HospitalInspections.org

Based on policy and procedure reviews, hospital document review, medical record reviews, and staff interviews; the hospital failed to ensure a patient's right to formulate an advance directive for one 1 of 11 patients reviewed (Pt # 34).
The findings include:
Review of policy "ADVANCE CARE DIRECTIVES TO PATIENTS", Number PR 120.02, reviewed/revised 04/2015 revealed "...D. If a patient does not have an Advance Care Directive, the staff member shall offer assistance in the development of an Advance Care Directive. If the patient requests further information the patient will be provided a booklet that describes Advance Care Directive. ..."
Review of Patient Rights document, dated 04/2011, revealed "...28. The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. ..."
Closed medical record review of Patient (Pt) # 34 revealed the patient, a 79 year old, was admitted on 05/29/2015 with altered mental status, urinary tract infection, and dehydration. Review of "Adult Admission History", entered on 05/30/2015 at 0116, revealed "...Advance Directives....Status of Living Will: Patient/family wishes to create or discuss a living will....Status of Healthcare Power of Attorney: Patient/family wishes to create or discuss a healthcare power of attorney. ..." Continued medical record review failed to reveal documentation that additional advance directive literature was given or that an advance directive/ health care power of attorney was created.
Staff Interview with RN # 1 and RN # 3, on 06/04/2015 at 1145, revealed that staff members do not give additional information or assist with advance directives / health care power of attorney. Interview revealed they "send them to the courthouse."
Interview with Administrative Staff (AS) # 3, on 06/04/2015 at 1415, revealed when patient/ family requests more information on advance directives, employees should give them the flyer "Choosing the Care You Want: ADVANCE DIRECTIVES". Interview revealed employees "...should not be routing patients to the courthouse."
Interview with AS # 2, on 06/05/2015 at 1320, revealed the courthouse is not a part of the advance directive process. Interview revealed hospital staff members did not follow policy when stating they would send a patient/ family to the courthouse.

Based on 2014-2015 Performance Plan review and staff interviews; the hospital staff failed to measure, analyze and track the effectiveness, safety and quality of dietary services to ensure patient safety.

The findings include:

Review of the 2014 Performance Improvement Plan conducted June 5, 2015 revealed, "Mission...Vision...Authority...Leadership...CHS (Carolinas Healthcare Systems) Structure / Roles & Responsibilities...Functions: The Performance Improvement Committee (PICC) receives reports from the departments of the hospital. The PIC shall act as appropriate on recommendations of these bodies and assure that efforts undertaken are effective and appropriately prioritized. Reports on the analysis and actions taken regarding the various quality and utilization functions shall be received and acted upon according to the routine reporting schedule in in the plan. ...

Review of the 2015 Performance Improvement Reporting Calendar conducted June 5, 2015 failed to revealed the Dietary Department reporting frequency.

Interview with the Chief Nursing Officer (CNO) conducted June 4, 2015 at approximately 1530 revealed the Performance Improvement staff failed to measure, analyze and track the effectiveness, safety and quality of dietary services.

Interview with the Performance Improvement staff conducted June 5, 2015 at approximately 1100 revealed the Performance Improvement staff failed to measure, analyze and tract the effectiveness, safety and quality of dietary services.

On June 3, 2015; the Life Safety Code (LSC) survey was conducted as per The Code of Federal Register at 42 CFR 482.41(a); using the 2000 New Health Care section of the LSC and its referenced publications. This building is Type II (222) construction, one story, with a complete automatic sprinkler system. In the exit conference, all deficiencies noted were discussed with administration.


At the time of survey:
Total Certified Bed Count = 15
Census = 0

All deficiencies determined during the survey are as follows:

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiency was noted: The standard is non-compliant, specific findings include:

The facility failed to have proper exit directional signs in the egress (exit) corridors.

The facilty does not have two visible exit directional signs near room 1314 leading from the operating rooms to the emergency department of the hospital.

This deficiency affected the one (1) egress corridor of approximately six (6) egress corridors.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations conducted 06/04/2015 at approximately 1:00 PM onward, the following deficiency was noted: This standard is non-compliant, specific findings include:

The emergency generator located on the exterior of the building had no remote manual stop switch located outside the generator set location.

This deficiency affected the entire facility as the generator supplies the entire facility's emergency power source.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non compliant, specific findings included:

1. The facilty does not have the bottom portion of the inactive leaf or the door (1019) for the storage room connected on the top and bottom of the door in the community room.

2. The facilty does not have the bottom portion of the inactive leaf or the door (1133a) at the emergency department.

3. The facilty does not have the bottom portion of the inactive leaf or the door at the radiology department.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on observations, on 6/3/2015 at approximately 9:00 AM onward, the following deficiencies were noted: The standard is non compliant specific findings include:

1. The facilty does not have a clear exit path to from the materials management hallway to the public way.

2. The exit path from the consult area leading to the main lobby does not have an eight foot clear path.

This deficiency affected the two egress corridor of approximately six (6) egress corridors.


3. The hospital does not have heating in the sprinkler riser room (1055) with outside entry. This location did not provide proper heating on the emergency circuit to prevent freezing of the sprinkler system and its components.

The deficiency would allow the sprinkler pipes to be susceptible to freezing in very low ambient temperatures. This deficiency affected the one sprinkler riser room for the facility.


Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Based on review of hospital policy for stock rotation and expired products, observations during tours, and staff interviews; the hospital staff failed to maintain the facility in a manner to ensure a level of safety by failing to remove out of date angiocaths (device used for delivering intravenous fluids) for 12 of 12 angiocaths.
The findings include:
Review of hospital policy "MANAGEMENT OF STOCK ROTATION AND EXPIRED PRODUCTS" with revision date of October 2014 revealed "If the product is expired or expiring, the storeroom lead will alert the (distribution center) to arrange for new product to be shipped in immediately or prior to the expiration date of the new product. Once the new product is received, the expiring product will be removed and replaced with the new product .....When a department requisitions non-stock or non-catalog products, the department will be responsible to monitor expiration dates and reorder replacement product. Expired product or about to expire are to be returned to Materials Resource Management for disposal."
Observation on 06/03/2015 at 1515 in Computerized Tomography (CT-special x-ray equipment to create detailed pictures) revealed 12 angiocaths with size of 18 gauge with expiration dates of 05/2015 (3 days past expiration).

Interview with administrative staff (AS) #1 on 06/03/2015 at 1518 revealed angiocaths were out of date.

Based on policy and procedure reviews, surgical log review, terminal cleaning log review, and staff interviews; the Infection Control Officer failed to ensure 1 of 1 operating room was terminally cleaned for 3 of 6 surgical days and failed to ensure the Emergency Department (ED) trauma room was sanitized.

The findings include:

1. Review of the hospital's policy, "CLEANING PROCEDURES, OPERATING ROOM," with a review date of March 2013 revealed, "POLICY: 1. The Operation Room will be cleaned on a prioritized schedule: a. ...c. Terminal room cleaning will be performed daily on an assigned schedule. d. ...3. The manager will be responsible for ensuring that all assignments are given and followed through."

Review of the Surgical Log conducted June 4, 2015 revealed on April 23, 2015, a colonoscopy (intestine procedure) surgical case was completed; on April 30, 2015, a colonoscopy and left inguinal hernia (intestine protrusion) repair with mesh (equipment for hernia repair) surgical cases were completed; and on May 21, 2015, a colonoscopy surgical case was completed.

Review of the terminal cleaning log revealed terminal cleaning would be performed everyday the operating room was in use. Review of the terminal cleaning log failed to reveal the operating room was terminally cleaned on April 23, 2015; April 30, 2015 and May 21, 2015.

Interview with the Chief Nursing Officer (CNO) conducted June 4, 2015 revealed the operating room would be terminally cleaned at the end of day when in use. Interview revealed the operating room was in use on April 23, 2015; April 30, 2015 and May 1, 2015. Interview failed to reveal the operating room was terminally clean for the days in use.



34827

2. Review of Hospital policy No. 100.11 Cleaning Patient Area Isolation Room Discharge or Transfer dated 6/4/2015(trauma rooms are treated as isolation rooms per Infection Control Corporate Director present), states: "Discharge and Transfer cleaning is performed upon the exit of the patient. Cleaning tasks are performed to ensure that all surfaces are sanitized in preparation for the admission of a new patient. ... Begin high dusting at the door, working counter-clockwise, dusting items such as door tops, pictures, over-bed lights ...vents, curtain rods. ... PATIENT ROOM CLEANING: BEGIN DAMP WIPING ALL SURFACES INCLUDING HIGH TOUCH AREAS. Using a clean cloth pre-moistened with Oxicide..."

Observation of the room cleaning procedure in the ED trauma room on 06/04/2015 at 1010 to 1057 with the Assistant Director of Housekeeping, Director of Infection Control revealed the environmental services staff member used a cleaning cloth to clean the trauma room with a cleaning solution. Observation further revealed the cleaning solution contained additional cleaning cloths. Observation further revealed after the cleaning process was initiated, the environmental services staff member placed the used cloth back into the cleaning solution. Observation further revealed the environmental services staff obtained cleaning cloth(s) from the cleaning solution to clean the remainder of the ED trauma room (equipment included). Observation failed to revealed equipment attached to the wall behind the stretcher were sanitized, including: sphygmomanometer (blood pressure measuring device), oxygen delivery device, suction port and call bell/bed control remote. Observation failed to reveal the environment service staff member ensured the ED trauma room was sanitized for a new patient use.

Interview conducted concurrently during the observation the Assistant Director of Housekeeping (Environmental Services) revealed the ED trauma room was not cleaned according to policy and procedure.

Based on policy and procedure review, closed medical record reviews, and staff interviews; the hospital failed to complete timely discharge planning evaluations for two (2) of 22 inpatient records reviewed. (Pts # 35, 37)
The findings include:
Review of policy "DISCHARGE PLANNING", reviewed/revised 02/2015, revealed "...The bedside admission nurse completes the Discharge Planning section on the Adult or Pediatric History Screening. If the patient scores a positive screen, Clinical Care Management (CCM) receives a consult electronically. Consults will be addressed within 48 hours, prior to discharge, and/or as changes, impact the discharge plan. ...Discharge planning evaluations and consults are completed within 48 hours of admission with a goal of 24. ..."
1. Closed medical record review for Pt # 37 revealed the patient was admitted on Sunday, 04/26/2015 from a skilled nursing facility. Review of History and Physical (H&P) revealed an impression of sepsis (infection) related to cellulitis (skin infection) of mandibular (jaw) region and lower lip. Review of the CCM Discharge Planning Assessment revealed it was performed on Thursday 04/30/2015 at 0950 (more than 72 hours after admission).
Interview with RN # 1, a Clinical Care Coordinator (CCC), on 06/04/2015 at 0915 revealed she completes a discharge plan on all inpatients using the Discharge Planning (DCP) Assessment form. Further interview with RN # 1, on 06/05/2015 at 1030, revealed the Discharge Planning Assessment for Pt # 37 was not completed until Thursday 04/30/2015, more than 48 hours after admission.
Interview with administrative staff (AS # 2), on 06/05/2015 at 1320, revealed the Discharge Planning policy was not followed.
2. Closed medical record review for Pt # 35 revealed the patient was admitted on Friday 05/08/2015. Review of H&P revealed Pt # 35 was admitted from a nursing home to be evaluated for tachycardia (elevated heart rate) and delirium (sudden change in mental status). Record review revealed a Discharge Planning Assessment was completed on Monday, 05/11/2015 (3 days later).
Interview with RN # 1 on 06/04/2015 at 0915 revealed she works Monday through Friday, not on the weekends. If a patient comes into the hospital over the weekend, interview revealed, nursing staff could call the sister hospital, Hospital A, when discharge planning services were needed. A staff member from Hospital A would then complete phone interviews and/or set up needed after discharge services. On Monday, RN # 1 stated, she reviews admissions and discharges from the weekend and makes sure any needed discharge services are set up. Further interview on 06/05/2015 at 1030 revealed the Discharge Planning Assessment for Pt # 35 was completed on Monday, 05/11/2015 (more than 48 hours after admission).
Interview with AS # 3, on 06/04/2015 at 1415, revealed the discharge planning process with Hospital A is an informal process. Interview revealed there is not a policy guiding the process for weekend coverage.
Interview with AS # 2, on 06/05/2015 at 1320, revealed patients admitted from a nursing home should follow the same discharge planning process as other patients. Interview revealed there were inconsistencies in the process. Further interview revealed the Discharge Planning policy was not followed.