HospitalInspections.org

Based on observation and interview, the provider failed to ensure safekeeping of blood and blood products in an unlocked room and cooler on a 24 hour a day basis. Findings include:

1. Observation throughout the survey from 2/15/11 through 2/16/11 at random times revealed seven units of blood and blood products were stored in an unlocked room across the hall from the laboratory. Further observation revealed the door to the storage cooler was not locked. Observation of the white refrigerator in the same room revealed several boxes of reagent material used in the laboratory also was stored in an unlocked refrigerator. It was observed that visitors, staff, clinic patients, and assisted living residents all had access to that area in the hallway.

Interview on 2/15/11 in the afternoon with laboratory manager E confirmed:
*The laboratory was only open from 8:00 a.m. until 4:30 p.m.
*There were patients who came from the clinic to the laboratory in the hallway.
*The doors to the storage room and the cooler were never locked.
*There was a camera monitor directed to the nurses station.
*There was not a policy about the safekeeping of blood and blood products.
*There was no record kept at the cooler site when blood was taken out for use.
*The cooler was alarmed to ring at the nurses station if the temperature deviated from the normal.

Interview on 2/15/11 in the afternoon with administrator A and director of nursing B confirmed:
*The blood cooler had been moved to the present location from the nurses station some time ago.
*The doors to the storage room and the cooler were never locked.
*The laboratory and other offices in the basement were closed after 5:00 p.m.
*The facility was accessible to the public until the outside doors to the building were locked at 9:30 p.m.
*There was not always someone at the nurses station to observe the camera monitor.

Review of the nursing staff meeting minutes dated 4/15/08 indicated the blood bank had been moved to the clean utility room in the basement. An additional alarm would be purchased and wired to the nurses station. There was no indication as to how they would ensure safekeeping of the blood or that the cooler or clean utility room would be locked.

Based on random observation and interview, the provider failed to maintain the facility and its belongings in a sound, clean, or safe condition. A facility tour revealed:
*On the basement level:
- A chair by the ambulance entrance door had a cracked vinyl seat exposing the foam underneath. The edge of the backrest had chipped wood along the lower edge.
- In the clean linen room there were boxes of clean paper supplies stored on the floor under a counter. The filter screen of the window air conditioner was thick with dust.
- The ceiling vent grate in the x-ray processing room was thick with dust.
- The door of the x-ray room and the x-ray bathroom doors had large gouges in the wood along the edges by the door knobs.
- A bathroom by the radiology department had mop board peeling away from the wall under the sink. The caulking around the toilet was rough and dirty.
- The physical therapy office next to the laboratory (lab) on the basement level had boxes of lab supplies stored on the floor under the sink.
- The central supply room had intravenous fluids stored over patient care paper products. There were liquid patient toiletries and bottles of alcohol stored over nebulizer and oxygen supplies and packaged dressing supplies.
*On the second floor:
- There were holes in the walls, and plaster and/or paint was cracked and/or peeling on the walls and/or ceilings in the following areas: the emergency room; around the scrub sink outside the emergency room; the women's locker/shower room; the surgical patient room; the clean linen room; the patient's shower room; patient rooms 212, 216, 218, and 200/222; the public bathroom; and the hallway.
- The flooring was peeling up on all four edges of the public bathroom.
- Ceiling vent grates were thick with dust in the emergency room, clean linen room, patient room 212 bathroom, and the public bathroom.
- There were holes and/or water stains in the ceiling tiles in the hallway and in room 218.
- The nurses desk in the surgical patient room had areas of peeling, chipped, and rough wood.
- There was a box of supplies stored on the floor in a supply closet outside of the operating room. That box appeared to have water damage stains on it.
- Patient room 212 had a cracked clock, cracked plastic light bulb shields in two over-the-bed light fixtures, and rough, gouged, wood along the front and edges of the bathroom door.
- A chair in the patient's shower room had numerous areas of chipped paint exposing raw wood.
Findings include:

1. Random observation on 2/15/11 from 8:30 a.m. through 10:15 a.m. revealed:

a. On the basement level:
1. Three chairs were sitting by the ambulance entrance. One of those chairs had a vinyl seat. That seat had an approximately one-foot long tear down the middle of the seat and along the front edge. It also had a torn area approximately two by three inches along the left side of the seat. Those torn areas exposed the foam padding and made the seat of the chair not cleanable (photo 1). The wooden back rest of that chair had rough, chipped wood along the bottom front edge that was hazardous and uncleanable (photo 2).
2. In the clean linen room there was one box each of toilet paper, Kleenex, and paper towels stored on the floor under a counter (photo 6). The filter screen of the window air conditioner unit above that counter was thick with dust.
3. The ceiling exhaust vent in the x-ray processing room was thick with dust and debris.
4. The doors to the x-ray room and the x-ray room bathroom were deeply gouged along the edges and by the doorknobs. Those areas were rough, uncleanable, and hazardous. Some of those areas had been taped with a clear tape.
5. The bathroom by the radiology (x-ray) department had loose mopboard coming away from the wall under the sink and along several other areas of the room. The gaps between the mopboard and the wall allowed dirt and debris to accumulate in those areas. The area under the sink had a dried, brown-colored substance along the top edge of the mopboard (photo 10). The caulking around the bottom of the toilet was dirty and had crevices and ridges that were not cleanable.
6. The physical therapy office had two boxes of laboratory supplies on the floor under the sink (photo 11).

b. On the second floor:
1. The wall behind the scrub sink outside the emergency room had four holes in it approximately one foot below the paper towel holder. Three of the holes had metal brackets in them. One of the holes had no bracket. The wall around that hole had missing paint approximately one inch by two inches wide making that area uncleanable (photo 23).
2. A closet outside the women's locker room had a box of Poole suction devices stored directly on the floor. That box had what appeared to be water stains along the bottom edges of the box (photo 22).
3. The patient shower room had a white chair sitting in the corner outside the shower. That white chair had numerous areas of chipped paint on the seat, back, and legs that exposed the bare wood (photos 32 and 33). The walls along the mopboard on both sides of the shower stall had bubbled and peeled paint, holes, and gouges in them (photo 34). Those areas had rust-colored staining and some black-colored areas that looked like mold. The wall to the right just inside the doorway had three small areas of scraped paint along the edge exposing raw wood (photo 36). None of those areas of peeled, bubbled, or chipped paint were cleanable surfaces.
4. The public restroom had a ceiling tile with a vent grate hanging loose above the stool (photo 72) which could have caused injury to anyone using that stool. The vinyl flooring was curled up in the corners and loose from the floor on all four sides. The corners of the floor contained a large amount of built-up dirt and debris (photos 73 and 74).

2. Random observation on 2/15/11 from 3:30 p.m. through 4:30 p.m. revealed:
a. A large hole approximately two feet in circumference under the scrub sink outside the emergency room. There were two smaller holes approximately two inches in diameter above and to the right of the large hole. Around the large hole was exposed plaster and missing paint under which the bare wall was exposed. The whole damaged area measured approximately three feet wide by two feet high and was a noncleanable surface (photo 24).
b. The women's locker room outside of the operating room had several areas of cracked and/or peeling paint on both sides of the ceiling light fixture (photos 16 and 17). The peeled area was approximately two inches by one inch. The two cracked areas were approximately five and ten inches in length. There was also cracked and peeling paint along all three lower edges ot the shower. Those areas exposed plaster and/or old paint. The area in the corner of the shower appeared rust-stained (photos 19 and 21).
c. Walls had holes and plaster and/or paint was cracked and/or eroded on the walls and doorways in the following areas:
1. The surgical patient recovery room (photos 12 and 15).
2. The emergency room walls (photos 25, 28, and 29).
3. The wall to the left of the emergency room scrub sink (photo 31).
4. The clean linen room (photo 37).
5. Patient rooms and/or bathrooms 212 (photo 52), 216 (photos 53, 55, and 56), 218 (photos 58, 59, 61, 62,and 66), and 200/222 (photo 68).
6. A wall edge in the hallway outside room 200/222 (photo 75).
d. Ceilings tiles had holes and/or water stains in the hallway (photos 69 and 70), and patient room and bathroom 218 (photos 60 and 65).
e. Patient room 212 had two beds. The area by the first bed had an approximately three foot long crack in the light bulb cover of the over-the-bed light fixture (photo 41). The plastic cover over the clock face also had an approximately six inch crack (photo 43). The light fixture over the second bed had an approximately one foot long crack and two by two inch hole in the overhead light cover. The front edge of the light fixture had several areas of chipped paint with what appeared to be rust (photo 51).
f. Water pipes in the bathroom and shower of patient room 218 had large areas of missing paint exposing rusty looking areas on those pipes (photos 62 and 63).
g. Ceiling vent grates were thick with dust and cobwebs in the emergency room (photo 27), clean linen room (photo 40), patient bathroom 212 (photo 46), and the hallway.
h. The nurses desk in the surgical patient recovery room had chipped wood along the front lower edge exposing raw wood (photo 13). The area where the patient charts would hang had gouged and unfinished raw wood along the right side (photo 14). Those areas were not cleanable.
i. The bathroom door in patient room 212 had large gouged and split areas in the wood along the front edge approximately six inches above the doorknob. The split area had been taped with clear tape in three different areas (photo 47). The edges of the door on both sides by the doorknob also had areas of gouged wood and unfinished spackling (photo 50).

3. Observation on 2/16/11 at 2:20 p.m. of the central supply room revealed there were eleven boxes of intravenous fluids stored on a shelf above paper products including patient disposable briefs, Chux (absorbent bed pads), oxygen tubing, and nebulizer (breathing treatment) supplies. There were also two bottles of alcohol, three bottles of lotion, and six bottles of antibacterial hand gel stored on a shelf directly over boxes of styrofoam drinking cups, paper medicine cups, and various dressing supplies.

Interview with maintenance director C at that time confirmed the above observation. He had not known liquids should not have been stored over resident-use items or paper products.

4. Interview on 2/16/11 from 2:30 p.m. through 3:40 p.m with maintenance director C confirmed the above observations. He further revealed:
*In the past the nurses had completed work orders when repairs had needed to be made.
*Since he had started as maintenance director he had not required formal work orders.
*The nurses would just "come down and tell me" what needed repair.
*He mostly got reports of equipment problems such as call lights or televisions not working, burnt out light bulbs, or minor plumbing issues.
*He had done walk-throughs every day throughout the whole facility.
*He had maintenance checklists, but there had been alot of things he had checked everyday that were not on the checklists.
*He was aware of the chipped paint throughout the facility, and it was "on his list."
*He had talked to the administrator about painting all the rooms, but everything cost money.
*He had been unaware of the large hole under the scrub sink outside of the emergency room.
*He was unable to find policies and procedures specific to maintenance. He thought the administrator would have them.

Interview with administrator A on 2/16/11 at 3:50 p.m. revealed maintenance director D had the maintenance policies and procedures.

Review of the facility daily maintenance check sheets revealed the items checked were:
*The air compressor.
*All doors.
*Fire escapes.
*Oxygen tanks.
*The sprinkler system.

Review of a second facility maintenance checklist revealed monthly, quarterly, annually, biannually, and triannually checks were completed of the following:
*Air conditioners, ducts, filters, and handling motors.
*Assisted living rooms.
*The boiler.
*Door alarms.
*Water temperatures.
*Duct dampers.
*Elevator.
*Exit lighting.
*Fire doors, fire alarm testing, extinquishers, fire drills, smoke detectors, fire sprinkler system and sprinkler heads, the kitchen fire system.
*Hot water heater, and operating and surgical room temperatures.
*Roof and exhaust fans.
*Suction pumps.

There were no other preventive maintenance schedules given to the surveyor by maintenance director D. Neither of the above maintenance checklists listed ongoing inspections of patient care areas to identify needed repairs of rooms or equipment.



23059

7. Observation of the operating room (OR) at 1:35 p.m. on 2/15/11 revealed a storage cart with an attached intravenous (IV) medication stand had rusted areas on the chrome handle and protruding bar.

Interview with director of nursing B at that time revealed that stand was used mostly to hang IV fluids and medications during cataract surgeries. She confirmed the above areas on the stand were rusted and should not have been in the OR.

Based on observation and interview, the provider failed to arrange adequate services to ensure the safety of patients with an unanticipated crisis in the cardiac rehabilitation area Findings include:

1. Observation on 2/15/11 at 8:30 a.m. during a tour of the facility revealed:
*The cardiac rehabilitation room was on the first floor in the home health director's office.
*The equipment was two recumbent stationary bicycles and two electric treadmills.
*No emergency equipment or medications were available at that site.
*No patients were using the equipment at that time.

Interview on 2/16/11 at 11:30 a.m. with director of nursing (DON) B confirmed:
*The DON and one other staff registered nurse were in charge of cardiac rehabilitation.
*There was no crash cart or medications kept in the cardiac rehabilitation room.
*The crash cart was kept on the second floor in the emergency room a long distance from the cardiac rehabilitation room.
*Cardiac rehabilitation was only done on scheduled days.
*There was a physician in the clinic in the basement when cardiac rehabilitation was being done.
*Level II and level III patients were rehabilitated at the hospital referred by consultant physicians.
*Telemetry monitoring was completed with exercise on the two treadmills.
*There were currently patients scheduled to do cardiac rehabilitation.
*The cardiac room had been moved from the second floor to the first floor, but she could not remember the exact date.
*Had never made the crash cart available in the cardiac room since it had been moved to first floor.

Review of the policy for out-patient service area revised 9/13/00 revealed:
*"The designated outpatient service area is in the cardiac rehabilitation room."
*"If the patient needs to lie down, place patient in a hospital bed or on the cart in the ER."

11933




26691




23059

Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, and/or times. A sample of 270 medical record entries revealed 130 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 97 written physicians' orders during review of medical records on all patient care areas revealed 1 was not signed, 3 were not dated, and 8 were not timed.

2. Review of 27 telephone or verbal physicians' orders during review of medical records on all patient care areas revealed 18 were not dated and 23 were not timed.

3. Review of 90 physicians' progress notes during review of medical records on all patient care areas revealed 21 were not timed.

4. Review of 56 miscellaneous forms regarding physician or staff contact with the patient during review of medical records on all patient care areas revealed 1 was not signed, 10 were not dated, and 45 were not timed.

5. Interview with director of nursing (DON) B on 2/16/10 at 10:10 a.m. revealed she was unaware all entries in the patient's medical record should have been signed, dated, and timed. She stated nurses had done 24 hour chart reviews. They would not necessarily notice if a signature, date, or time was missing on any entry. The provider had no formalized process for that review.

Review of the provider's August 2004 documentation policy revealed all entries must contain the month, day, year, and time.

Review of the provider's 9/12/00 medical staff bylaws revealed all entries in the medical record should have been legible, dated, and authenticated by the responsible practitioner.

Review of the provider's 3/9/10 and 4/13/10 medical staff meeting minutes revealed the physicians had been reminded to sign, date, and time all orders.

Based on record review and interview, the provider failed to ensure all contracted services were evaluated for quality, and quality assurance/program improvement (QAPI) activities were reported to the governing board. Findings include:

1. Interview with director of nursing (DON) B at 9:50 a.m. on 2/16/11 revealed contracted services provided by laundry and the blood bank had not been reviewed to ensure those services:
*Were provided in accordance with the terms of the contract/agreement.
*Maintained quality standards determined by the provider.

Interview with administrator A at 10:25 a.m. on 2/16/11 confirmed the above two services had not been included or reviewed as a part of their QAPI program.

Review of the board of trustees (governing body) meeting minutes from 12/08/09 through 1/11/11 revealed no mention of any QAPI reports.

Interview with DON B at 9:50 a.m. on 2/16/11 revealed she had not shared any of the quality assurance reports or program improvement plans with the governing board. She confirmed those activities should have been shared with board members.

Interview with administrator A at 10:25 a.m. on 2/16/11 revealed he might have shared QAPI reports with the governing board on an informal basis. He confirmed nothing had been documented about those reports.