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Based on document review, interview & observation the facility failed to ensure 1 of 1 nonconforming business occupancy buildings were separated from health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8, failed to ensure it maintained 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station for the last 4 quarters, failed to ensure 1 of 1 portable space heaters were not used in areas accessible to patient, and failed to ensure the hospital grade electrical receptacles in 25 of 25 patient sleeping rooms and in 2 of 2 operating rooms were tested after initial installation, replacement, or servicing of the device (see tag C231).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, interview & observation the facility failed to ensure 1 of 1 nonconforming business occupancy buildings were separated from health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8, failed to ensure it met to maintain 1 of 1 fire alarm systems in accordance with NFPA 72, as required by LSC 101 Sections 19.3.4.5.1 and 9.6. NFPA 72, Section 14.3.1 states that unless otherwise permitted by 14.3.2, visual inspections shall be performed in accordance with the schedules in Table 14.3.1, or more often if required by the authority having jurisdiction. Table 14.3.1 states that the following must be visually inspected semi-annually:
a. Control unit trouble signals
b. Remote annunciators
c. Initiating devices (e.g. duct detectors, manual fire alarm boxes, heat detectors, smoke detectors, etc.)
d. Notification appliances
e. Magnetic hold-open devices,
failed to ensure 9 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions, failed to ensure 1 of 1 portable space heaters were not used in areas accessible to patient, and failed to ensure the hospital grade electrical receptacles in 25 of 25 patient sleeping rooms and in 2 of 2 operating rooms were tested after initial installation, replacement, or servicing of the device. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data. Section 6.3.3.2 states Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces) for 1 facility.

Findings include;

1. Based on observations during a tour of the facility on 12/10/19 at 3:20 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator:
The hospital, a two story building of Type II (111) construction was connected to a two story medical office building of Type V (111) construction by a breezeway of Type V (000) construction. The Hospital lacked a fire barrier separation having a least a two hour fire resistance rating. Based on interview at the time of observation, the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager confirmed the lack of a two fire barrier separation and indicated the hospital had a variance when the hospital was constructed and installed additional sprinklers where the two hour fire barrier would be.

2. During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, an annual visual/functional fire alarm inspection conducted on 10/17/19 was provided but documentation regarding a visual semi-annual fire alarm system inspection conducted six months prior to the annual was not provided. Based on interview at the time of record review, the Corporate Director of Facilities, Technical Operations Manager, and Facilities Manager stated a visual semi-annual inspection of the fire-alarm system was not completed.

3. During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, after February 2019 the fire drill forms did not indicated transmission of signal to the monitoring company. Based on interview at the time of record review, the Police Captain stated the drill form was changed at the beginning of the year and did not include a space to record the transmission of the alarm signal to the monitoring company.

4. Based on observations during a tour of the facility on 12/10/19 at 3:00 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator, a portable fire place containing a space heater was used in a patient area. In the main entrance waiting area there was a moveable electric fire place with a heater. When tested, the heater did turn on and produced heat. Based on interview at the time of observation, the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, stated there is a working electric fire place with a heater in an area accessible to patients.

5. Based on observations during a tour of the facility on 12/10/19 between 1:00 p.m. and 3:40 p.m. with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, and the Safety Coordinator, the facility's 25 patient care rooms contained over 10 hospital grade electrical receptacles, and the two operating rooms were general anesthesia is administered contained around 20 hospital grade electrical receptacles.
During record review on 12/10/19 at 11:14 a.m., with the Corporate Director of Facilities, Technical Operations Manager, Facilities Manager, Quality Accreditation Specialist, Safety Coordinator, Vice President of Patient Services, Police Captain, SVP Support Manager, and the Director of Emergency Preparedness, no documentation was available to show electrical receptacles in the patient care rooms and in the operating rooms were tested after initial installation, replacement, or servicing of the device. Based on interview at the time of the observation and records review, the Corporate Director of Facilities, Technical Operations Manager, and Facilities Manager confirmed all of the electrical receptacles in the patient care rooms and in the operating rooms were hospital-grade and stated it is unknown if initial testing per NFPA 99, Receptacle Testing requirements was conducted

Based on document review, observation and interview the facility failed to follow policy and procedure to ensure the ultrasound carts were cleaned/disinfected in three (3) instances (Rehabilitation Department Room 7); the treatment tables were cleaned/disinfected in five (5) instances and linen storage cabinets were clean/disinfected in five (5) instances (Rehabilitation Department Rooms 1, 2, 3, 4 & 8); the shelves in the clean storage room were cleaned/disinfected in four (4) instances (Medical Surgical Unit); the blood glucose meters were cleaned/disinfected according to the manufacturers recommendation for eight (8) of eight (8) glucometers in four thousand seven hundred fifty two (4,752) instances since January 01, 2019.

Findings include:

1. Review of the hospital policy titled Rehab Therapy "Cleaning of Equipment and Environment", indicated the department will provide a safe and clean environment to promote infection control. The staff shall be responsible for visually inspecting the area for cleanliness. All equipment in its' entirety shall be cleaned after use with the designated cleaning agent. This policy was last reviewed in 12/2019.

2. Review of the hospital policy titled "Cleaning Responsibilities for Departmental Personnel", indicated cleaning and disinfecting of environmental surfaces "is essential to patient safety and comfort". Clinical areas will be kept clean and orderly. Patient cabinets should have all items removed and cleaned and disinfected with approved solutions whenever contamination "is observed or suspected". Patient stretchers, gurneys, transport carts, etc should be cleaned and disinfected after every patient encounter.

3. Review of the hospital policy titled "Chemicals-EVS" (Environmental Services), indicated the approved disinfectant was AF3 Sani Cloth germicidal disposable wipe for disinfecting hard non-porous surfaces. Contact time "is" 3 minutes. Allow to air dry. This policy was last revised in 01/2019.

4. Review of the hospital policy titled "Whole Blood Glucose-Accu-Chek Inform II Meter", indicated meters must be cleaned and disinfected between each patient use. This policy was last revised in 03/2017.

5. Review of the "Accu-Chek Inform II" package insert, indicated if the meter must be used on more than one patient, then the meter must be properly cleaned and disinfected after each patient. Read and follow the ACCU-CHEK Inform II cleaning and disinfecting instructions found in the operator's manual.

6. Review of the "Accu-Chek Inform II Operator's Manual", Maintenance and Care chapter 10, indicated acceptable cleaning/disinfecting agents were Clorox Germicidal Wipes (EPA # 67619-12) and/or Super Sani-Cloth Germicidal Disposable Wipes (EPA # 9480-4). Note always use one of the two acceptable agents. Do not use any other cleaning or disinfecting solution. Using a different solution could result in damage to the system components.

7. On 12/10/2019 at approximately 11:20 am this writer accompanied by administrative staff members A # 3 (Quality & Accreditation Specialist) and A # 4 (Rehabilitation Manager) toured the Rehabilitation (Rehab) unit. The unit had six (6) treatment rooms and two (2) therapy rooms. The linen cabinets and treatment tables had visible wipeable dust in five (5) rooms (Room 1, 2, 3, 4 and 8). The three (3) ultrasound carts had visible wipeable dust (Room 7).

8. On 12/12/2019 at approximately 11:01 am this writer accompanied by administrative staff members A # 3 and A # 1 (Inpatient Manager) toured the Medical Surgical unit. The clean storage/utility room had two (2) metal carts with five (5) shelves each. The bottom two (2) shelves, of each cart, had liners with visible wipeable dust.

9. In interview on 12/10/2019 at approximately 12:35 pm with administrative staff member A # 4, confirmed the linen cabinets in the five (5) rooms, three (3) ultrasound carts and the five (5) treatment tables were visibly dusty.

10. In interview on 12/11/2019 at approximately 2:30 pm with administrative staff member A # 3, confirmed the facility was not using the correct cleaning/disinfecting product to clean the Accu-Chek meters. The facility "is using" the Sani-Cloth gray top with an EPA # 9480-9 and the facility should be using the purple top Sani-Cloth with an EPA # 9480-4.

11. In interview on 12/12/2019 at approximately 12:00 pm with administrative staff member A # 1, confirmed there should not be visible dust on the shelves in the clean storage room.

Based on document review and interview, the hospital failed to follow established policies and procedures for monitoring dietary intake for three of six patient medical records (patients #25, #29, and #30) reviewed for dietary intake.

Findings included:

1. Review of policy titled: "Patient Tray assembly, Delivery, Retrieval and Intake Monitoring," policy number unknown, last approved on "2/2019," read: "Nursing will also record that patient's food intake in the graphic section of the medical chart."

2. Review of patient medical records indicated the following:
a. Patient #25 was admitted to the hospital on 11-7-2019 at 9:05 AM and discharged on 11-12-2019 at 4:36 PM. There was no documentation the patient ate or refused: breakfast on 11-8-2019 and 11-9-2019; lunch on 11-7-2019, 11-8-2019, and 11-9-2019; and dinner on 11-7-2019, 11-8-2019, and 11-11-2019.
b. Patient #29 was admitted to the hospital on 10-24-2019 at 4:43 PM and discharged on 11-6-2019 at 2:33 PM. There was no documentation the patient ate or refused: breakfast on 10-3-2019, 10-31-2019, 11-1-2019, and 11-3-2019; lunch on 10-28-2019, 11-1-2019, 11-2-2019, 11-3-2019, and 11-4-2019; and dinner on 10-28-2019, 10-29-2019, 10-30-2019, 10-31-2019, 11-4-2019, and 11-5-2019.
c. Patient #30 was admitted to the hospital on 11-10-2019 at 9:54 AM and discharged on 11-12-2019 at 2:35 PM. There was no documentation the patient ate or refused: breakfast on 11-11-2019; lunch on 11-10-2019, 11-11-2019, and 11-12-2019; and dinner on 11-10-2019, and 11-11-2019.

3. On 12-12-2019 at 4:10 PM, LS25, Quality Accreditation Specialist, confirmed dietary intake information was missing for the above patients on the dates noted and confirmed the dietary intake or refusal should be documented in the patient's medical record for each meal.

Based on document review and interview, the registered nurse failed to ensure appropriate documentation was entered into the electronic medical record (MR) post blood transfusion procedure for one (1) of six (6) MR's reviewed. (Patient # 4)

Findings include:

1. Review of the hospital policy titled "Blood and Blood Component Administration", indicated blood and blood products administered to patients within this healthcare system will be administered according to the procedure outlined in this document. The end of the transfusion the nurse should assess the patient for reaction, obtain vital signs and document. This policy was last revised in 07/2019.

2. Review of Patient #4's medical record (MR) on 12/12/2019 at approximately 10:55 am, indicated the MR lacked the date and time the blood had been issued from blood bank and lacked the blood transfusion stop time in the blood transfusion record.

3. In interview on 12/12/2019 at approximately 10:55 am with A # 5 (Registered Nurse-Education), confirmed the issue date and time of blood should be documented in the MR and the stop time should be documented on the blood flow sheet. It "is a nursing responsibility".

4. In interview on 12/12/2019 at approximately 1:50 pm with administrative staff member A # 3 (Quality & Accreditation Specialist), confirmed a zero (0) should have been documented, in the blood transfusion section of the electronic medical record, when the transfusion had completed infusing.

Based on document review and interview, the nurse failed to implement a patient care plan in two (2) instances. (Patient # 7 & Patient # 9)

Findings include:

1. Review of the "Swing Bed Program Patient Handbook", page 4, indicated upon the patients arrival "an admission assessment will be completed" by the nurse. The information gathered during the assessment process lays the foundation for the patient's care plan while in the swing bed program. The "individualized care plan is designed to meet" the patients "health care needs and will be evaluated weekly".

2. The following medical records (MR's) were reviewed on 12/12/2019:
a. The History and Physical (H&P) dated 12/06/2019 indicated Patient # 7 had been admitted with a Lumbar surgical wound. The Physician wrote orders for wound care and Physical Therapy (PT) to evaluate and treat on 12/05/2019. The MR lacked individualized care plans for wound care and PT.
b. The H&P dated 11/30/2019 indicated Patient # 9 had been admitted with debility. The Physician wrote an order for PT to evaluate and treat on 11/30/2019. The MR lacked an individualized care plan for PT.

3. In interview on 12/12/2019 with administrative staff member A # 1 (Inpatient Manager), confirmed patient # 7 should have had a care plan implemented for "Impaired Skin Integrity" and "Physical Therapy". Patient # 9 should have had a care plan implemented for "Physical Therapy".