HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure that the hospital is constructed, arranged, and maintained to ensure the safety of the patient.
(See Tag A724)

Findings include:


During tour of radiology department on 6/18/13 at approximately 12:45PM escorted by staff #4, revealed the floors in several exams rooms were sealed with duct tape, the tiles were lifted, as well as air bubbles in the flooring, putting patients and staff at risk for tripping and/or falls.


Interview on 6/18/13 at approximately 12:50PM with staff #36 when asked about the flooring, stated that they are currently working on getting the floors fix.


Interview on 6/18/13 at approximately 2:37pm when asked what the current status on the completion of the flooring repairs are, she stated that the facility is currently in litigation with the construction company regarding the flooring. She stated after the opening of the facility, that slowly the flooring began to rise.


Interview on 6/18/13 at approximately 2:45PM with Staff #5 revealed that the other areas of the facility that have flooring damage are the medical surgery nurses ' station, laboratory, surgical services, emergency room, and radiology, however surgical services and the emergency room have been repaired. She stated that "radiology was next on the list to be completed; they were waiting on funds to complete the repairs."


Interview on 6/18/13 at approximately 3:20PM with the staff # 38 revealed that the facility has purchased the materials needed to complete the repairs; however they do not have the funds available to complete the repairs.


Interview on 6/19/13 at approximately 10:41AM with staff #39 revealed that the facility is in the process of replacing the floors; however they are "financially strapped". He stated that there is not an estimated date as to when the repairs will be completed. When asked what the facility has in place to keep the patients safe and prevent falls, he stated that patients are escorted in stretchers, beds, wheel chairs, and hand over hand for ambulatory patients or side by side.

Interview on 6/19/13 at approximately 11:14AM with staff # 37 revealed that there is not a written plan or memo for staff to follow regarding patient safety when entering, walking through or exiting area of the facility that have floor damage, currently staff verbally tell patient to "watch for bubbles in the floor".
Record review of facility meeting minutes revealed that the facility was currently in litigation witht the construction company that was responisble for the original floor installation.

During the same tour of the Nursing station on 6/18/13 at approximately 3:30pm revealed duct tape on the floor near the patient charts and the nurses' charting area in multiple areas putting staff at risk for tripping and falls.

It was confirmed in an interview on the afternoon of 6/18/13 with staff #27 that the duct tape on the flooring was from the it rising. She stated that staff was only allowed in the nurses station. She confirmed that the floor had not been fixed due to funding. Staff #27 stated the facility was in litigation.

During a tour of the Nursing 300 hall on 6/19/13 at approximately 8:45am revealed the flooring was lifted in front of 4 patient rooms (302, 304, 306, 308) putting patients and staff at risk for tripping and/or falls.

It was confirmed in an interview on the morning of 6/19/13 with staff #27 and #29 that the flooring was bubbling and rising which placed patients and staff at risk for tripping and falls. She confirmed that the floor had not been fixed due to funding and the 300 was an Outpatient area and was not used often. Staff #27 stated the facility did not have the funding and was in litigation with the contractor.

During the moring of 6/19/13, the surveyor witnessed an obstetrical (OB) patient being discharged and walking unescorted out of the 300 hall.

In an interview with staff #29 the morning of 6/19/13, she confirmed that the 300 hall was used for overflow. Staff #29 also confirmed that patients OB patients are encouraged to "walk" out of the facility instead of being taken out in a wheelchair. Staff #29 stated that her staff was not aware of the condition of the 300 hall and there was no plan in place for patient or staff safety.

Additional Findings include:

During tour of the sterilization room on 6/19/13 at approximately 9:00AM escorted by staff #33, revealed multiple previously sterilized instruments were found in the closed position. These included: 8 towel clips, 8 Kelly clamps, 2 Jorgenson scissors, 1 Potts scissors, 3 Mayo scissors, and 1 needle driver.
Interview on 6/19/13 at 9:20AM with staff #33confirmed instruments were previously sterilized in the closed position.
Record review of facility policy revealed all surgical supplies and equipment must be sterilized in the open position.

During a tour of the Nursing station on 6/18/13 at approximately 3:30pm revealed duct tape on the floor near the patient charts and the nurses' charting area in multiple areas putting staff at risk for tripping and falls.

It was confirmed in an interview on the afternoon of 6/18/13 with staff #27 that the duct tape on the flooring was from the it rising. She stated that staff was only allowed in the nurses station. She confirmed that the floor had not been fixed due to funding. Staff #27 stated the facility was in litigation.

During a tour of the Nursing 300 hall on 6/19/13 at approximately 8:45am revealed the flooring was lifted in front of 4 patient rooms (302, 304, 306, 308) putting patients and staff at risk for tripping and/or falls.

It was confirmed in an interview on the morning of 6/19/13 with staff #27 and #29 that the flooring was bubbling and rising which placed patients and staff at risk for tripping and falls. She confirmed that the floor had not been fixed due to funding and the 300 was an Outpatient area and was not used often. Staff #27 stated the facility did not have the funding and was in litigation with the contractor.

During the moring of 6/19/13, the surveyor witnessed an obstetrical (OB) patient being discharged and walking unescorted out of the 300 hall.

In an interview with staff #29 the morning of 6/19/13, she confirmed that the 300 hall was used for overflow. Staff #29 also confirmed that patients OB patients are encouraged to "walk" out of the facility instead of being taken out in a wheelchair. Staff #29 stated that her staff was not aware of the condition of the 300 hall and there was no plan in place for patient or staff safety.

Additional Findings include:

During tour of the sterilization room on 6/19/13 at approximately 9:00AM escorted by staff #33, revealed multiple previously sterilized instruments were found in the closed position. These included: 8 towel clips, 8 Kelly clamps, 2 Jorgenson scissors, 1 Potts scissors, 3 Mayo scissors, and 1 needle driver.
Interview on 6/19/13 at 9:20AM with staff #33confirmed instruments were previously sterilized in the closed position.
Record review of facility policy revealed all surgical supplies and equipment must be sterilized in the open position.

During a tour of the Emergency Department with staff # 27 and #28 on 6/18/13 at 12:50pm, revealed a packaged sterilized vaginal speculum in the "gynecology room, room #3" which was available for patient use. Inside near the tip revealed an unknown substance in the form of a clump approximately 1 cm.

It was confirmed in an interview with staff #27 and #28 the afternoon of 6/18/13 that the instrument had an unknown substance and was not properly sterilized.

During a tour of the Emergency Department with staff #27 and #staff #28 on 6/18/13 at 12:50pm, revealed approximately 6 sterilized instruments which were in the closed position. 1 of the instruments were closed and clamped.

It was confirmed in an interview with the staff #27 and #28 the afternoon of 6/18/13 that the instruments were not properly sterilized.

During a tour of the Emgergency Department with staff #27 and #28 on 6/18/13 at 12:50pm, the following expired supplies were found available for patient use:

1. 1 Monoject Magellan 3 cc syringe with safety needle expired 6/10
2. 2 Red top vacutainers expired 11/10
3. 2 purple top vacutainers expired 9/10
4. 1 blue top vacutainer expired 4/10
5. 1 Staple remover expired 9/11
6. 1 Thick & Easy 8 oz expired 10/11
7. 1 Culture swab expired 2/12
8. 3 Sodium Chloride 10 ml syringes expired 4/13
9. 1 DeLee Mucus Trap with Vacuum Breaker expired 3/13
10. 20 Culture swabs expired 1/13
11. 1 Pedialyte 1 quart expired 2/13
12. 1 Pedialyte 1 quart expired 3/13

It was confirmed in an interview with the staff #27 and staff #28 on 6/18/13 that the supplies were expired and available for patient use.

During a tour of the Birthing Center with staff #27 and staff #29 on 6/18/13 at 3:00pm, the following supplies were expired and available for patient use:

1. 2 Protective IV Catheters 18 gauge 4/09
2. 3 Introcan IV Catheter 18 gauge expired 10/09
3. 3 Introcan IV Catheter 20 gauge expired 12/09
4. 1 Skin thermometer probe expired 2/10
5. 4 Filter needles expired 1/10
6. 1 TB syringe expired 9/10

It was confirmed in an interview with the staff #27 and staff #29 the afternoon of 6/18/13 that the supplies were expired and available for patient use.

During a tour of the Nursing Units with staff #27 on the afternoon of 6/18/13 and the morning of 6/19/13 the following expired supplies were found and available for patient use:

1. 4 ABG kits expired 5/05
2. 2 tongue blades expired 5/11
3. 4 Heparin Flush 100u/ml 5ml syringes expired 10/12

It was confirmed in an interview with staff #27 the morning of 6/19/13 that the supplies were expired and available for patient use.

During a tour of the Birthing Center with the staff #27 and #29 on 6/18/13 at 3:00pm, there was a patient room labeled the "pump room." There were 3 breast pumps with an inspection date of 8/10.

It was confirmed in an interview with the staff #27, staff #29, and the Facility Maintenance Manager the afternoon of 6/18/13 that the breast pumps had an expired inspection date. The Facility's Maintenance Manager also confirmed that the equipment was inspected annually.

Facility document entitled "Cleaning and Processing Instruments, Central Service" stated, "I. Policy: Provide a system for decontaminating, cleaning, processing instruments and reusable supplies for OR and facility wide." "B. 2. All reusable instruments are washed and decontaminated by CS personnel. 3. Instruments are packaged for sterilization according to procedure ... 4. After Sterilization, instruments are returned to their respective departments by CS personnel."

Facility document entitled "Cleaning and Processing Instruments, Central Service" stated, "I. Policy: Provide a system for decontaminating, cleaning, processing instruments and reusable supplies for OR and facility wide." " II. Procedure: A. All instruments and supplies to be used for patient care and procedures must be appropriately processed to ensure they are free from infectious bacteria."

Facility document entitled "Shelf Life- Event Related Sterility" stated, "I. Standards of Practice: A. Selection and Use of Packaging Materials: 1. Criteria a: permit penetration of the sterilizing agent."

Facility document entitled "Supply Goods Storage and Handling, Materials Management" stated the Purpose: To "Have the right supply, in the place, at the time and in the right condition."

Facility document entitled "Preventative Maintenance, Equipment Management" stated, "II. Policy: A. It is the responsibility of the Facilities Management Services (FMS) Manager to keep the preventative maintenance program accurate and ongoing." "III. Procedure: A. Facilities Management Services will develop preventative maintenance procedures for all medical devices that are serviced by the (FMS). The preventative maintenance procedures are developed using the specific device's manufacture's preventative maintenance recommendations ..."

Based on observation, interview, and record the facility failed to ensure facilities, supplies, and equipment was maintained to ensure an acceptable level of safety and quality.


Findings include:


During tour of radiology department on 6/18/13 at approximately 12:45PM escorted by staff #4, revealed the floors in several exams rooms were sealed with duct tape, the tiles were lifted, as well as air bubbles in the flooring, putting patients and staff at risk for tripping and/or falls.

Interview on 6/18/13 at approximately 12:50PM with staff #36 when asked about the flooring, stated that they are currently working on getting the floors fix.


Interview on 6/18/13 at approximately 2:37pm when asked what the current status on the completion of the flooring repairs are, she stated that the facility is currently in litigation with the construction company regarding the flooring. She stated after the opening of the facility, that slowly the flooring began to rise.


Interview on 6/18/13 at approximately 2:45PM with Staff #5 revealed that the other areas of the facility that have flooring damage are the medical surgery nurses ' station, laboratory, surgical services, emergency room, and radiology, however surgical services and the emergency room have been repaired. She stated that "radiology was next on the list to be completed; they were waiting on funds to complete the repairs."


Interview on 6/18/13 at approximately 3:20PM with the staff # 38 revealed that the facility has purchased the materials needed to complete the repairs; however they do not have the funds available to complete the repairs.


Interview on 6/19/13 at approximately 10:41AM with staff #39 revealed that the facility is in the process of replacing the floors; however they are "financially strapped". He stated that there is not an estimated date as to when the repairs will be completed. When asked what the facility has in place to keep the patients safe and prevent falls, he stated that patients are escorted in stretchers, beds, wheel chairs, and hand over hand for ambulatory patients or side by side.

Interview on 6/19/13 at approximately 11:14AM with staff # 37 revealed that there is not a written plan or memo for staff to follow regarding patient safety when entering, walking through or exiting area of the facility that have floor damage, currently staff verbally tell patient to "watch for bubbles in the floor".
Record review of facility meeting minutes revealed that the facility was currently in litigation witht the construction company that was responisble for the original floor installation.

During a tour of the Nursing station on 6/18/13 at approximately 3:30pm revealed duct tape on the floor near the patient charts and the nurses' charting area in multiple areas putting staff at risk for tripping and falls.

It was confirmed in an interview on the afternoon of 6/18/13 with staff #27 that the duct tape on the flooring was from the it rising. She stated that staff was only allowed in the nurses station. She confirmed that the floor had not been fixed due to funding. Staff #27 stated the facility was in litigation.

During a tour of the Nursing 300 hall on 6/19/13 at approximately 8:45am revealed the flooring was lifted in front of 4 patient rooms (302, 304, 306, 308) putting patients and staff at risk for tripping and/or falls.

It was confirmed in an interview on the morning of 6/19/13 with staff #27 and #29 that the flooring was bubbling and rising which placed patients and staff at risk for tripping and falls. She confirmed that the floor had not been fixed due to funding and the 300 was an Outpatient area and was not used often. Staff #27 stated the facility did not have the funding and was in litigation with the contractor.

During the moring of 6/19/13, the surveyor witnessed an obstetrical (OB) patient being discharged and walking unescorted out of the 300 hall.

In an interview with staff #29 the morning of 6/19/13, she confirmed that the 300 hall was used for overflow. Staff #29 also confirmed that patients OB patients are encouraged to "walk" out of the facility instead of being taken out in a wheelchair. Staff #29 stated that her staff was not aware of the condition of the 300 hall and there was no plan in place for patient or staff safety.

Additional Findings include:

During tour of the sterilization room on 6/19/13 at approximately 9:00AM escorted by staff #33, revealed multiple previously sterilized instruments were found in the closed position. These included: 8 towel clips, 8 Kelly clamps, 2 Jorgenson scissors, 1 Potts scissors, 3 Mayo scissors, and 1 needle driver.
Interview on 6/19/13 at 9:20AM with staff #33confirmed instruments were previously sterilized in the closed position.
Record review of facility policy revealed all surgical supplies and equipment must be sterilized in the open position.

During a tour of the Emergency Department with staff # 27 and #28 on 6/18/13 at 12:50pm, revealed a packaged sterilized vaginal speculum in the "gynecology room, room #3" which was available for patient use. Inside near the tip revealed an unknown substance in the form of a clump approximately 1 cm.

It was confirmed in an interview with staff #27 and #28 the afternoon of 6/18/13 that the instrument had an unknown substance and was not properly sterilized.

During a tour of the Emergency Department with staff #27 and #staff #28 on 6/18/13 at 12:50pm, revealed approximately 6 sterilized instruments which were in the closed position. 1 of the instruments were closed and clamped.

It was confirmed in an interview with the staff #27 and #28 the afternoon of 6/18/13 that the instruments were not properly sterilized.

During a tour of the Emgergency Department with staff #27 and #28 on 6/18/13 at 12:50pm, the following expired supplies were found available for patient use:

1. 1 Monoject Magellan 3 cc syringe with safety needle expired 6/10
2. 2 Red top vacutainers expired 11/10
3. 2 purple top vacutainers expired 9/10
4. 1 blue top vacutainer expired 4/10
5. 1 Staple remover expired 9/11
6. 1 Thick & Easy 8 oz expired 10/11
7. 1 Culture swab expired 2/12
8. 3 Sodium Chloride 10 ml syringes expired 4/13
9. 1 DeLee Mucus Trap with Vacuum Breaker expired 3/13
10. 20 Culture swabs expired 1/13
11. 1 Pedialyte 1 quart expired 2/13
12. 1 Pedialyte 1 quart expired 3/13

It was confirmed in an interview with the staff #27 and staff #28 on 6/18/13 that the supplies were expired and available for patient use.

During a tour of the Birthing Center with staff #27 and staff #29 on 6/18/13 at 3:00pm, the following supplies were expired and available for patient use:

1. 2 Protective IV Catheters 18 gauge 4/09
2. 3 Introcan IV Catheter 18 gauge expired 10/09
3. 3 Introcan IV Catheter 20 gauge expired 12/09
4. 1 Skin thermometer probe expired 2/10
5. 4 Filter needles expired 1/10
6. 1 TB syringe expired 9/10

It was confirmed in an interview with the staff #27 and staff #29 the afternoon of 6/18/13 that the supplies were expired and available for patient use.

During a tour of the Nursing Units with staff #27 on the afternoon of 6/18/13 and the morning of 6/19/13 the following expired supplies were found and available for patient use:

1. 4 ABG kits expired 5/05
2. 2 tongue blades expired 5/11
3. 4 Heparin Flush 100u/ml 5ml syringes expired 10/12

It was confirmed in an interview with staff #27 the morning of 6/19/13 that the supplies were expired and available for patient use.

During a tour of the Birthing Center with the staff #27 and #29 on 6/18/13 at 3:00pm, there was a patient room labeled the "pump room." There were 3 breast pumps with an inspection date of 8/10.

It was confirmed in an interview with the staff #27, staff #29, and the Facility Maintenance Manager the afternoon of 6/18/13 that the breast pumps had an expired inspection date. The Facility's Maintenance Manager also confirmed that the equipment was inspected annually.

Facility document entitled "Cleaning and Processing Instruments, Central Service" stated, "I. Policy: Provide a system for decontaminating, cleaning, processing instruments and reusable supplies for OR and facility wide." "B. 2. All reusable instruments are washed and decontaminated by CS personnel. 3. Instruments are packaged for sterilization according to procedure ... 4. After Sterilization, instruments are returned to their respective departments by CS personnel."

Facility document entitled "Cleaning and Processing Instruments, Central Service" stated, "I. Policy: Provide a system for decontaminating, cleaning, processing instruments and reusable supplies for OR and facility wide." " II. Procedure: A. All instruments and supplies to be used for patient care and procedures must be appropriately processed to ensure they are free from infectious bacteria."

Facility document entitled "Shelf Life- Event Related Sterility" stated, "I. Standards of Practice: A. Selection and Use of Packaging Materials: 1. Criteria a: permit penetration of the sterilizing agent."

Facility document entitled "Supply Goods Storage and Handling, Materials Management" stated the Purpose: To "Have the right supply, in the place, at the time and in the right condition."

Facility document entitled "Preventative Maintenance, Equipment Management" stated, "II. Policy: A. It is the responsibility of the Facilities Management Services (FMS) Manager to keep the preventative maintenance program accurate and ongoing." "III. Procedure: A. Facilities Management Services will develop preventative maintenance procedures for all medical devices that are serviced by the (FMS). The preventative maintenance procedures are developed using the specific device's manufacture's preventative maintenance recommendations ..."