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1001 STERIGERE STREET

NORRISTOWN, PA 19401

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide each Medicare patient their patients' rights in advance of discontinuing patient care for five of five records reviewed (MR35, MR36, MR37, MR38, and MR39).

Findings include:

A request was made on May 4, 2012, to EMP1, for a copy of the facility's policy regarding notifying Medicare patients of their rights prior to discontinuing patient care. None was provided.

Review on May 4, 2012, of MR35 revealed the patient was discharged on August 26, 2011. Further review of MR35 revealed no documentation this Medicare patient was notified of their rights prior to the facility discontinuing patient care.

Review on May 4, 2012, of MR36 revealed the patient was discharged on December 12, 2011. Further review of MR35 revealed no documentation this Medicare patient was notified of their rights prior to the facility discontinuing patient care.

Review on May 4, 2012, of MR37 revealed the patient was discharged on March 13, 2012. Further review of MR35 revealed no documentation this Medicare patient was notified of their rights prior to the facility discontinuing patient care.

Review on May 4, 2012, of MR38 revealed the patient was discharged on September 1, 2011. Further review of MR35 revealed no documentation this Medicare patient was notified of their rights prior to the facility discontinuing patient care.

Review on May 4, 2012, of MR39 revealed the patient was discharged on November 9, 2011. Further review of MR35 revealed no documentation this Medicare patient was notified of their rights prior to the facility discontinuing patient care.

Interview with EMP1 on May 4, 2012, confirmed there was no documentation MR35, MR36, MR37, MR38, and MR39 that these Medicare patients were notified of their rights prior to the facility discontinuing patient care. EMP1 confirmed the facility did not have a policy in place to provide or notify each Medicare patient of their rights prior to the facility discontinuing patient care.

No Description Available

Tag No.: A0442

Based on a review of facility documents, observation, and staff interview (EMP), it was determined the hospital failed to ensure patient records were not accessible to unauthorized individuals.

Findings include:

Review on May 1, 2012, of the facility policy "Safety and Security of Patient Health Information," dated December 2005, revealed "Procedure: 1. Access to individual patient records may only be provided to authorized staff members who are involved in the treatment of the patient ... Under no circumstances should staff, who are not involved in the treatment of the patient, be permitted access to the record."

1) Observation on April 30, 2012, at 10:50 AM, of the Medical Records Department revealed in the Main Records Room, located at ground level, there were five windows that were not locked. These windows were accessible by individuals from the outside. This room contained at least eight boxes of medical records. This surveyor was able to open and close the windows. The windows could not be locked.

Observation of Room 20, which was at ground level and accessible to individuals from the outside, revealed there were two unlocked windows. Room 20 contained medical records scattered throughout the room.

Observation of Room 56, which was at ground level and accessible to individuals from the outside, revealed there were two unlocked windows. Room 56 provided access to individuals from the outside to the Medical Records Department.

Observation on May 3, 2012, of patient unit 9 AR, at approximately 11:40 AM, revealed Shift Record Reports for the years 2006 and 2008 stored in two unlocked drawers in the locked All Purpose Room. These Shift Record Reports contained patient identification information. Patients and staff had access to these shift reports during patient activities, groups, or meetings.

Interview with EMP2, on April 30, 2012, at 10:55 AM, confirmed the Main Records room had five unlocked windows and contained at least eight boxes of medical records. EMP2 further confirmed the latches on the windows were unable to be locked due to dried paint throughout the Medical Records Department. EMP2 confirmed there were two unlocked windows in Room 20, and medical records were stored in this room. EMP2 confirmed there were two unlocked windows in Room 56. EMP2 confirmed the windows were not locked at night time. EMP2 confirmed these rooms were at ground level and accessible to individuals from the outside.

2) Observation on May 1, 2012, at approximately 9:42 AM, of the Medical Records Department revealed two male individuals exiting Room 006. Room 006 contained medical records from a closed State Psychiatric facility.

Interview with EMP2, on May 1, 2012, at approximately 9:43 AM, confirmed two males exited Room 006 on May 1, 2012, at approximately 9:42 AM. EMP2 confirmed Room 006 contained medical records from a closed State Psychiatric facility, and the medical records were under Norristown State Hospital's jurisdiction. EMP2 confirmed the two males were from the Norristown State Hospital's Maintenance Department. EMP2 noted the Maintenance staff were required to inform the Medical Records Department when they were required to pass through Room 006 to get the Room 007, which was a maintenance room. EMP2 further confirmed the Maintenance staff were allowed unsupervised access to Room 006 and the medical records contained in the room.

CONTENT OF RECORD: ORDERS,NOTES,REPORTS

Tag No.: A0467

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the nursing staff failed to ensure the administration of medication policy and procedures were followed for accurate documentation of the site used for insulin administration in five of five medical records reviewed for insulin site documentation (MR16, MR24, MR25, MR26, and MR28 ).

Findings include:

Review on May 9, 2012, of the facility's "Administration of Medications" policy, last revised October 2011, revealed "... J. Charting The Administration Of parenteral Medication ... 3. Indicate rotation of injection sites beneath initials on the MAR (Medication Administration Record) using the following key: RB Right Buttock; RT Right Thigh; RA Right Arm; LB Left Buttock; LT left Thigh; LA Left Arm; ABD Abdomen...".

Review of MR16, MR24, MR25, MR26 and MR28 on May 8, 2012, revealed these patients received insulin injections. Further review of the medication administration records revealed no documentation of the site of the insulin injections.

Interview with EMP4 on May 9, 2012, at approximately 11:30 AM, confirmed the nursing staff did not follow their policy and procedures for documenting the site of insulin injections for MR16, MR24, MR25, MR26 and MR28.

PHARMACY ADMINISTRATION

Tag No.: A0491

Based on review of the facility's policy and procedures, facility documents, observation, and interview with staff (EMP), it was determined the facility failed to ensure all areas where medications were stored were inspected on a regular basis by the Pharmacy.

Findings include:

Review on May 2, 2012, of the facility's Pharmacy Department policy "Ward/Medical Clinic Inspections, revised January 2012, revealed "To ensure that ward medication rooms and Medical Clinic in Building 1 rooms are inspected on a regular basis. Surveys will include review of medication on the unit and clinic ... Medical Clinic will be inspected monthly ... "

Observation on May 2, 2012, of the Dental Clinic located in Building 51 revealed "Mepivacaine HCL Injection 3%, 50 cartridges 1.7 ml" was stored in the clinic.

Review on May 2, 2012, of the Pharmacy monthly inspection logs revealed no documentation of monthly inspections for the the Dental Clinic located in Building 51.

Interview on May 2, 2012, with EMP6 at approximately 11:30 AM confirmed there was no documentation that monthly inspections occurred for the Dental Clinic located in Building 51.

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to maintain the hospital environment in a manner that assured the safety and well-being of patients.

Findings include:

On May 1, 2012, surveyor requested facility environmental policies and procedures. None were provided.

1) Nursing Stations: Observation tour of Building 9 AF, on May 1, 2012, at approximately 10:15 AM, revealed the following: The nurses' station was dimly lit. The work areas were cluttered with books and papers. Numerous information papers were taped to the glass of the nurse's station. These information papers obstructed the view into patient care areas.
The countertops were soiled with dust, crumbs, and a dried gray substance. The doors to the nurses' station were sticky and splattered with an unidentified substance. The floor was soiled under the furniture, the desks, and the emergency cart.

Observation tour of Building 9CF, on May 2, 2012, at approximately 10:30 AM, revealed the following: The nurses' station was dimly lit. The work areas were cluttered with books and papers. Numerous information papers were taped to the glass. The information papers obstructed the view into patient care areas. The countertops were soiled with dust, crumbs, and a dried gray substance. The doors to the nurses' station were sticky and splattered with an unidentified substance. The floor was soiled under the furniture, the desks, and the emergency cart.

Observation tour of Building 9 AR, on May 2, 2012, at approximately 11:30 AM, revealed the following: The nurses' station was dimly lit. The work areas were cluttered with books and papers. Numerous information papers were taped to the glass. The information papers obstructed the view into patient care areas. The countertops were soiled with dust, crumbs, and a dried gray substance. The doors to the nurses' station were sticky and splattered with an unidentified substance. The floor was soiled under the furniture, the desks, and the emergency cart.

Interview on May 2, 2012, at 11:30 AM with EMP11 confirmed "It is difficult to maintain the environment. The staff performs environment of care rounds weekly."

2) Occupational Program/All Purpose Room: Observation tour of Building 10 C2, on May 1, 2012, at approximately 10:15 AM, revealed the following: There were in excess of 20 ceiling tiles that were stained. The stains varied in size from the size of a dime to four inches in diameter. All of the stains were brown in color. There were three ceiling tiles that did not fit properly, exposing the plaster ceiling beneath the tiles.

Observation tour of Building 9 AR,on May 3, 2012, at approximately 11:00 AM, revealed the following: Commercial Bleach Wipes were stored in an open cabinet in the All Purpose Room and were accessible to patients.

Observation tour of Building 9 CF,on May 3, 2012, at approximately 12:00 PM, revealed the following: The floor of the All Purpose Room 1076 had a buildup of dust and dirt under the convection heating board.

Interview on May 3, 2012, at 12:15 PM with EMP11 confirmed "It is difficult to maintain the environment. The bleach wipes should have been in a locked cabinet."

3) Shower Rooms: Observation tour of Building 10 C2, on May 1, 2012, at approximately 11:20 AM, revealed the following: The Shower Room was unlocked. There were no patients or staff in the room. The cabinet containing the mixing valve to regulate the water temperature was open and accessible to patients. In the anteroom of the shower room, there were plastic boxes for each patient on the unit. The lids to these boxes had a buildup of dust. The cart that these boxes rested on had a buildup of a white powdery substance. One of the boxes contained a styptic pencil. The styptic pencil was accessible to patients. The styptic pencil contained an astringent to stop bleeding, which may be harmful if ingested.

Observation tour of Building 9 AR, on May 3, 2012, at approximately 11:40 AM, revealed the following: In this shower room there were six missing floor tiles and 14 cracked wall tiles approximately five feet from the floor. One open and unlocked cabinet had a sign on the door "Nurse has key Keep Locked". This cabinet contained after shave lotion, toothpaste and deodorant. There were ten open storage shelves that were rusted. The ceiling vents were clogged with an accumulation of dust.

Observation tour of Building 9 CF,on May 3, 2012, at approximately 12:00 PM, revealed the following: In this shower room there was in excess of 24 bottles of skin lotion and after shave lotion in an unlocked cabinet. There was no handle on this cabinet. A brown metal cabinet that was not attached to the wall fell forward when opening the doors.

Interview on May 3, 2012, at 12:15 PM with EMP11 confirmed "There is no need for the patient to have a styptic pencil, because all patients use electric razors. The cabinets containing skin lotion, after shave lotion and toothpaste should have been locked. It is difficult to maintain the environment."

4) Housekeeping Closets: Observation tour of Building 10 C2, on May 1, 2012, at approximately 11:20 AM, revealed the following: Housekeeping Closet 2092 had a buildup of a black substance over the entire floor. Housekeeping Closet 2105 contained a bucket with black liquid in it and a mop resting in the black liquid. There was an accumulation of a black substance in the bottom and the sides of the flush sink. The bedpan hopper was entirely coated with rust that was flaking and peeling.

Observation tour of Building 9, on May 3, 2012, at approximately 10:00 AM, revealed the following: The Housekeeping Closet 1004 air vent was rusted. There was a piece of rusted drain pipe placed on the shelf in the closet. The drain in the floor sink had an accumulation of rust. The base of the floor sink had an accumulation of a black substance. Eight floor tiles were missing, exposing the subfloor. The subfloor had an accumulation of a black substance. In Housekeeping Closet 1112, the lids of the biohazardous waste containers were rusted. The paint was peeling off the biohazardous waste containers. Five of the ten metal storage shelves were rusted.

Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:20 AM, revealed the following: The Housekeeping Closet 1129 air vent was rusted. The drain in the floor sink was rusted.

Observation tour of Building 9 AR, on May 3, 2012, at approximately 11:40 AM, revealed the following: Housekeeping Closet 1109 had ten storage shelves that were rusted and stained with a brown substance. The bottom of the flush sink was covered with a black substance.

Interview on May 1, 2012, at 11:30 AM with EMP5 confirmed "The environment is difficult to keep clean. I'll have my staff take of it." Interview on May 3, 2012, at 11:45 AM with EMP5 confirmed "I can see what you're pointing out and I'll have my staff take care of it."

5) Patient Bathrooms: Observation tour of Building 10 C2, on May 1, 2012, at approximately 11:20 AM, revealed the following: Patient Bathroom 2121 had a heavy urine odor. The floor was littered with unidentified debris and dust. Patient Bathroom 2114 had a can of bleach cleanser on the sink and was accessible to patients. The water mixing valve closet was open and not secured and accessible to patients. The corners where the wall and flooring intersect had a black substance in numerous places along the perimeter of the room.

Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:20 AM, revealed the following: The Patient Bathroom had four containers of an agent to absorb water in an unlocked closet and was accessible to patients. This material was a potential eye irritant. The shower drain had a buildup of a black substance and hair. There were two areas on the wall tiles with a green substance measuring approximately 2.5" x 6". An area approximately 2' x 4' of missing tile and grout was noted behind a patient bathtub.

Observation tour of Building 9 AR, on May 3, 2012, at approximately 10:20 AM, revealed the following: An area approximately 2' x 4' of missing tile and grout was noted behind a patient bathtub. The floor of the bathroom had accumulated dust in the corners. There was a urine odor in this bathroom.

Interview on May 1, 2012, at 11:30 AM with EMP11 confirmed "It is difficult to maintain the environment. The staff performs environment of care rounds weekly."

Interview on May 3, 2012, at 11:45 AM with EMP11 confirmed "It is difficult to maintain the environment. The staff should keep cabinets containing any hazardous materials locked."

6) Patient Sleeping Areas: Observation tour of Building 10 C2, on May 3, 2012, at approximately 10:20 AM, revealed the following: Room 2112 had dead hornets on the floor. Room 2094 had dried liquid splatters on the walls, an accumulation of dust in the corners of the room, and a urine odor. Cubicle L had a dried substance splattered down the wall at the head of the patient's bed and also on the wall adjacent to the patient's bed.

Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:20 AM, revealed the following: There were numerous small black flies throughout the bed dorm. A handle was hanging by one screw from a patient wardrobe in the first cubicle to the right on entering the bed dorm. This was brought to EMP3 attention. EMP3 pulled off the handle and indicated the problem was solved. The window frames in all the patient cubicles had areas of peeling paint. The hampers in cubicle C were dirty with a gray colored substance. A urine odor was noted in the patient's Short Hallway and the source of the odor could be identified.

Observation tour of Building 9 CF ,on May 3, 2012, at approximately 12:00 PM, revealed the following: In the S-K cubicle of the bed dorm, the entire convection heating cover was rusted. In the L-C cubicle of the bed dorm, there was an area of floor covering measuring approximately 1' x 3" that was missing. The subfloor was exposed and covered with an accumulation of a black substance.

Observation tour of Building 9 AR, on May 3, 2012, at approximately 11:20 AM, revealed the following: The long hallway patient sleeping area had fall mats in cubicle B and C. These fall mats were covered with dried on dust and liquid splatters.

Interview on May 3, 2012, at 12:30 PM with EMP11 confirmed "This area is not used and housekeeping probably does not check this area on a regular basis."

7) Cafeteria: Observation tour of Building 9, on May 3, 2012, at approximately 10:00 AM, revealed the following: The ceiling over the tray line had cracks and missing plaster. This measured approximately 8' x 10". There were three large garbage cans under this area to catch the water leaking from this area of the ceiling.

Observation tour of building 10 C2, on May 1, 2012, at approximately 10:15 AM revealed the following: The wall behind the trash can in the entrance of the cafeteria was covered with dried splatters of food and an unidentified substance. The outside of the trash can was soiled. The door leading to the bathroom was soiled with a dry pink and brown tinged substance. The paint was peeling on this door. The table and chairs had an accumulation of dried food and dust. The countertops and table tops were sticky to the touch. All the window sills were littered with dried leaves and gray dust.

Observation tour of building 10 A2 on May 2, 2012, at approximately 10:15 AM revealed the following: The floor had a dust accumulation in the corners of the room and under four sets of table and chairs. The legs of the table and chairs had an accumulation of dust and dried food. The coffee cart was was dusty. There was dried coffee in various places on the cart. The ceiling tiles were damaged and spotted with a black substance. All the window sills were littered with dried leaves and gray dust. The entrance door was splattered with a clear substance. The acrylic wall protector was covered with dried liquid splatters. There were dried splatters between the wall and the acrylic wall protector.

Interview on May 2, 2012, at 10:30 AM with EMP11 confirmed "I see what you are pointing out, but it is difficult to maintain the environment. The staff performs environment of care rounds weekly."

8) Medication Rooms: Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:00 AM, revealed the following: The two medication carts in Room 142 / 144 were stained with various colored and dried substances on three sides. The area between the sides of the medication cart and the rubber bumpers had an accumulation of dust and various colored, dried, and tacky substances. The lid on the biohazardous trash receptacle was rusted. The corners of the medication room floor between the molding and the tiles had a buildup of dirt.

Observation tour of Building 10 A2, on May 2, 2012, at approximately 11:00 AM, revealed the following: The door to the medication room was splattered with various colors of a dried substance. The hallway adjacent to the medication room had a 4' area of missing tile and missing grout.

Interview on May 3, 2012, at 11:15 AM with EMP3 confirmed "The medication carts are old and stained."

Interview on May 2, 2012, at 11:10 AM with EMP11 confirmed "The environment is difficult to keep clean."

9) Laundry Rooms: Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:00 AM, revealed the following: The interior of the trash container in the Laundry Room was stained with a black material. Lint and dust were hanging from the ceiling tiles.

Observation tour Building 9 AR on May 3, 2012, at approximately 10:15 AM revealed the following: The floor in the laundry area was soiled with dust and lint. Lint was hanging from the ceiling tiles. The top inside of the washing machine tub had a gray powdery film.

Observation tour of Building 10 A2, on May 2, 2012, at approximately 11:00 AM, revealed the following: The ceiling over the washer and dryer had lint hanging from the tiles. The window screens had an accumulation of gray colored dust. The floor was dusty and contained debris.

Interview on May 3, 2012, at 11:15 AM with EMP5 confirmed "I can see what you're pointing out and I'll have my staff take care of it."

Interview on May 2, 2012, at 11:00 AM with EMP5 confirmed "I can see what you're pointing out and I'll have my staff take care of it."

10) Pantry: Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:00 AM, revealed the following: There was a buildup of crumbs by the light inside the microwave. The shelves in the cabinets were stained with a brown substance.

Interview on May 3, 2012, at 11:00 AM with EMP3 confirmed "I can see what you're pointing out and I'll have EMP5 take care of it."

11) Treatment Room/Clinical Room: Observation tour of Building 9 AF, on May 3, 2012, at approximately 11:00 AM, revealed the following: There were three of three culture specimen containers that were expired. Two containers were dated with expiration dates of May 2011 and one dated December 2011. There was one bottle of Hydrogen Peroxide with an expiration date of May 2010. There was one wound / incisional "canister vac" [vacuum] with an expiration of May 2010. This was an accordion shaped plastic container. When compressed the device provided a vacuum to collect wound drainage. There was one of one balloon replacement feeding device with an expiration date of October 2007.

Observation tour of Building 9 AR, on May 3, 2012, at approximately 11:40 AM, revealed the following: There were two bottles of normal saline that were opened and not dated. There was one bottle of Betadine that was opened and not dated.

On May 3, 2012, surveyor requested the facility policy regarding the dating of solutions when opened. None was provided.

Interview with EMP3 on May 3, 2012, at approximately 11:30 AM confirmed "We don't use these things anymore. They should have been thrown out. There should be dates on the saline and Betadine. I'll throw them out."

12) Dental Clinic Building 51: Observation on May 1, 2012, of the Dental Clinic located in Building 51 revealed one bottle of oral peroxide with expiration date of December 2011, two tubes of radiopaque calcium hydroxide composition with expiration date of February 2006, one spray cleaner with expiration date of April 1993, and one Zirconium Sulfate Prophylaxis paste with expiration date of January 1, 2006.

Interview on May 1, 2012, with EMP7 at approximately 2:00 PM confirmed the above supplies located in the Dental Clinic in Building 51 were expired.

Building 10: Observation tour on May 3, 2012, at approximately 10:30 AM revealed the disinfection room in the dental office did not have a separate area for the processing of dirty instruments prior to steam sterilization. This disinfection room was also the area were the clean dental impressions were processed.

Interview on May 3, 2012, at 11:30 AM with EMP7 confirmed "This is where we make our dental impressions and clean our instruments."

FACILITIES

Tag No.: A0722

Based upon review of the Guidelines for Design and Construction of Health Care Facilities, observation, and interview of staff (EMP) it was determined the facility failed to ensure the Dental Clinic in Building 10 was designed and maintained to reflect the scope and complexity of the services offered in accordance with acceptable standards of of practice.

Findings include:

Review on May 3, 2012, of the "Guidelines for Design and Construction of Health Care Facilities," 2010 edition, revealed "2.2-5.1 Central Services The following shall be provided: 2.2-5.1.2 Soiled and Clean Work Areas The soiled and clean work areas shall be physically separated. 2.2-5.1.2.1 Soiled workroom (1) This room shall be physically separated from all other areas of the department. (2) Work space shall be provided to handle the cleaning and initial sterilization/disinfection of all medical/surgical instruments and equipment. Work tables, sinks, flush-type devices and washer/sterilizer decontaminators shall be provided. (3) Pass-through doors and washer/sterilizer decontaminators shall deliver into clean processing area/workrooms.

Observation tour on May 3, 2012, at approximately 10:30 AM, of the Dental Clinic located on the second floor in Building 10 revealed a disinfection/dirty utility room. Observation revealed the room was used for the cleaning and the initial sterilization/disinfection of dirty dental instruments, for the steam sterilization of dental instruments, for making dental impressions, for processing dental impressions and for storing the dental impressions. There was no separate area for the processing of the dirty dental instruments prior to the steam sterilization. Further observation of this room revealed the countertop was cluttered with instruments, books and boxes. The floor was soiled with a dried gray substance. There was an accumulation of dust in the floor corners and on the countertops.

Interview on May 3, 2012, at 11:30 AM with EMP7 confirmed the dirty dental instruments were cleaned in this room prior to steam sterilization. Further interview with EMP7 revealed "This is where we make our dental impressions." Further interview with EMP7 confirmed "the area is very small, we try our best to keep it clean."

VENTILATION, LIGHT, TEMPERATURE CONTROLS

Tag No.: A0726

Based on review of the facility documents and staff interview (EMP), it was determined the facility failed to monitor the temperature levels in the Pharmacy.

Findings include:

Review on April 30, 2012, of the facility Pharmacy policy and procedure manual revealed no policy for staff to follow for monitoring the temperature in the Pharmacy Department.

Interview with EMP6 on April 30, 2012, at approximately 1:30 PM confirmed there was no policy for staff to follow for monitoring the temperature of the Pharmacy Department. EMP6 further confirmed there was no documentation the temperature levels in the Pharmacy Department were monitored to ensure adequate temperature controls.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

Based on review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to maintain a sanitary environment in a manner that avoided sources and transmission of infections and communicable diseases by failing to maintain the hospital environment in a manner that assured the safety and well-being of patients (A701), by failing to ensure the Dental Clinic was designed and maintained to reflect the scope and complexity of the services offered in accordance with acceptable standards of practice (A722), by failing to monitor the temperature levels in the Pharmacy (A726), by failing to develop a system for controlling infections and communicable diseases for personnel (A749), and by failing to maintain a log of incidents related to infections and communicable disease for staff, volunteers and contracted services (A750).

Findings include:

Review on May 3, 2012, of the "Norristown State Hospital Infection Control Plan 2012" revealed "Scope of Care or Service: The Infection Control Program of Norristown state Hospital strives to provide a safe and therapeutic environment for patients, staff, students, volunteers, contract service workers, and visitors, through which patients may gain the best opportunity for growth and recovery. This is accomplished through surveillance, prevention, and treatment of infectious organisms to reduce the risk of facility associated infections. This program services all areas of the hospital. ... Program Components: Outcome and Process measures ... Outcome ... 3. Identification of hospital areas through Environment of Care rounds that are noncompliant with infection control guidelines. ... Process ... 3. Rounds of patient care areas and non-patient care areas on a weekly basis by the Infection Preventionist. Each patient care area is seen two or more times each year. "

Cross reference:
482.41(a) Maintenance of Physical Plant
482.41(c) Facilities
482.41(c)(4) Ventilation, Light, Temperature Controls
482.41(a)(1) Infection Control Officer Responsibilities
482.41(a)(2) Infection Control Log

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on review of facility documents and interview with staff (EMP), it was determined the infection control officer failed to develop a system for controlling infections and communicable diseases for personnel.

Findings:

Review on May 1, 2012 and May 4, 2012, of the facility document "Norristown State Hospital Infection Control Plan 2012" revealed no infection control plan measures specific for each department of the facility to evaluate, obtain and review data related to employees and volunteers as part of a hospital-wide infection control plan.

Review on April 30, 2012, of the facility document "Infection Control Manual," updated 2012, revealed no policies for staff to follow to identify, investigate and report infections and communicable diseases of staff and volunteers.

Interview on April 30, 2012, and May 4, 2012, with EMP9 confirmed there were no measures in place to identify, investigate, and report infections and communicable disease for staff, volunteers and contract workers. "I don't get the information from nursing due to HIPAA (Health Insurance Portability and Accountability Act)."

Interview on May 4, 2012, with EMP10 confirmed information was not collected or reported to the Infection Preventionist concerning employee and volunteer infections and communicable diseases.

Interview on May 4, 2012, with EMP11 confirmed employee information concerning infection or communicable diseases was not reported to the Infection Preventionist.

INFECTION CONTROL SURVEILLANCE, PREVENTION

Tag No.: A0750

Based on review of facility documents, and interview with staff (EMP), it was determined the facility failed to maintain a log of incidents related to infections and communicable diseases for staff, volunteers and contracted services.

Findings include:

Review on April 30, 2012, of the "Norristown State Hospital Infection Control Plan 2012" revealed "Purpose: 1. To identify and reduce the risks of acquiring and transmitting infections among patients, staff, volunteers, students, contract service workers, and visitors. ... 3. To monitor compliance with standards of accrediting and government agencies as they apply to infection control. ... Objectives: 1. Maintain a coordinated process to reduce the risks of facility associated infections in patients, staff, students, volunteers, and visitors. 2. Track facility associated infections, as well as those deemed epidemiologically significant by the Infection Control Committee. ..."

On April 30, 2012, the log of incidents for staff and volunteers related to infection and communicable diseases was requested. None was provided.

Interview on April 30, 2012, with EMP9 confirmed there was no log maintained of incidents related to employee and volunteer infections or communicable diseases.

Interview on April 30, 2012, with EMP10 confirmed there was no log maintained of incidents related to employee and volunteer infections or communicable diseases.

OPO AGREEMENT

Tag No.: A0886

Based on review of facility policy and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the Organ Procurement Organization (OPO) was notified in a timely manner of deaths that occurred at the facility for two of four medical records reviewed for OPO notification (MR9 and MR11).

Findings include:

Review on May 1, 2012, of the facility's policy "Tissue/Organ Donation," reviewed April 2009, revealed "Norristown State Hospital will participate with the ... Transplant Program to facilitate the procurement of tissue and organ donations from individuals who die on the grounds in order to improve the quality of life for others .... Procedures 1. For the patient who dies on the grounds of Norristown State Hospital, the pronouncing physician will call the [OPO] transplant program ... as soon as possible after the pronouncement."

Review on May 1, 2012, of MR9 revealed the patient died at the facility on January 26, 2012. Further review of MR9 revealed no documentation the OPO was notified of the death by the pronouncing physician.

Review of May 1, 2012, of MR11 revealed the patient died at the facility on December 21, 2011. Further review of MR11 revealed no documentation the OPO was notified of the death by the pronouncing physician.

Interview with EMP4 on May 2, 2012, at approximately 11;00 AM confirmed the deaths of MR9 and MR11 that occurred at Norristown State Hospital were not reported to the OPO by the pronouncing physician.