HospitalInspections.org

Based on observation and interview the facility failed to provide safe and functional environment for boiler room staff resulting in the potential for harm in the event of an accident at facility's boiler room. Findings include:

On May/02/2017 between the hours of 1000 and 1400 during the inspection of the boiler room, a work stable was observed placed immediately under the steam pipes and control valves. at least one of the control valves was dripping hot and steaming liquid. If the hot/steaming drips falls on the head of the working staff it could subject the staff an immediate jeopardy and harm giving the fact that the boiler room is not accessed by every staff member at the facility. Depending on harm, effected staff may spend an extended time before obtaining proper treatment and/or even saved in a timely manner.

Finding confirmed by accompanying director of operations on May/02/2017 during the inspection.

Based upon observation and interview, the facility failed to maintain the physical environment (typical eyewash station) to provide the occupants a safe and functional environment resulting in the potential for patient and/or staff harm for all patients treated by the facility. Findings include:

On May/02/2017 and between the hours of 1000 and 1400 it was observed that the typical eyewash stations at the lab room and the boiler room did not conform to applicable code. The eyewash station in the lab and adjacent to the blood draw area did not have the required tepid water (cold water only) and the eyewash station in the boiler is not a hands free type (handheld) and does comply with applicable code subjecting working staff to a potential harm if an eye injury occurs. The typical eyewash station shall be provided with tepid water and readily accessible for use and to comply with applicable code. Areas where subjected to handling blood and/or cleaning and handling of bleach and other corrosive materials are used to conduct daily services at this facility must have a fully compliant eyewash station(s) per OSHA/ANSI (Occupational Safety and Health Administration/American National Standards Institute) requirements ANSI Z358.1 - 2004;

All above findings were confirmed by accompanying staff on May/02/2017 at the time of the observation/inspection.

Based on observation and interview the facility failed to provide and monitor a sanitary environment to minimize the transmission of infectious agents and subject all patients and staff to potential harm. Findings include:

The following observations were found during inspection of the facility on May/02/2017 between the hours of 1000 and 1400 of the facility:

1. Dirty and dusty high surfaces of the top of the typical wall cabinets in the radiology department as well as at the emergency department trauma room. The top surfaces exhibited high dusting and filth build-up, and

2. Visible dirt and debris on mast arms of the task lights in trauma bays A and B serving the emergency department


Above findings were confirmed by director of nursing and directort of operations, accompanying staff during the observation/inspection on May 2, 2017.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/1/17, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 5/1/17 for Life Safety Code.

K-0321
K-0353
K-0511
K-0712

Based on observation, interview, and record review, the facility failed to ensure sharps containers were replaced when full in 1 of 2 observations of use resulting in the potential of exposure to blood borne pathogens and the risk of spreading infectious agents to all patients served by the facility. Findings include:

On 5/1/2017 at 1500, Staff I was observed administering a subcutaneous (under the skin) injection. After giving the medication, Staff I walked behind the patient chair to dispose of the syringe in a wall mounted sharps box. It was observed that the protective flap in which to dispose of the syringe was partially blocked and the manufacturer's "FULL" was present on it indicating the box needed to be changed. Staff I was observed pulling down on the protective flap, inserting the syringe and then pushing the flap back up so the syringe would drop into the box.

On 5/1/2017 at 1525, Staff I was queried as to how often the syringe boxes were changed to which she replied, "Oh, you saw that. We change them when they're full. I'll be changing it as soon as (the patient) is gone."

On 5/1/2017 at 1618 facility policy #007.P032 titled "Installation and Disposal of Sharps Containers, Including Pharmaceutical Waste Disposal Containers (Purple Bins)V6", approved 12/2012, was reviewed. Policy states: "Sharps containers are to be maintained upright and secure throughout use, replaced routinely and not allowed to overfill. They must be replaced when approximately 3/4 full."

Based on record review and interview, the facility failed to provide a post anesthesia assessment prior to discharge for 2 (#9, 10) of 3 surgical patients reviewed for anesthesia recovery by a qualified practitioner out of a total sample of 20 patients resulting in the potential for poor outcomes from unrecognized anesthesia related problems for all surgical patients served by the facility. Findings include:

On 5/1/2017 at 1405 review of Patient #9's medical record revealed there was no post- operative assessment completed by the certified registered nurse anesthetist (CRNA) Staff J following administration of monitored anesthesia care (MAC).

Operating Room Manager Staff D was queried on 5/1/2017 at 1425 as to if a post-operative assessment by the CRNA had been completed to which she stated, "This wasn't a general anesthesia case...The CRNA gives report to recovery and then we do our own discharge protocol." Staff D was further queried as to if the CRNA had documented any cardio-pulmonary status, level of consciousness or complications the patient might have had after the procedure to which she replied "no."

On 5/1/2017 at 1430, review of Patient #10's medical record revealed there was no post-operative assessment completed by Staff J following administration of MAC anesthesia.

On 5/1/2017 at 1438, Chief Nursing Officer Staff B stated in an interview "I checked with (XXX medical center) because we do what they do. They have a sign off portion on the electronic record that we do not have here. We need to figure out what we're going to do."

On 5/1/2017 at 1618 facility policy #094.001 titled "Delivery of Anesthesia at (XXX) Medical Center and at (YYY) Memorial Health Center V13" approved 6/1/2016 was reviewed. Policy states: "The decision to discharge a patient from PACU (post anesthesia care unit) will be ...under the direction of the anesthesia provider responsible for discharge. A post anesthesia evaluation is required on all patients...before they leave the recovery area..."

Based on document review and interview the facility failed to specify the type and complexity of privileges the Certified Registered Nurse Anesthetist (CRNA) is approved to perform, resulting in the potential harm to all patients receiving surgical treatment at this facility. Findings include:

On 5/1/2017 at 1600 during the review of the form titled "Certified Registered Nurse Anesthesthetist Delineation of Privileges" for staff J CRNA it was noted that she had not been approved for Monitored Anesthesia Care (MAC). This was the documented procedure found during the record review for the surgical patients #9 and #10.

On 5/1/2017 at 1610 staff B was queried as to why the procedure "Monitored Anesthesia Care (MAC)" was not included on the the list of privileges for staff J. Staff B stated "Staff J is approved for general anesthesia doesn't that cover everything?"

On 5/1/2017 at 1618 the policy titled "Delivery of Anesthesia at Munson Medical Center" #094.001 dated approved 6/1/2017 was reviewed. On page 1 of 3 under number 1. it states "Anesthesia personnel must be privileged through the medical staff/allied health credentialing process..."

Based on interview and record review the facility failed to provide an activity needs assessment and failed to provide an ongoing activities program for 2 of 3 swing bed patients (#1, #2), out of a total sample of 20 patients, resulting in the potential for poor quality of life affecting the physical, mental and psychosocial well-being of each patient. Findings include:

During record review on 05/01/16 at 1430, the following information was revealed:

Patient #1

A face sheet (undated) indicated Patient (Pt) #1 was admitted to a swing bed on 09/27/16 and discharged on 10/12/16. A clinical order dated 09/27/16 at 1515 indicated Pt #1 may participate in therapeutic activities. Additional review of this closed record revealed no evidence that an activity needs assessment had been completed on behalf of Pt #1 during course of stay in the swing bed or that any activities were actually offered or provided during course of stay in the swing bed.

Patient #2

A face sheet (undated) indicated Pt #2 was admitted to a swing bed on 09/28/16 and discharged on 10/10/16. A clinical order dated 09/28/16 indicated Pt #2 may participate in therapeutic activities. Additional review of this closed record revealed no evidence that an activity needs assessment had been completed on behalf of Pt #2 during course of stay in the swing bed or that any activities were actually offered or provided during course of stay in the swing bed. It should be noted that Pt #2 was specifically assessed for activity related needs on 10/21/16 per the five page activity assessment form completed by Staff N, however, this assessment was completed approximately eleven days after Pt #2 was discharged from the swing bed.

During an interview with Staff B on 05/01/17 at 1505, Staff B said, after reviewing the records of Pt #1 and Pt #2, "I do not see anything in the charts" related to the completion of an activity needs assessment or the actual provision of activities during the time frames each patient occupied a swing bed.

During an interview with Staff A on 05/01/17 at 1520, Staff A said the facility did not have a policy or procedure for activities specific to swing bed patients, but instead refers to the activity policy used within the long term care portion of the facility. Staff A said the person responsible for coordinating facility activities was Staff N.

During an interview with Staff N on 05/01/17 at 1555, Staff N said patients are generally assessed for activity needs within two days of admission using a five page assessment form. Staff N said the facility did not complete activity related care plans for swing bed patients and was unsure how swing bed patients activity participation was documented. Staff N said the general procedure was to incorporate swing bed patients into the long term care milieu for activities.

On 05/01/17 at 1615 the long term care nursing policy titled, "Diversional Therapy", with approval date of 08/10/16 was reviewed. This policy indicated the facility "must provide an ongoing program of activities that are designed to meet, in accordance with the comprehensive assessment, the interests and physical, mental and psychosocial well-being of each resident."