure that is required for this type of room.

The clean utility room of the Labor and Delivery unit (L&D) was found to have a negative air pressure instead of the required positive air pressure for this type of room.

The floors of Operating Rooms (OR) A and B in the Labor and Delivery (L& D) unit were found to be dirty, sticky and to have black spots on different areas of the floors.

The medication room of the Post Cardiac Care Unit on the 3rd floor, exhibited negative air pressure instead of the required positive air pressure for this type of room.

A soiled linen hamper was observed being stored in the bathroom of Room 335 of the Post Cardiac Care unit.



During a tour of the Acute Inpatient Dialysis unit on 12/14/2017 at approximately 10:35 AM, the following items were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Preparedness Coordinator; and the Director of the Dialysis Unit, who acknowledged the findings.

The Reverse Osmosis (RO) water room which houses the reverse system that is used to purify the water used for patient dialysis, was found to be used for the storage of clean supplies, dialysis machines and two (2) portable reverse osmosis unit.
During interview with the Director of Dialysis during the tour of the water room, it was revealed that this room was also used as to fix and perform maintenance of the dialysis machines, portable RO and other equipment.
This use of the water room is a potential for the transmission of infections.


Review of the of the MRI rooms of the main hospital and the Dyson MRI room revealed that the annual physicist reports for these two (2) MRI's were not done in a timely manner and were overdue for the annual testing by the physicist, as per the manufacturer recommendation.
The previous annual reports for these two (2) MRI were done in March 2016 and were due in March 2017, however, they were not done until the date of the survey on 12/15/2017.


On 12/11/2017, at 12:52 PM, it was observed that the pipe under the sink of the designated Accessible bathroom in the Post Operating Area on the second floor, was exposed, ant it lacked a plastic protective cover. This could potentially cause body injury to a patient in a wheelchair.

At interview with Staff A, Corporate Manger Facility & Operation, on 12/10/2017 at approximately 12:54 PM, he confirmed this finding.


On 12/12/2017 at 11:13 AM, a missing ceiling tile, approximately 12 inches x 12 inches, was noted in Room #1 in the Radiology holding area on the second floor of the hospital.

A concurrent interview with Staff A, confirmed the finding.









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Based on observation and staff interview, the facility did not ensure an effective system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings include:

During a tour of the Emergency Department (ED) at 12/11/2017, approximately at 11:30 AM, the following were identified:
The soiled utility room in the minor care area of the ED was found to have a positive air flow, instead of the required negative air flow for this type of room.
The soiled utility room of the expansion area of the ED was found to have a positive air flow instead of the negative air flow that is required for this type of room.


During a tour of the pharmacy on 12/11/2017 at approximately 2:20 PM, the following were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Preparedness Coordinator; and the Director of the pharmacy, who acknowledged the findings.

Some of the ceiling tiles of the IV preparation room of the pharmacy were not from the cleanable or washable type that are required for this room to prevent the transmission of infection.

There were gaps between ceiling tiles which allows for the buildup of germs or dust and this hinders proper cleaning of the ceiling tiles.

The split ductless air conditioner unit on the IV preparation room of the pharmacy had supply openings which impairs cleaning this unit. This is a potential of transmission of infection.



During a tour of the Labor and Delivery Unit (L&D) and the post Cardiac Care Unit on 12/13/2017 at approximately 11:30 AM, the following were identified in the presence of Staff E, Staff D, Staff L, and the Director of the pharmacy, who acknowledged the findings.

The clean utility room of the orthopedic unit exhibited negative air pressure instead of a positive air pressure that is required for this type of room.

The clean utility room of the Labor and Delivery unit (L&D) was found to have a negative air pressure instead of the required positive air pressure for this type of room.

The floors of Operating Rooms (OR) A and B in the L& D unit were found to be dirty, sticky and have black spots on different areas of the floors.

The medication room of the Post Cardiac Care Unit on the 3rd floor, exhibited negative air pressure instead of the required positive air pressure for this type of room.

A soiled linen hamper was observed being stored in the bathroom of Room 335 of the Post Cardiac Care Unit.



During a tour of the Acute Inpatient Dialysis unit on 12/14/2017 at approximately 10:35 AM, the following items were identified in the presence of Staff E, Staff D, Staff L, and the Director of the Dialysis Unit, who acknowledged the findings.

The Reverse Osmosis (RO) water room which houses the reverse system that is used to purify the water used for patient dialysis, was found to be used for the storage of clean supplies, dialysis machines and two (2) portable reverse osmosis unit.
During interview with the Director, during the tour of the water room, it was revealed that this room was used also to fix and perform maintenance of the dialysis machines, portable RO and other equipment.
This use of the water room is a potential for the transmission of infections.

Based on medical record review (MR), document review and interview, in two (2) of eight (8) medical records reviewed, the discharge planning assessments did not address whether discharging the patients back to the setting from which they were admitted to the hospital, was still appropriate (Patient # 1, Patient # 6).

Findings include:

Grievance file for Patient # 1 was reviewed. Patient's family filed a grievance with the facility on 11/23/2017. In this grievance, the family requested a review of the patient's stay in the hospital on 11/18/2017 - 11/22/17. The family believed the patient was not properly discharged; he was discharged to a homeless shelter.

Review of MR for Patient #1 identified: This was a 61-year-old homeless patient with metastatic cancer, presented to the facility's Emergency Department (ED) on 11/18/2017, with syncope episode and diarrhea. Medical evaluation revealed that the patient had metastatic cancer with vertebral metastases. MRI showed that the patient also had liver metastases. During inpatient stay, the patient was seen by Oncologists and treated with radiation therapy. It was documented that the patient's prognosis was poor.
The discharge planning assessment indicated that, prior to admission, the patient was staying with a friend. However, he was unable to return after discharge. The patient was not interested in living in a room or homeless shelter because of the environment. The patient was medically stable for discharge on 11/22/2017. The discharge planner documented that the patient stated he had a few other friends he may stay with but the patient did not have the friends' contact information or confirmation of the availability to stay with them. On the day of discharge, the patient was given a voucher for transportation. The patient's residence post discharge was unknown.
There was no documentation that inpatient hospice service was explored with the patient or the reasons why this was not an option.
This patient was readmitted to the facility on 11/28/2017 with chief complaint of pain; the patient was unable to walk.


Review of MR for Patient #6 identified: This patient was a 81-year-old skilled nursing facility (SNF) resident, who was transferred to the facility's ED on 12/8/2017, after an unwitnessed fall. The patient was evaluated and it was discovered she sustained hip fracture. She underwent right hip hemiarthroplasty. On 12/11/2017, the case manager documented that the "patient is a long-term resident at this nursing home, bed hold confirmed, patient wishes to return to the SNF." The patient was discharged back to the facility on 12/11/2017.
The discharge planning assessment did not include if this facility was still an appropriate placement for this patient. The discharge evaluation did not address whether that facility has the capability to provide the post-hospital care this patient may require.


The facility policy and procedure (P &P) titled "General Patient Discharge Procedure," last revised 9/2016, states: "the case manager evaluation will include an assessment whether the patient could be cared for in the same environment from which he/she entered the hospital." This policy was not implemented.

During interview with Staff F, LSW Manager; Staff G, Director, Case Management and Staff H, Corporate AVO, on 12/14/17 at approximately 9:52 AM, the discharge planning issues identified were brought to their attention.

Based on medical record (MR) review, document review and interview, in 2 (two) of 8 (eight)) medical records reviewed, the facility, as part of the discharge process, did not inform the patients/patient's representative of the freedom to choose post hospital care providers (Patient #2, Patient #7)


Findings include: -

Review of MR for Patient #2 identified: This 85-year-old patient went to the facility's Emergency Department (ED), on 11/25/2017, due to shortness of breath. The patient was admitted with diagnosis of new congestive heart failure (CHF).
The discharge plan assessment, dated 11/28/2017, indicated the patient needed assistance in transferring, ambulation, bathing, dressing and grooming and the discharge plan was home with family care.
On 11/29/2017, the discharge plan was changed to home with family support and home health services (skilled nursing and physical therapy). On 12/4/2017, case manager noted that the home care referral was initiated.
The patient was discharged, on 12/9/2017, after the case manager confirmed that the home care services will be initiated on 12/10/2017.
The discharge planning assessment did not include if the patient/patient's representative was given a choice of home care agency prior to discharge. There was no documentation that a choice list was given.


Review of MR for Patient #7 identified: This was a 68-year-old patient, who was admitted to the facility on 12/6/2017 with diagnosis of right toe osteomyelitis. The patient underwent amputation of the right toe on 12/6/2017. The patient was evaluated by physical therapy and it was determined that the patient would benefit from subacute rehabilitation for ongoing physical therapy.
The case manager met with patient on 12/8/17 to discuss the discharge plan. The patient gave the name of the facility he would like to be referred for rehab. This patient was not informed that there was no guarantee that he would be discharged to this facility.
There was no documented evidence that the patient was given a list of skilled nursing facilities. The patient was discharged on 12/11/17. This patient was not discharged to the facility the patient requested. The reason the patient was not discharged to the requested facility was not documented.


The facility policy and procedure titled "General Patient Discharge Procedure," last revised 9/2016, states: "Patients should be given the freedom of choice to select from a list of providers." This policy was not implemented.
This policy did not include that the choice should be documented in the medical record.

These findings were brought to the attention of Staff F, LSW Manager; Staff G, Director Case Management and Staff H, Corporate AVP, on 12/14/17 at approximately 9:52 AM.