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Based upon observation, interview, and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

A-0701 - Failure to maintain an environment free of ligature risks
A-0703 - Failure to ensure an adequate supply of on-site emergency fuel for boilers and emergency generator
A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code
A-0720 - Failure to maintain a safe environment with respect to the maintenance and labeling of the medical gas system as well as maintenance of the electrical isolated power system and in respect to the storage of compressed oxygen and carbon dioxide cylinders
A-0724 - Failure to maintain a sanitary environment and remove outdated supplies
A-0726 - Failure to maintain proper light, ventilation, and temperature controls

Based on observation, interview, and document review the facility failed to maintain a safe physical environment for 21 of 30 patients (pt.#'s 12, 14, 15, 35, 36, 37, 38, 39, 43, 44, 45, 47, 48, 49, 54, 57, 58, 59, 60, 61, and 62) by failure to provide a ligature free environment resulting in the potential for a patient to hang oneself resulting in physical harm and/or death. Findings include:

On 4/12/2021 at 1120 during the tour of 4 South Psychiatric Unit a room designated as the "tub room" was noted to be locked. Staff G was queried if the room was in use for patients. Staff G stated the room was never used for patients. Staff G was asked to unlock the room for observation. The tub room was observed to have a trash receptacle full of trash with a blue composition notebook with a name and birth date on the front cover. Further observation in the room revealed exposed piping above the open tub area, a silver slide bar with an open area behind the bar, two water control fixtures (handles) over the tub, and elongated copper colored pipe protruding from the wall over the open tub area, an open area under the hand washing sink with exposed piping, a toilet with exposed piping, a silver hand rail with and open area between the wall and the handrail, a round protruding door handle, and a door closure device with a triangular open area between the device. Staff G was queried why the trash was full and a composition book was located in the trash receptacle. Staff G replied, "I'm not sure...patients do not use this room."

On 4/12/2021 at 1130 a review of the patient hard charts located at the nurse's station occurred. The name recovered from the composition book was identified in the patient charts. Document review of the patient chart identified the patient's name and date of birth to be the same as the name and birth date located on the composition book located in the "tub room."

On 4/12/2021 at 1135 an interview occurred with staff S, the registered nurse in charge on the psychiatric unit. Staff S was queried if patients were allowed to use the "tub room." Staff S responded, "yes...when a patient uses the quiet room the tub room is used for the patient to use the restroom." Staff S was then queried if she was aware of the ligature risks located in the "tub room." Staff S turned to staff G and stated she didn't understand what was meant by the question of ligature risks. Staff S was asked to view the room. Staff S was shown the ligature risks located in the "tub room." Staff S was asked if patients were kept in view while using the "tub room." Staff S stated patients were not kept in view while using the "tub room." Staff S stated that the door would be unlocked and staff would check on the patients every 2 - 3 minutes.

On 4/12/2021 at 1330 a document review occurred of all 30 current patient charts of patients located on 4 South Psychiatric Unit to identify patients with documented risk to self or suicidal ideation. Of the 30 patient charts reviewed 21 patients (pt.#12, 14, 15, 35, 36, 37, 38, 39, 43, 44, 45, 47, 48, 49, 54, 57, 58, 59, 60, 61, and 62 ) had documented risk to self or suicidal ideation documented in the patient record.

On 4/13/2021 at 1400 a policy was requested for ligature risks. On 4/14/2021 at 1245 a second request was made for a policy pertaining to ligature risks. Staff A, the Director of Quality and Risk responded, "Ligature training for staff is available but there is not a specific policy for ligature risks."


28539

During an interview with Pt #12 on 04/12/21 at 1605, Pt #12 said she had used the quiet room bathroom on Unit 4 South several times during her recent course of stay. Pt #12 said there were two locked doors leading into the quiet room bathroom, one from within the quiet room and the other from the outside hallway. Pt #12 said staff would unlock one of the doors allowing her entry into the bathroom. Pt #12 said, after unlocking the bathroom door, staff would "walk away" to allow privacy. Pt #12 said she had observed staff unlocking the door multiple times allowing other patients to use the quiet room bathroom. Pt #12 said she did not recall staff ever monitoring other patients while they used the quiet room bathroom, stating staff "let you in and walk away".

During an interview with Pt #35 on 04/13/21 at 1040, Pt #35 said she had used the quiet room bathroom on Unit 4 South "a few times" during her recent course of stay. Pt #35 said patients were not able to enter the quiet room bathroom because the doors were locked. Pt #35 said staff would unlock one of the bathroom doors to allow her entry. Pt #35 said, once inside the bathroom, staff would leave her "alone in there".

During an interview with Pt #14 on 04/13/21 at 1055, Pt #14 said she had used the quiet room bathroom on Unit 4 South "once" during her recent course of stay. Pt #14 said patients usually did not use the quiet room bathroom because the doors were locked however, if requested, staff would unlock the doors to allow entry. Pt #14 said she was left alone when using the quiet room bathroom.

Based on observation and interview, the facility failed to ensure an adequate supply of on-site emergency fuel for boilers and emergency generator. Failure of the boilers or generators could result in the failure of heating plant and/or critical life safety equipment in the event of a power failure resulting in potential serious harm to all patients using such equipment.

Findings include:

1. On 4/13/2021 at 0915 during a tour of the powerhouse, observed that the equipment used to measure the amount of on-site emergency fuel oil was not working. Red "Alarm" light was on the Veeder-Root (fuel gauge) and the screen read "Probe out" indicating the fuel level could not be measured. No record of recent levels were available. At the time of teh observation, Staff GG was queried and said that calls were made to fix the equipment but the repair company had not come out yet.

Based upon observation, interview and record review the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated April 14, 2021.
K-0222
K-0300
K-0311
K-0321
K-0341
K-0342
K-0346
K-0351
K-0353
K-0354
K-0355
K-0363
K-0374
K-0379
K-0521
K-0712
K-0761
K-0781
K-0912
K-0918

This citation has two Deficient Practice Statements (DPS)

Deficient Practice Statement #1
Based upon observation, interview, and document review, the facility failed to maintain a safe environment in particular with respect to the maintenance and labeling of the medical gas system as well as maintenance of the electrical isolated power system. The lack of adequate isolated power system maintenance could result in significant harm to those patients undergoing invasive surgical procedures should an electrical fault occur and continue undetected. Improper maintenance and labeling of medical gas valves increases the risk of medical gas failure for the medical gas outlets not maintained with potential adverse outcomes. Without proper labeling of the medical gas shutoff valves, staff may not be able to quickly and accurately isolate the oxygen supply to the patient rooms which may need to have the oxygen turned off in an emergency resulting in serious potential harm to all patients from smoke and fire.

Findings include:

1. On 4/12/21 at 1225, observed that the oxygen shutoff valve across from Room 445 on 4 South was not labeled as to the area(s) served. This was confirmed by Staff K at the time of the finding.

2. On 4/12/21, at 1614, observed that the operating rooms were provided with isolated power panels. At that time, the isolated power panels were tested by pushing the test buttons. The audible alarm for the isolated power panel in Operating Room (OR) 5 did not sound when tested. This was confirmed by Staff K at the time of the finding.

3. On 4/13/21 at 0930 during document review with staff BB, identified that there was no record of any preventive maintenance on the isolated power panels available for review. Staff BB explained that the facility was aware of the need to conduct maintenance on the isolated power system and that an electrical contractor had come out twice to look at the panels, but the work had not yet been done. This was confirmed by Staff BB at the time of the finding.

4. On 04/13/21 at approximately 1400, during document review, observed that the medical gas valves for the 3 South triage room were not included in the annual medical gas inspection report. This was confirmed by Staff GG who commented the he would arrange to have the company come back to conduct the testing for this room.


43001


Deficient Practice Statement #2
Based on observation and interview, the facility failed to maintain a safe environment with respect to the storage of compressed oxygen and carbon dioxide cylinders in the medical gas storage room. Inadequate storage of these cylinders can lead to serious harm to staff if the cylinders were to tip over, break and become a projectile.

On 4/13/21 at approximately 0930, during a tour of the hospital basement level, observed three unsecured carbon dioxide compressed gas cylinders and two unsecured oxygen cylinders in the main medical gas manifold room. This was confirmed by Staff GG at the time of the finding.

Based on observation and interview, the facility failed to adequately maintain the building and equipment with regards to wall, ceiling and floor finishes, exhaust fans and other equipment at an acceptable level for patient care resulting in the potential for poor outcomes to all patients. Findings include:

On 04/12/21 at 0930 during the initial observation tour of the Intensive Care Unit (ICU), it was noted in the "Clean Supply" room that there was one 4 x 3 cm Tegaderm bandage that expired on "03/2020" and one Huber needle that expired on "09/2020".

On 04/12/21 at 0940 during the initial observation tour of the Intensive Care Unit (ICU), it was noted that the one "Computer on Wheels (C.O.W.) contained a large amount of white dust, paper clippings, and what appeared to be a cut off fingernail.

During interview with the Director of Nursing (Staff G) at the same time of tour, Staff G confirmed that the supplies were outdated, available for patient use and that the C.O.W. was "dusty".


38269

On 04/12/2021 at 1050 during a tour of the intensive Care Unit (ICU) the following outdated supplies were found available for patient use:

1. Two size 32 Fr nasopharyngeal airways; date of expiration 2013-01 and 2019-06
2. Three packaged Laryngoscope Blades; date of expiration 2019-12
3. Eight Ambu Flexible video scopes; date of expiration 2018-08-01

The above findings were confirmed by staff H at the time of observation (04/12/2021 1050).
On 04/12/2021 at 1300 and again on 04/14/2021 at 1000 a policy related to expired supplies was requested. On 04/14/2021 at 1130 Staff A stated, "we have no policy regarding expired supplies available".


19647

Based upon observation and interview the facility failed to adequately maintain the hospital physical environment building finishes and fixed equipment so that they were kept in good condition and working properly resulting in potential for harm to all patients, visitors and staff. Findings include:

Findings include:

1. On 04/12/21 at 1020, during building tour a very loud whining noise coming from above the ceiling in an empty patient room 768 was heard. Later, at approximately 1450, during a tour of the main roof, it was determined that the noise was coming from a rooftop exhaust fan (EF# 10). The fan was still exhausting air but there was something wrong with the operation of the fan that needed attention (such as a bad bearing or fan belt) before it failed prematurely.

2. On 04/12/21 at 1143, observed the room unit ventilator under the window sill in Room 467 had an large amount of dirt and debris in the top heating coils which could affect the proper functioning of the unit.

3. On 04/12/21 at approximately 1200, during the building tour of 4 South, observed numerous areas of the main corridor flooring which were damaged, deteriorated and not lying smoothly with observed cuts, cracks, and areas where the floor covering was buckled/bubbled up. Specific items were:
a. At 1143 observed floor in Room 467 was buckled.
b. At 1205 observed floor at toilet in Room 456 was coming up and buckled.

4. On 04/12/21 at 1230, observed that the 4 South Medication room was missing a section of baseboard.

5. On 04/12/21 at 1550, observed that the 5 South Medication room was missing a section of baseboard under the counter.

6. On 04/12/21 at 240 observed in Room 502 that the baseboard in the room had come loose, making that portion of the wall and floor difficult to clean.

All of the above findings were confirmed by staff K at the time of the survey.

7. On 04/13/21 at 1010 observed a hole in the wall in the janitor's closet in Radiology that was approximately 6 inches x 6 inches square that had not been patched. This was confirmed by Staff BB at the time of the finding

8. On 4/13/21 at 1015 observed that the handwashing sink in ICU Room 139 provided only a very low flow when the foot pedal actuator was depressed. The other foot pedal operated sinks in ICU were working with a full flow of water when activated. This was confirmed by Staff BB at the time of the finding.

9. On 4/13/21, at 1156, observed that the main Environmental services room had nine 5-gallon containers of corrosive floor stripper chemical. The room was not provided with an approved eyewash facility for employee to use in the event that some of this corrosive chemical is accidentally splashed into their eyes. This was confirmed by Staff FF at the time of the survey.

10. On 04/13/21 at 1506 observed during the facility tour of 3rd floor multi-specialty unit, that the nurse call audible alarms were disabled since the dome light serving Room 303 was constantly blinking and could not be turned off even when the call was answered. This was confirmed by Staff FF at the time of the finding.

Based upon observation, interview, and document review the facility failed to maintain proper light, ventilation and temperature controls in patient care areas. This deficient practice could result in staff not being able to properly perform their duties due to poor lighting which would negatively affect all surgical patient outcomes. A ventilation system that does not provide proper humidity can compromise the integrity of sterile supplies or other patient products resulting in the potential for less than optimal outcomes for all surgical patients.

Findings include:

1. On 4/12/2021 at 1651 in the Central Sterile delivery room, observed that there were two ceiling light fixtures that had bulbs burned out. This was confirmed by Staff K at the time of the finding.

2. On 4/12/2021 at 1653 in the Central Sterile decontamination room, observed that there were three ceiling light fixtures with bulbs burned out. This was confirmed by Staff K at the time of the finding.

3. On 4/13/21 at approximately 0930, during document review with Staff BB, Staff BB provided copies of the recent ventilation survey from Contractor A conducted on 03/19/21. Inspection of this documented revealed that the report documents that the ventilation of Operating Rooms (OR) 1, 3, 4, 5, 6, and 7 were "not currently passing all code requirements." The OR assistant (Staff W) explained that only OR 1, 2 & 3 were currently being used. She explained that OR 4, 5, 6, & 7 were being used for storage. Typical non-compliance for ORs 1 & 3 as documented by the Contractor A report included lack of adequate air volumes for required air changes per hour, and room pressure not meeting the required + 0.01 inches water column.

Based on observation and interview, the facility failed to ensure an acceptable water quality for the buildings potable water system as evidenced by a lack of implementation of a building water quality management program, failed to ensure sanitary conditions in patient care areas, and failed to ensure sanitary conditions in the kitchen, resulting in the increased potential for cross contamination, foodborne illness and transmission of infectious agents to all patients, staff, and visitors.

Findings include:

1. On 4/12/21, at 1015, observed that the built-in wardrobe in the newly renovated patient room 768 was missing its trim around the top and sides exposing a void between the wardrobe and the alcove which would be difficult to clean and would provide harborage for insects and vermin. This finding was confirmed by Staff K at the time of the survey.

2. On 4/12/21 at 1114, observed the backsplash for the sink in the dining room had open seams that were exposed due to failed caulking which could collect moisture, swell the substrate and grow harmful bacteria. This finding was confirmed by Staff K at the time of the survey.

3. On 4/13/21, at 1350 during document review, identified that the water management plan which was revised as of 3/4/2021 had not yet been approved by the governing body and not implemented. The previous water management plan was dated 03/9/2018. The revised water management plan was reviewed and found to be lacking in any specific water testing protocols and acceptable ranges for control measures. There was no documentation available for any water testing for any month in 2020. There were no records of any meetings of the water management team available for review. The list of staff members comprising the water management team included the former infection control nurse who is no longer with the facility. The list has not been updated to include the current infection control nurse. Staff BB confirmed this finding during document review.


22960

Based on observation, interview and record review the facility failed to ensure sanitary conditions in the kitchen, resulting in the increased potential for cross contamination, foodborne illness and transmission of infectious agents. These deficient practices had the potential to affect all patients, staff and visitors that consume food from the kitchen. Findings include:

On 4/12/21 during a dietary tour of the kitchen between 10:00 AM and 12:50 PM, the following observations and interviews took place:

1. On 4/12/21 at approximately 10:30 AM, in the walk-in cooler, there were opened and undated containers of thousand island dressing, tartar sauce, blue cheese dressing, raspberry vinaigrette dressing, culinary cream and sour cream. When queried at that time, Dietary Manager (DM) "E" stated, "They should be labeled with the opened date." In addition, there was a 10 pound container of macaroni salad dated 3/30. When queried at that time, DM "E" stated, "That's past date, I'll throw it out." The flooring inside the walk-in cooler was observed with food debris, onion skins and lettuce pieces. The rack for the salad dressing was observed encrusted with dried on food spills. When queried, DM "E" stated "I'll change that rack out."

Review of the facility's undated food storage "Policy #B003" on 4/15/21 at 9:45 AM, noted: "Label when product is opened."

2. On 4/12/21 at approximately 11:00 AM, the lids for the steam table pans were observed to be heavily soiled with dried on spills and food debris. In addition, the wells inside the steam table were observed with cloudy water, with food debris collected on the bottom. When queried at that time regarding how often the steam table is cleaned, DM "E" stated, "Not often enough."

3. On 4/12/21 at approximately 11:30 AM, Dietary Staff "T" was observed wearing black disposable gloves, collecting trash from the kitchen. Dietary Staff "T" used a rolling trash bin to transport the refuse to the exterior dumpster. Dietary Staff "T" returned to the kitchen, and wearing the same black gloves, began rinsing out the rolling trash bin with a hose sprayer. Dietary Staff "T" then went directly to the 3 compartment sink room, and with the same black disposable gloves, began putting away clean equipment throughout the kitchen. On 4/12/21 at approximately 11:50 AM, DM "E" was queried regarding the infection control practices observed by Dietary Staff "T" and stated, "My expectation would be for him to wash his hands when he comes back into the kitchen."

On 4/15/21 at 10:00 AM, review of the facility's "Sanitation and Infection Prevention/Control, Hand Hygiene, Policy #F007", updated July 2019 noted: "In the Food & Nutrition Services Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times:

Before each shift
Before handling food or clean utensils/dishes/equipment
Before putting on gloves
Between handling raw and cooked foods
After taking a break/when returning to kitchen
After touching hair, skin, beard or clothing
After caring for or handling support animals (seeing - eye dogs) or aquatic animals
After using tobacco, eating or drinking After handling money
After use of toilet
After handling soiled silverware/utensils
After handling garbage
After handling cleaning equipment
After handling shipping containers
After coughing, sneezing, or blowing nose
After removing gloves
After any other activity that may contaminate the hands"

4. On 4/12/21 at approximately 12:00 PM, Dietary Staff "U" was observed preparing food in the food prep area of the kitchen. There were 2 rags observed lying on the food preparation table. There was no bucket observed with sanitizer solution in the area. Dietary Staff "U" was observed wetting the rags underneath running water, and then wiping down the food preparation counter. When queried at that time about the wiping cloths not being stored in a sanitizer bucket, DM "E" confirmed that the rags were to be stored in the sanitizer bucket.

Based on document review and interview the facility failed to show evidence that the Organ Procurement Organization was being notified in a timely manner of all patient deaths, as required per the agreement between the organ procurement organization and the facility in 3 of 3 patients sampled (Pt. #8, 9, 10). Findings include:

A review of 3 of 3 patient death records (Pt. #8, 9, 10) and the facility's organ procurement files revealed that the facility failed to maintain any written documentation or records showing evidence of contact or referrals made to Organ Procurement Organization regarding patient deaths within one hour as required. There was no evidence of the facility's ability to monitor for timeliness of referrals as required.

On 04/13/2021 at 1430 during an interview, Staff A stated, "I was not aware that the time of call was not recorded. I will add that to the document and do education with the appropriate staff."

Document review revealed an "Agreement Between the (organ procurement organization) and the (Facility), version 9-7-17 entered into on the 23rd day of January 2018" Page one of ten "Definitions, section 1. - Definitions ...1.2. Timely Referral is defined as a telephone call or other real time communication to (procurement organization) by appropriate hospital staff, within one hour of Donor Hospital personnel identifying a patient who meets the clinical trigger for organ donation and when the medical condition or status of a potential donor changes ...1.3. Clinical Trigger is defined as the clinical condition of any DONOR HOSPITAL patient who: a) is intubated and connected to a functioning ventilator, and b) has intact cardiac circulation, and c) Meets a minimum Glasgow Coma Scale, or other objective evaluation method, that indicates that a patient has a devastating neurological injury. d) Brain death testing or withdrawal ... e) Mention of donation or Gift ..."