HospitalInspections.org

Based upon the observations during the life safety code tour of the hospital on 01/26/10 to 01/28/10 and interview with staff, the hospital failed to meet the requirements of the 2000 Life Safety Code of the National Fire Protection Association.Findings include:Refer to the Life Safety Code Survey Report Form for 2000 New - Building one of two.Deficiencies were issued at:
K-25 Penetrations in smoke barriers
K-27 Doors in smoke barriers not on self closure and no astragals
K-29 Penetrations in hazardous areas and door not latching
K-38 Egress exit access not paved to common way
K-47 No exit signage in outpatient therapy department
K-56 Sprinkler head obstructed
K-72 Obstruction in the corridor
K-78 Humidity levels not maintained at 35% or greater
K-130 Smoke detectors within 36 inches of air flow

Based on interview and review of quality assurance committee meeting minutes, the facility failed to ensure the quality assurance program, as it pertained to dietary and anesthesia, had a system to identify and prevent potential problems and evaluate corrective actions. This has the potential to affect all patients in the facility.


Findings:

Review of the quality assurance meeting minutes for all of 2009 was completed on 01/28/10. The review revealed the Chief Executive Officer attended two meetings in 2009: March and December. The review did not reveal meetings occurred in April, May, July, or September. The review did not reveal the head of the anesthesiology department, Staff J, attended any of the meetings.

Review of the contract between the facility and its anesthesia services was completed on 01/28/10. The review revealed: the anesthetists group "shall participate in such quality enhancement and performance improvement initiatives to the extent necessary to achieve the goal of increased value of health care services" and "such quality enhancement and performance improvement initiatives may include ...operational improvements, (and) clinical outcome improvement initiatives ..." and "shall participate in quality improvement activities, which may include mock c-section drills and other emergency drills, and shall assist Hospital in meeting all applicable standards related to its survey and accreditiations ..."

In an interview in the afternoon of 01/27/10, the Chief Nursing Officer (Staff D) was unable to say what quality indicators were being tracked and trended in the anesthesia department.

Review of the Quality Improvement Council member roster completed on 01/28/10 did not reveal anybody from nutrition services was a member. Review of the facility's organizational chart completed on 01/28/10 revealed the Nutrition Services Manager reported to the Plant Engineering Manager, who reported to the Chief Operating Officer.

On 01/27/10 at 4:30 P.M. in an interview, the Chief Operating Officer stated among the quality indicators that are looked at in the dietary department, include, among other things, number of meals served and number of meals served to patient families. She said analysis of whether the patients get the right meals in the right form (that is, pureed, mechanical soft, or regular), or whether patients receive a meal as ordered by the physician, are not reported to the quality improvement committee.

Review of the Nutrition Services Manager's personnel file revealed her performance evaluation was completed by the Plant Engineering Manager.

On 01/28/10 at 1:15 P.M. in an interview, the Plant Engineer Manager stated he had not received education to determine whether the meals as served match meals as ordered by the physician, for example, mechanical soft, clear and full liquids.

On 01/28/10 at 1:30 P.M., the Chief Operations Officer stated the Quality Improvement Committee meetings for April, May, July, and September were canceled.