HospitalInspections.org

Based on observation, policy review, manufacturing guideline review and staff interview the facility failed to ensure the safety of patients with the use of hot packs in two rehabilitation units. Interview of Staff A on 8/03/11 at 2:00 PM revealed the main rehabilitation unit within the hospital used the hot packs 5 times in the month of July, 2011 and the outpatient rehabilitation center used hot packs 40 times in the month of July, 2011


Findings include:

Review of the main hospital rehabilitation unit on 08/02/11 at 8:15 AM revealed one hydrocollator (heating unit of water) that holds hot packs for treatment of patients during therapy. A water temperature was taken by Staff C of the water in the hot pack holder per request of the surveyor. The water temperature was 172 degrees Fahrenheit. Review of the daily temperature logs revealed readings of 168 degrees to 170 degrees Fahrenheit from 01/17/11 to 08/02/11. Interview of Staff E on 08/02/11 at 1:20 PM (who was described by Staff C as being the person who typically does the temperature readings) revealed that he/she was unaware of the maximum acceptable temperature readings of the hot packs. Review of the manufactures guidelines provided revealed the operating temperatures of the water temperature of the hot packs should be between 160 to 166 degrees Fahrenheit. Review of the facility's policy for hydrocollators is silent to the maximum temperature of hot packs.

Review of the outpatient rehabilitation unit on 08/03/11 at 10:15 AM with Staff C revealed five hydrocollators in use at the outpatient center. A temperature of hydrocollator #2 by Staff F at that time revealed a water temperature of 170 degrees. The other four hydrocollator's water temperatures were within acceptable limits. Review of the water temperature logs for hydrocollator #1 for the dates of 05/31/11 to 07/29/11 revealed the water temperatures were logged in at temperatures from 168 to 172 degrees Fahrenheit. Review of the logs for the water temperatures for hydrocollator #3 logged for the dates 05/31/11 to 07/29/11 revealed the water temperatures were logged in at temperatures 170 to 180 degrees. There was no evidence the temperature had been adjusted and retested. Review of the manufactures guidelines provided revealed the operating temperatures of the water temperature of the hot packs should be between 160 to 166 degrees Fahrenheit. Review of the facility's policy for hydrocollator's is silent to the maximum temperature of hot packs.

These findings were confirmed by Staff A on 08/02/11 and 08/03/11 during the tours of the two rehabilitation areas. Interview of Staff A on 08/03/11 at 2:00 PM revealed the main rehabilitation unit within the hospital used the hot packs 5 times in the month of July, 2011 and the outpatient rehabilitation center used hot packs 40 times in the month of July, 2011.

Based on medical record review and staff interview the facility failed to follow their policy regarding physician's orders for the length of time for re-evaluation for one of two patients whose records were reviewed in the distinct acute psychiatric unit (Patient 21). The census was 14.

Findings include:

Review of the clinical record of Patient 21 on 08/02/11 revealed this patient was admitted to the psychiatric unit on 02/03/10. This patient was placed in 4 point restraints from 7:20 PM until 10:30 PM and 2 point restraints until 8:08 PM when the patient was then placed in a seclusion room for violent and self-destructive behavior. The patient was again placed in 4 point restraints at on 02/04/11 at 3:45 AM, 7:45 AM, 11:45 AM, 4:00 PM, 10:00 PM and 11:00 PM and continuing through 02/05/10 until 8:00 AM. The patient was placed in a locked seclusion room on 02/05/11 at 8:00 AM to until 1:00 PM. Further review revealed there was 6 hours between physician's orders on 02/03/11 from 2:15 PM until 8:08 PM when the patient was in 4 point restraints and, 6 hours between physician's orders on 02/04/11 from 4:00 PM until 10:00 PM when the patient was in 4 point restraints. This finding was confirmed by Staff D on 08/02/11 at 9:30 AM.

Interview of Staff D on 08/02/11 at 10:30 AM further revealed there were chart audits completed for patients being restrained. Review of the chart audits revealed there was no audit of physician's orders being received per the facility policy. The policy Addendum A for the Restraint time table revealed that physician's orders must be obtained every four hours for patients that were being restrained for violent/ self destructive behavior.

21893

Based on medical record review, staff interview, and protocol review; the facility failed to ensure skin integrity and skin breakdown were assessed on all patients and preventative measures were put in to place to prevent skin breakdown. This affected one of 46 medical records reviewed (Patient 46). The facility failed to ensure all staff working in the dialysis unit wore personal protective equipment as required per the facility policy. This affected three of three dialysis staff observed.

Findings include:

The medical record for Patient 46 was reviewed on 08/04/11. The patient was admitted to the facility on 07/21/11. Review of the medical record revealed the patient had no skin breakdown on the coccyx per the nursing admission assessment. The medical record indicated a Braden Score of 12 (High Risk of skin breakdown) on 07/21/11 at 5:00 PM. On 07/27/11, photographs of the coccyx area were noted on the medical record with reddened areas and intact skin with a notation of suspected deep tissue injury. The medical record lacked documentation of wound measurements. The nursing progress note dated 07/27/11 at 9:40 AM noted found deep tissue injury to coccyx, pictures taken, turn patient every two hours, and foam protector intact to coccyx. The medical record lacked documentation of a pressure wound to the coccyx from 07/27/11 until 08/01/11. On 08/01/11 at 1:00 AM the medical record contained a notation of a Stage 1 pressure ulcer to the coccyx. On 08/03/11 at 10:00 AM the nursing progress notes stated assessed wound to coccyx, dressing removed, site red, moist, with red drainage. One small unstageable area seven centimeters by three centimeters with unknown depth, cleaned with normal saline, and dressing applied. The medical record contained documentation of orders on 08/03/11 to turn the patient every two hours and to consult wound care. On 08/03/11 at 8:00 AM, the Braden score was 9, very high risk. On 08/04/11 at 10:48 AM, the wound care nurse (Staff Q) documented a one centimeter by two centimeter by zero centimeter open area on the right buttock, a two centimeter by two centimeter by zero centimeter open area on the left buttock, and a coccyx wound that measured six centimeters by three centimeters by zero centimeters. Staff Q recommended wound care orders and a specialty mattress. The medical record contained orders dated 08/04/11 for dressing changes to the coccyx and a specialty mattress. The medical record contained documentation on the Daily Pressure Ulcer Prevention Protocol Plan from 07/21/11 through 08/04/11 for the patient to be turned and repositioned every two hours. The medical record lacked documentation the patient was turned and repositioned every two hours from 07/21/11 through 08/04/11. This information was verified with Staff A, N, and O on 08/04/11 at 11:30 AM.

Staff Q was interviewed on 08/04/11 at 11:15 AM. Staff Q stated that if a pressure wound was identified that was not present on admission to this facility, he/she would expect a wound care consultation to be ordered at the time the wound was identified.

The Pressure Ulcer Prevention and Treatment Protocol was reviewed on 08/04/11. This protocol defines a suspected deep tissue injury as a purple or maroon localized area of discoloration of intact skin or a blood filled blister due to underlying soft tissue from pressure or stress. The protocol stated a systematic risk assessment for skin breakdown using the Braden Scale was to be performed on admission, transfer to another floor or unit, daily, and with any change in condition. The pressure ulcer treatment protocol would be activated for Braden scores less than 18. A Braden score of 13-18 was a moderate risk, 10-12 was high risk, and 9 and below was a very high risk. For a Braden score of 18 or less, the patient should be turned every two hours.

Per observation on 08/01/11 between 10:52 AM and 11:20 AM in the area where acute dialysis is performed, three of three staff members were observed to provide care to four patients who were observed being dialyzed. Three were in beds in the large area and one patient was being dialyzed in a bed in the isolation room. None of the three staff had eye protection on or gowns/laboratory coats while standing next to the dialyzing patients or when Staff W removed the two dialysis needles from Patient 47's right upper arm access. This was observed between 11:08 AM and 11:20 AM. Staff W had disposable gloves on, but no other personal protective equipment. After removing the first dialysis needle at 11:08 AM, Staff W held the site and then removed the second needle at 11:12 AM. The first gauze was observed to be bloody and was replaced with a clean folded gauze. When Patient 47's needle sites had obtained homeostasis, the areas were bandaged and the under pad which was below the patient's right arm was removed. The under pad was noticeably bloody when removed. There is a potential during canulation and de-cannulation of blood splatter. Per policy review, dialysis staff should don a mask and a gown whenever there is a likelihood of blood splatter which could be at any time while the patient is dialyzing. Staff R was present with the surveyor during these observations.

Based on staff interview, policy review and review of physician's medical record delinquencies revealed 404 delinquent medical records by a total of 107 physicians. There were four of four physicians reviewed were delinquent in completing patient's medical records (Staff J, K, L, and M). Per medical record review and staff interview, the facility failed to ensure all physician documentation in the medical record was legible, and contained a time and date. This affected seven of 46 medical records reviewed (Patients 23, 17, 18, 19, 24, 26, and 36).

Findings include:

Review of the physician's medical record delinquencies on 08/03/11 at 1:45 PM revealed Staff J has been over 30 days delinquent on 42 medical records. One record was from 5/26/11.

Review of the physician's medical record delinquencies on 08/03/11 at 1:45 PM revealed Staff K has been over 30 days delinquent on 3 medical records. One record was from 2/19/11.

Review of the physician's medical record delinquencies on 08/03/11 at 1:45 PM revealed Staff L has been over 30 days delinquent on 1 medical record. This record was from 6/06/11.

Review of the physician's medical record delinquencies on 08/03/11 at 1:45 PM revealed Staff M has been over 30 days delinquent on 1 medical record. This record was from 4/22/11.

Review of the facility Medical Staff Rules and Regulations approved on 06/27/11 revealed physicians will be placed on full suspension if the physician has not completed all charts within 30 days of patient discharge. Further review of the above document revealed that the Bi-weekly Health Information Services will contact all physicians to notify them of their incomplete charts. Interview of Staff A on 08/04/11 at 12:40 PM revealed there was no evidence that the physicians had been notified.

Interview of Staff A on 8/04/11 at 12:40 PM confirmed the above findings.


Per medical record review of Patient 23 on 08/02/11, a telephone order obtained on 07/07/11 to start the patient on an anticonvulsant at one gram intravenously over one hour and then 100 milligrams intravenously every eight hours with a blood level of Dilantin to be drawn in the morning of 07/28/11. The facility's policy was for telephone orders to be signed within 48 hours per Staff R at the time of the medical record review.

Per medical record review of Patient 23 on 08/02/11, two physician progress notes written on 08/02/11 and three written on 08/01/11 had no time written to determine at what point during the day the progress note was written. A progress note written by a cardiovascular surgeon on 07/31/11 was also not timed. This was confirmed by Staff R at the time of the record review.

Per medical record review on 08/01/11 in MICU (medical intensive care unit), Patient 17 had progress notes written by the endocrinologist and the cardiovascular surgeon on 07/31/11 which were not timed. A progress note by the infectious disease specialist on 07/30/11 was also not timed to determine when he/she saw the patient. Entries made by the gastrointestinal physician, the endocrinologist and infectious disease physician were not legible, even to Staff S, a regular RN in this unit. These findings were confirmed by Staff R at the time of the record review.

Per medical record review on 08/01/11 on MICU, a telephone order obtained on 07/26/11 for Patient 18 to do an MRI without contrast with it being OK to go to open MRI was written at 03:00 PM. As of 08/01/11, the physician order had not been signed. This was confirmed by Staff R at that time.

Per medical record review in CCU on 08/01/11, Patient 19 had two progress notes written by an endocrinologist and a cardiologist which were not timed. Additionally, Staff T, a CCU nurse could not read the entries written by two physicians on 08/01/11, two physician entries written by physicians on 07/30/11 and one physician entry written on 07/30/11. All of these illegible entries were in progress notes as verified by Staff T at 04:49 PM on 08/01/11.

Per medical record review on SICU on 08/02/11, Patient 24 had two physician progress notes which were not timed by the physicians. One of these two physicians's entry was not legible as verified by Staff U, a regular SICU nurse familiar with reading physician progress notes.

Per medical record review on 08/02/11 of Patient 26, a physician progress note written on 08/02/.11 was not timed. One line of the progress note was illegible even to Staff V, a regular RN on 2 North. Staff R was also present during this record review.

Per medical record review on 08/03/11, Patient 36 was admitted to the CCU on 02/19/11 and discharged on 02/24/11. Telephone orders were not signed or timed by the infectious disease physician, the endocrinologist, the medical house physician, the cardiologist, the general surgeon, the internal medicine physician and the nephrologist from 02/21/11, 02/22/11, 02/23/11 and 02/24/11 before the medical record was sent to the medical records department. Physician progress notes on 02/20/11, 02/21/11, 02/22/11, 02/23/11 and 02/24/11 did not include times of each entry. These findings were verified during the record review by Staff R.




07312

Based on the life safety code inspection conducted on 08/01/11 thru 08/05/11, it was determined that this facility was not maintained in a manner safe from fire. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey.
Findings include:

Please refer to the following Life safety code violations:

K-11 Common walls of nonconforming buildings are constructed with at least a two hour fire resistance rating.

K-18 Doors protecting corridors openings are constructed to resist the passage of smoke for at least twenty minutes.

K-22 Directional and exit signs are located in areas to ensure proper way of travel to an exit discharge.

K-25 Smoke barriers are constructed with at least a one half hour fire resistance rating.

K-27 Door openings in smoke barriers had at least a 20-minute fire protection rating.

K-29 Hazardous areas are constructed with at least a one hour fire rated construction.

K-33 Ensure the stairwell exit discharge door closed and latched properly.

K-43 Ensure that patient room doors are arranged so that patients could open the door from inside without using a key.

K-45 Ensure that exit discharges were provided with emergency lighting.

K-50 Ensure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift.

K-75 Ensure all trash containers exceeding 32 gallon capacity, while not attended, are stored within a room with at least a one hour fire rated construction.

K-76 Ensure medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

K-130 *Ensure directional and exit signs are located in areas to ensure proper way of travel to an exit discharge.

*Ensure that all exit discharges were provided with emergency lighting.


*Ensure all exit accesses were readily available in regards to a safe walkway from the exit discharge to a paved common way.

*Ensure that emergency illumination was provided in accordance with section 7.9 with regards to documentation of monthly and yearly testing.

Based on the life safety code inspection conducted on 08/01/11 thru 08/05/11, it was determined that this facility was not maintained in a manner safe from fire. This had the potential to affect all those utilizing this area of the facility. The facility had a capacity of 346 beds with a census of 235 patients at the time of the survey..
Findings include:

Please refer to the following Life safety code violations:

K-11 Common walls of nonconforming buildings are constructed with at least a two hour fire resistance rating.

Based on observation during tour and staff verification it was determined this facility failed to ensure the common walls of nonconforming buildings were constructed with at least a two hour fire resistance rating.
Findings included:
1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor corridor, above the ceiling tiles at the fire door, between facility building #1 and facility building #6 revealed penetrations. One penetration was surrounding a pipe. The other open area was estimated to be approximately 14 feet long, 1 to 2 feet wide and open to the floor decking above. Staff present on tour verified that facility building #1 was construction type I(332) and facility building #6 was construction type II(000).
Review of facility schematics revealed the wall was to be a two hour fire rated wall between the two buildings. Staff present on tour verified the two fire rated wall was not complete.

2. Tour of the second floor common wall area located between the physician's offices (building # 6) and the surgical area (building # 9) was completed the morning of 08/05/11 with staff members MMM and NNN. This common wall was designated as a smoke barrier according to the schematics.
Observation above the ceiling tile revealed an approximate three inch penetration from which this surveyor and both staff members were able to determine the wall was constructed with two layers of 5/8 inch drywall making it a one hour fire rated construction. Included in this observation was the wall below the ceiling which was also determined to be constructed with a one hour fire rated construction. The door in this assembly was determined to be 3/4 hour fire resistance rated. The entire common wall area of the second floor between building # 6 and building # 9 was not constructed with the required two hour fire resistance rating and this area was estimated to be approximately ten feet wide by twelve feet high.

3. Tour of facility building #1 basement took place on 08/03/11, with staff member NNN. During tour of the two hour fire rated common wall separating the physician's offices from the main building near the cardiac center, observation was made of one penetration above the double doors with blue wires passing through. Additionally, one leaf of the double doors failed to close and latch shut.

This finding was verified by staff member MMM during tour on 08/04/11.




K-18 Doors protecting corridors openings are constructed to resist the passage of smoke for at least twenty minutes.

Based on observation during tour and staff verification it was determined this facility failed to ensure the doors protecting corridors openings were constructed to resist the passage of smoke for at least twenty minutes.

Findings included:

Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the corridors, observation was made of two corridor doors which failed to close properly in order to resist the passage of smoke in the following locations:
Basement:
*At the northwest corner of the dish room of the dietary department from the corridor side, observation was made of the corridor dish room door which failed to shut properly leaving a small gap between the door and the door frame.
First floor:
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made of the smoke barrier doors failing to close properly when disengaged from the holding devices.

These findings were verified by the staff present during tour on 08/03/11 and 08/04/11.


K-22 Directional and exit signs are located in areas to ensure proper way of travel to an exit discharge.

Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs were located in areas to ensure proper way of travel to an exit discharge.
Findings include:
Tour of the basement of building # 1 took place on 08/03/11 with staff NNN. During tour of the 9,375 square foot medical records/IT department observation was made of two exit directional signs, one at the northeast end of the room and the other at the southeast end. Both signs directed flow to an exit access located on the east side, center of the room. Observation was made of three doors located in the east side center of this room, none of which had an exit sign designating it as the exit access. This surveyor was not able to determine which door was the exit access and was not able to locate a fire escape plan within this department to verify the designated exit route.
The exit access door was revealed to this surveyor by staff NNN. Observation was made by this surveyor and staff NNN that no directional sign was mounted in order to direct any persons to the exit access door, nor was there an exit sign located above the exit access door.
Additionally, observation was made of stairs located outside of this exit door which were assessable only once one was outside of this room.



K-25 Smoke barriers are constructed with at least a one half hour fire resistance rating.

Building # 1
Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one half hour fire resistance rating.

Findings included:

1. On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located in the vascular/lab corridor, penetrations were noted surrounding a heat pump loop and data cable wires.
* Located above B311, a penetration was noted approximately 1 inch by 2 inches. Also visible was an unsealed area surrounding conduit.
* Located above B314 a penetration was noted approximately 1/2 inch by 1 inch and 3 unsealed areas surrounding conduit.

2. On 08/03/11 between 10:00 A.M. and 4:00 P.M. tour of the second floor was completed with Staff MMM. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
* Located at the surgical waiting area, near the elevators, penetrations were observed surrounding a protected beam.
* Located at the surgical waiting area, near the heart vascular institute, two penetrations were observed. one area was approximately 4 inches square and the other approximately 2 inches square.
* Located in the same area was an unsealed opening surrounding an area where at least six data cable lines penetrated the wall.
*Located near stairwell C a open area was noted surrounding a conduit and a hole approximately 3 inches square.
* Located at the CCU smoke doors, near the cath lab entrance, a penetrations was noted surrounding conduit and an area was not sealed surrounding an I-beam.

3. Tour of the basement of building # 1 took place on 08/03/11 with staff NNN and first floor on 08/04/11 with staff members MMM and NNN. During tour of the smoke barriers, observation was made of several penetrations located in the smoke barrier above the ceiling tile in the following locations:
First floor:
* Above the west double doors of the smoke barrier bordering the infusion therapy room of the oncology department, observation was made of one, two inch open ended conduit.
* The smoke barrier bordering the south side of the pastoral care room and near the stairs, observation was made of two one inch unsealed penetrations.
Additionally, observation was made of a four inch penetration and two unsealed insulated lines above a dryer near the same area.
* Above the double doors between the PBX room and the breast center, observation was made of four unsealed penetrations. Additionally, at the southeast corner of the breast center, observation was made of two-two inch unsealed penetrations in the smoke barrier.
* Above the double doors by the stairwell between the PBX and EMS room, observation was made of two unsealed areas where data lines penetrated through the drywall. Additionally, above the smoke barrier doors at the west end of the east-west corridor, adjacent to the previous doors, observation was made of one, three inch unsealed silver conduit.
* Within the emergency department at the west end smoke barrier doors, observation was made of two unsealed conduits with wires passing through.
* Within the emergency department at the east end smoke barrier doors, observation was made of two unsealed insulated lines passing through two sleeves and one unsealed three inch sleeve with wires passing through.
* Within the corridor between the emergency department and laboratory and at the southeast corner of the emergency department, observation was made above the smoke barrier doors of a large penetration around the duct.
* Within the same corridor by room #170, observation was made of one, one inch unsealed conduit.

Basement:
*Above the smoke barrier doors located between pathology and nuclear medicine, observation was made of an approximate four by eight foot section of missing drywall.
*Within the "pop storage" room adjacent to the physical therapy offices, observation was made of a penetration around an electrical chase.
*Within the dish room of the dietary department at the east wall near the wall mounted fan, one unsealed conduit was observed. Also, on the north wall near the portable fire extinguisher another unsealed conduit was observed. Additionally, from the corridor on the north side of the dish room and near the corridor door bordering the locker room, observation was made of one unsealed conduit and one unsealed black wire passing through the smoke barrier.
* Above the smoke barrier door within the volunteers TV service area, observation was made of two unsealed orange flex lines.
*Above the smoke barrier corridor door by community room number eight, observation was made of an approximate four foot by two and a half foot area of missing drywall.
*Within the corridor wall bordering the south side of the community health room, observation was made of three open end conduits with flesh colored wires passing through.

These findings were verified by staff MMM and NNN during tour on 08/03/11 and 08/04/11.

Building # 5
Based on observation during tour and staff verification it was determined this facility failed to ensure the smoke barriers were constructed with at least a one hour fire resistance rating.

Findings included:

1. On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the smoke barriers which included the spaces above ceiling tiles. The following locations were noted to have penetrations located in the smoke barrier above the ceiling tile:
*Located above the fire doors leading to the emergency department from the business occupancy, an area approximately 10 inches in diameter was not sealed. The area at the floor decking above was also not sealed.
* An area was not sealed in the smoke barrier wall at the floor decking at the back wall of the men's bathroom.

Staff present on the tour verified the observation and findings with regards to penetrations in the smoke barrier wall.



K-27 Door openings in smoke barriers had at least a 20-minute fire protection rating.

Based on facility tour and staff interview and verification the facility failed to ensure that door openings in smoke barriers had at least a 20-minute fire protection rating.

Findings included:

On 08/02 and 08/03/11 tour of the second and third floors of the facility was completed with Staff MMM and NNN. During tour of the second and third floors, observation was made of the corridor smoke doors. Testing of the corridor smoke doors revealed that gaps greater than 1/8 inch were present at the door edges when the smoke doors were in the closed position.

The affected smoke barrier doors were observed near the third floor psychiatric unit for geriatric patients and on the second floor near the coronary care unit.

Staff present on tour verified the gaps at the door edges were greater than 1/8 inch and would permit the passage of smoke.



K-29 Hazardous areas are constructed with at least a one hour fire rated construction.

Building # 1
Based on observation during tour and staff verification it was determined this facility failed to ensure hazardous areas were constructed with at least a one hour fire rated construction regarding doors in storerooms and soiled utilities.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the oncology department and within their medical records storeroom, observation was made of the one hour fire rated door failing to shut and latch properly.
During tour of the northeast section of the outpatient center and within the soiled utility room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
During tour of the east section of the radiology center and within the soiled utility room located across from the medical gas room, observation was made of a large mobile trash container stored within this room. The door of this soiled utility room lacked a fire resistance rating.
These findings were observed and acknowledged by staff members MMM and NNN during tour on 08/04/11.

Building # 5
Based on facility tour, review of facility documentation and staff interview and verification, the facility failed to ensure that hazardous areas were protected in accordance with 8.4. The areas were to be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4).

Findings included:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of soiled utility areas and areas designated to store biohazard materials until picked up for disposal. The following observations were noted of the areas considered to be hazardous storage.

* Review of facility schematics revealed the soiled utility room located in the emergency department did not have walls that provided a one hour fire rated barrier. Observation of the walls above the ceiling tiles verified the information on the schematic. The door to the soiled room was noted to have a 20 minutes fire resistance rating.

* Observation of an area identified to be used for biohazard storage until picked up for disposal, revealed areas were not sealed in the fire rated walls at the floor decking. Areas surrounding 4 pipes observed above the door to the biohazard room were not sealed.

*A room identified as a soiled linen hold area was noted by review of schematics drawing have been increased in size. When the room was increased in size , two walls were not provided with a one hour fire resistance rating. The door to the room did not have a 3/4 hour fire resistance rating.

Staff present on tour observed and verified the findings.

K-33 Ensure the stairwell exit discharge door closed and latched properly.

Based on observation during tour and staff verification it was determined this facility failed to ensure the stairwell exit discharge door closed and latched properly in order to preserve the two hour fire resistance rating of this exit component.

Findings included:

Tour of the basement of building number # 1 took place on 08/03/11 with staff member NNN. During tour of stairwell J, observation was made of the exit discharge door leading directly outside, failing to close and latch when tested. This left at least a two inch gap between the door leaf and the door frame.
This finding was verified by staff member MMM during tour on 08/03/11.



K-43 Ensure that patient room doors are arranged so that patients could open the door from inside without using a key.

Based on facility observation and staff interview and verification, the facility failed to ensure that patient room doors were arranged so that patients could open the door from inside without using a key. Ten of ten patients residing on the secured psychiatric unit were affected. The psychiatric unit capacity was eleven patient rooms.

Findings included

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of the secured psychiatric unit for geriatric patients. Observation of the unit revealed that patient sleeping rooms had deadbolt type locks present on the doors in addition to the door handle. Interview of unit staff revealed that patient room doors could be locked from the outside using a key. Once the doors were locked, doors could not be opened from inside the room by use of the door handle. The bathroom doors, inside the patient rooms, were equipped with the same deadbolt type locks as well as roller latches.

Staff on the unit stated that no patients were locked in the rooms but the purpose of the locks was to secure the rooms so that patients would not go into unoccupied, clean rooms or could not go into rooms to hide. Patient room doors were observed to be open during tour of the unit.


K-45 Ensure that exit discharges were provided with emergency lighting.

Based on facility tour and staff interview and verification, the facility failed to ensure that exit discharges were provided with emergency lighting. Potentially any patient, visitor or staff utilizing the exit could be affected.

Findings included:

On 08/02/11 between 2:00 P.M. and 2:30 P.M. tour of the fourth floor was initiated with Staff MMM and NNN. Observation of two exit stairwells to the point of exit discharge revealed the exits lacked adequate emergency lighting.

Stairwell L was noted to have no emergency lighting present at the exit discharge and Stairwell F had one light fixture at the exit discharge. A second means of lighting was a remote parking lot light.

Staff MMM present on tour verified the emergency lighting was not present for stairwell L and limited for stairwell F.




K-50 Ensure that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift.

Building # 3
Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift.

Finding included:

On 08/02/11 between 11:00 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review of fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second second shift in the second quarter of 2011. Staff TTT verified there was no documented evidence the fire drill had been completed.

Building # 5
Based on facility documentation review and staff interview and verification, the facility failed to ensure that fire drills were held at unexpected times under varying conditions, at least quarterly on each shift.

Finding included:

On 08/02/11 between 11:45 A.M. and 12:00 P.M. review of facility documentation was completed with Staff MMM and TTT. Review fire drills for 2010 and to date in 2011 was competed. Staff TTT presented the information. Review of the fire drills for the offsite location revealed that no fire drill was completed for the second shift in the third quarter of 2010 and the third shift for the first quarter of 2011. Staff TTT verified there was no documented evidence the fire drills had been completed.



K-75 Ensure all trash containers exceeding 32 gallon capacity, while not attended, are stored within a room with at least a one hour fire rated construction.

Based on observation during tour and staff verification, it was determined this facility failed to ensure all trash containers exceeding 32 gallon capacity, while not attended, are stored within a room with at least a one hour fire rated construction.
Findings include:
Tour of the first floor of building # 1 took place on 08/04/11 with staff members MMM and NNN. During tour of the laboratory department and near the southwest exit, observation was made of a large mobile trash container located just inside the exit access. This mobile trash bin contained layers of cardboard boxes and this surveyor asked the department manager if this container is kept here all day and removed when full and then replaced with an empty container. The department manager stated "yes" . This finding was acknowledged by staff MMM during tour.



K-76 Ensure medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

Building # 1
Based on facility tour and staff interview and verification, the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities. Two of two operating rooms located on the maternity unit were affected. Potentially, patients, visitors and staff in the operating room area could be affected. The hospital had a capacity of 346 certified beds with a census of 235 patients at the time of the survey.

Findings included:

On 08/02/11 between 2:35 P.M. and 5:00 P.M. tour of the third floor was completed with Staff MMM and NNN. Observation of the third floor revealed the presence of two operating rooms located on the maternity unit. Tour of the operating rooms and the surgical area revealed a small room noted to store medical gases. Four H-sized cylinders of nitrous oxide were secured in the small room. In addition, the small room contained stored items in boxes and containers as well as some equipment used on the unit. A light switch inside the room was placed less than 5 feet from the floor of the room. The door to the room had no identified fire rating.

Observation of the facility schematic indicated the room walls did not provide for adequate fire rating for at least two walls of the small room. Staff present on tour verified the observation and findings.

Building # 5
Based on facility observation and staff interview and verification the facility failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

Findings include:

On 08/01/11 between 1:40 P.M. and 3:20 P.M. tour of the offsite facility was completed with Staff MMM and NNN. During the tour observation was made of the medical gas storage area. Observation of the medical gas storage area revealed the presence of 21 full H size tanks of oxygen and 7 empty H size tanks of oxygen. The light switch to the room was observed to be inside the storage room and was placed at less than 5 feet from the floor.

Staff present on tour verified the medical gas room was full and that a recent shipment of oxygen had been delivered. Staff present verified the light switch was less than 5 feet from the floor of the room.




K-130 *Ensure directional and exit signs are located in areas to ensure proper way of travel to an exit discharge.

*Ensure that all exit discharges were provided with emergency lighting.


*Ensure all exit accesses were readily available in regards to a safe walkway from the exit discharge to a paved common way.

*Ensure that emergency illumination was provided in accordance with section 7.9 with regards to documentation of monthly and yearly testing.

Building # 2
Based on observation during tour and staff interview it was determined this facility failed to ensure directional and exit signs are located in areas to ensure proper way of travel to an exit discharge according to the National Fire Protection Association (NFPA) 7.10.1.4 Access to exits is marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
No directional sign was observed mounted in this room providing direction to this door nor was there an exit sign displayed above this designated exit door.
This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on facility tour and staff interview and verification, the facility failed to ensure that all exit discharges were provided with emergency lighting according to the National Fire Protection Association (NFPA) 19.2.8 and 7.8 Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

Findings included:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Observation was made of this exit discharge lacking any emergency lighting at the exterior of the door.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.



Based on observation during tour and staff interview it was determined this facility failed to ensure all exit accesses were readily available in regards to a safe walkway from the exit discharge to a paved common way according to the National Fire Protection Association (NFPA) 19.2.1 and 7.7.1.

Findings include:

Tour of the endoscopy center took placed on 08/04/11 with staff members MMM and NNN. Within the northwest section of this 4,595 square foot complex, observation was made of a fire plan mounted on the wall near a door which lead directly to the outside of the building. The fire plan indicated this door was a designated exit and observation was made of a fire pull station mounted on the wall just inside of this door.
Upon discharge from this door observation was made of a six foot by five and a half foot cement stoop. Surrounding the cement stoop was a grassy area which extended approximately 45 feet before ending at a paved common way.

This finding was acknowledged by staff MMM during tour on 08/04/11. Staff MMM stated he/she did not think this particular door should have been marked as a designated exit on the fire plan.


Building # 4
Based on facility observation, review of facility documentation and staff interview and verification, the facility failed to ensure that emergency illumination was provided in accordance with section 7.9 with regards to documentation of monthly and yearly testing. The facility was an offsite location which provided outpatient therapy services, MRI testing and a community fitness facility.

Findings included:

On 08/02/11 between 8:50 A.M. and 9:40 A.M. tour of the facility and review of facility documentation was completed with Staff MMM, NNN, and OOO. Observation of the facility revealed there was no emergency generator for provision of lighting in the event of a power outage. Battery powered emergency lighting was observed throughout the facility. Review of facility information revealed there was no documented evidence that battery powered emergency lighting was tested monthly or yearly.

Interview of Staff OOO revealed that battery back-up lighting was tested but there was no documentation of the testing.