HospitalInspections.org

Based on review of the facility's maintenance records, the facility failed to maintain the emergency generator in accordance with NFPA 99, Sec. 3.4.4.1 and NFPA 110, Standard for Emergency and Standby Power Systems.

Findings include:

Cross Reference to K 144 NFPA 101 Life Safety Code Standard

On 6/27/12 the facility maintenance supervisor was unable to produce documentation that the emergency generator was inspected, tested and maintained annually. The generator was last inspected, tested and maintained on 5/23/11 by Hawthorne Pacific.

Based on observation, staff interview, and policy review, the facility did not maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings include:

1. Observation was made on 6/26/12 at 10:55 A.M. of licensed staff doing a blood sugar test for Patient #2. Staff placed a case with supplies and Accu-chek glucometer directly on the patient's bedside table without any barrier. After cleaning the patient's finger with an alcohol swab and wiping the finger with a gauze, the used items were placed on the table. At the completion of the test, staff took the supply case and glucometer back to the medication room. The glucometer was returned to the docking station. No observation was made of disinfection of the glucometer or the patient's bedside table.

Interview with staff at 11:15 A.M. revealed that the glucometer is used for any patient and/or resident in the facility. Staff revealed that the glucometer should be disinfected after each use with the facility's disinfectant product.

A review of the facility's policy on "Accu-Chek Inform Meter" was done. It was noted under Cleaning and disinfecting the meter: "After each meter use, use a dampened microfiber cloth or paper towel dampened with one of the following: Viritec EO Water Cleaner and EO Water Disinfectant.... While carefully avoiding the meter/base connectors and base unit circuitry, gently wipe exposed surfaces of the meter and base unit".

2. Observation of medications and supplies on the second floor in the medication storage room on 6/27/12 at 10:45 A.M. revealed the following - 5 packages of sterile central line dressings with expiration date of 6/1/11 and 1 PICC Plus catheter stabilization device with expiration date of 5/2010. The medications and supplies were used by both the long term care and Critical Access Hospital units of the facility. Interview with registered nurse (RN#1) on 6/27/12 confirmed expiration date of supplies. No log could be located in the area for checking supplies.

Interview was conducted with Director of Nursing (DON) on 6/28/12 regarding policy/practice on checking for expired medical supplies. No policy could be produced for a system to check for expired items.

Based on closed record reviews, staff interview, and policy review, the facility did not ensure for each patient receiving health care services, the facility maintains a record that includes a brief summary of the episode, disposition, and instructions to the patient for one of 18 closed records reviewed.

Findings include:

Closed record review done on 6/26/12 noted a patient was admitted to the hospital on 4/23/12 with diagnoses including exacerbation of chronic obstructed pulmonary disease and shortness of breath. Progress notes indicated the patient was discharged to an assisted living facility on 4/26/12. Further review of the record could not find a discharge summary. Interview with medical records staff confirmed that a discharge summary was not done. Staff reported that physicians can complete records at home via the electronic medical records system. Review of the facility's policy on "Chart Completion and Analysis" noted "Medical records will be completed within 30 days of discharge".