HospitalInspections.org

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include deficiencies in following areas:
K11 common wall between occupancies,
K12 building construction type,K17 spaces open to the corridor,
K18 corridor door that latched,
K25 fire rating and integrity of smoke barrier walls,
K29 hazardous areas,
K38 doors in the means of egress swinged and were unlocked,
K39 width of corridors,
K48 training of staff for fire,
K56 sprinklers,
K67 HVAC system,
K75 size and location of trash receptacles,
K76 medical gas storage.

Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 485.623. The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation and interview, the facility did not provide proper ventilation in the facility. This deficiency occurred in 1 of the 8 smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
1. On 9-14-2010 at 2:00 pm surveyor #12187 observed that the ventilation to the space could not be confirmed to be compliant with accepted standards. The clean utility room in the patient wing is under negative pressure. Dirty air from the corridor is drawn into the clean room without proper filtering. This observed situation was not compliant with CFR 485.23(b)(5).
2. On 9-14-2010 at 2:05 pm surveyor #12187 observed that the ventilation to the space could not be confirmed to be compliant with accepted standards. The soiled utility room in the patient wing is under positive pressure. Dirty air from the soiled room is entering the corridor. This observed situation was not compliant with CFR 485.623(b)(5).

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include deficiencies in following areas:
K11 common wall between occupancies,
K12 building construction type,K17 spaces open to the corridor,
K18 corridor door that latched,
K25 fire rating and integrity of smoke barrier walls,
K29 hazardous areas,
K38 doors in the means of egress swinged and were unlocked,
K39 width of corridors,
K48 training of staff for fire,
K56 sprinklers,
K67 HVAC system,
K75 size and location of trash receptacles,
K76 medical gas storage.

Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 485.623. The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observations and 2 of 4 interviews with facility staff (F and G), the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment for the prevention of potential contamination or infection.


Findings include:

Hospital policy #21228 states; "Clean patient care equipment and supplies can be found in the storage area on the Med/Surg unit or the supply cart restocked by Materials Management staff. There is no storage in the dirty utility room."

During a tour of the hospital on 09/14/2010 at 10:00 it was discovered clean items including scissors and tweezers were stored in the dirty utility room in the emergency department (room #254SU).

During a tour of the hospital on 09/14/2010 at 2:10 PM it was discovered clean items including; washcloths, lotion, make-up and toiletries stored in dirt utility room #600SU.

During observation of surgery on 09/15/2010 at 12:35 PM the CRNA (D) was preparing the patient for surgery. In the midst of preparations D was observed inserting his left index finger into his ear. Following this, D proceeded to access intravenous lines connected to the patient. D did not change gloves at anytime during the observations.

These findings were confirmed per interview with Quality Director G on 09/15/2010 at 4:30 PM.

Based on review of 4 of 30 clinical records, 4 of 4 swing bed patients clinical record reviews, interview with staff and patients, and review of facility policy, the hospital failed to provide activities that met the individual needs of swing bed patients.

Findings include:

Hospital policy #13001 which delineates the provision of activities for swing bed patients states; "Care planning involves identification of the resident's interests, preferences, and abilities; and any issues, concerns, problems, or needs affecting the resident's involvement/engagement in activities. Activity goals related to the comprehensive care plan should be based on measurable objectives and focused on desired outcomes, not merely on attendance at a certain number of activities per week."

Patient (pt.) #4 was admitted as a swing bed on 06/15/2010, per review of the clinical record on 09/15/2010 there was nothing in the patient's nursing care plan addressing provision of activities related to individual needs or abilities.

Pt. #5 was admitted as a swing bed on 09/04/2010, per review of the clinical record on 09/15/2010 there was nothing in the patient's nursing care plan addressing provision of activities related to individual needs or abilities.

Pt. #13 was admitted as a swing bed on 09/03/2010, per review of the clinical record on 09/15/2010 there was nothing in the patient's nursing care plan addressing provision of activities related to individual needs or abilities.

Pt. #30 was admitted as a swing bed on 07/15/2010, per review of the clinical record on 09/15/2010 there was nothing in the patient's nursing care plan addressing provision of activities related to individual needs or abilities.

Per interview with social worker E on 09/14/2010 at 1:15 PM patients are evaluated for appropriate activities and provided various activities. This was not reflected in the care plans of the records reviewed. Per interviews with current swing bed patients activities consist of puzzles and watching television in the activity room with few organized activities. Swing bed activity schedules provided by the facility for the weeks of 09/12/2010 and 09/19/2010 indicate on Sunday, Tuesday, Thursday and Saturday the only activity being watching television. On Wednesday the 15th of September is listed a "Swingbed Luncheon", there are no other activities listed. The lack of activities was acknowledged by DON F per interview on 09/15/2010 at 11:00 AM.