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Based on record review, policy review and interview patients presenting for care in the Emergency Department (ED)or at the Jones Memorial Medical Practice were not provided with a copy of the patient rights. Not providing patients with a copy of the patient rights could result in the patient being unaware of their rights.

Findings include:

Review of Policy #P-05, Patient Bill of Rights/Patient Responsibilities last revised 07/31/14 revealed each patient or patient's representative receives a copy of these rights upon admission for treatment as an inpatient, outpatient and/or emergency room patient.

Interview with Staff (F), ED secretary on 02/05/18 at 12:05 PM revealed patients are given a copy of their patient rights after they are seen by the provider and it is determined they are going to be an inpatient.

Interview with Staff (LL), Jones Memorial Medical Practice receptionist on 02/07/18 at 09:50 AM revealed patient rights are not provided to first time patients when they arrive and they are not mailed out prior to coming. Staff LL indicated she would give them to a patient if the patient asked for a copy

Review of Jones Memorial Medical Practice patient records on 02/07/18 at 10:00 AM revealed no evidence that a copy of patient rights were given to Patients #24 - #26.

Review of ED records on 02/07/17 at 2:15 PM revealed no evidence that a copy of patient rights were given to Patients #30 - #32.

Interview with Staff (KK), Clinical Practice on 02/07/18 at 10:00AM and Staff (D), Patient Care Services on 02/07/17 at 2:15 PM confirmed the above noted findings.

Based on medical record review, policy review and interview, the nursing staff has not ensured the ongoing documentation of patient-ventilator system performance in accordance with facility policy in 2 of 4 patients receiving ventilator care. Lack of consistent documentation could result in a failure to address all components of the patient-ventilator system.

Findings include:

Review of facility policy entitled " Adult Ventilator Management ", last reviewed October 2016 revealed the cardiopulmonary services/respiratory care will provide in-house ventilator support 24 hours per day with properly trained RN ' s monitoring ventilation with assistance and support of respiratory care practitioners during their scheduled hours and after hours on call coverage. It is noted that routine checks, at least every two hours, of patient-ventilator system performance are mandatory.

Review of facility policy entitled " Ventilated Patients, Care of, and Prevention of Ventilator-Associated Pneumonia ", last reviewed October 2016, revealed ventilators will be checked no less than every two hours for proper function by respiratory therapy staff or ICU nursing staff and recorded in Meditech under RT documentation interventions.

Review of Mechanical Ventilation: RT and Mechanical Ventilation: ICU documentation for Patient #2 revealed a ventilator check was conducted on 01/19/18 at 4:00 PM, with the next documented check on 01/20/18 at 06:17 AM. On 01/20/18 a ventilator check was conducted at 8:15 PM, with the next documented check on 1/21/18 at 06:40 AM.

Review of Mechanical Ventilation: RT and Mechanical Ventilation: ICU documentation for Patient #4 revealed a ventilator check was conducted on 11/14/18 at :45 PM, with the next documented check on 11/15/18 at 07:08 AM.

Interview with Staff (A), Quality and (D), Patient Care Services on 2/7/18 verified that the nursing staff are not consistently documenting patient-ventilator system performance every two hours during the hours a respiratory therapist is not onsite.

Based on observation and staff interview, the facility does not ensure that refrigerator temperatures are obtained twice/day (trayline cooler and trayline salad cooler) for 3 of 3 months (November 2017, December 2017 and January 2018). Failure to obtain temperatures at designated times may result in patients receiving food products that are not within the specified temperature ranges.

Findings include:

Review of the trayline refrigerator log and the trayline salad refrigerator log on 02/07/18 at 11:00 AM did not indicate that temperatures of these refrigerators were obtained twice/day. Review of these logs indicated that the temperatures of these refrigerators "must be recorded a minimum of twice during each 24 hour period".

Interview with Staff (PP), Dietary on 02/07/18 at 11:10 AM verified this finding.

Based on observation and interview, the facility does not ensure that the hot water is maintained at a safe temperature for patient, staff and visitor use. Failure to maintain hot water temperature at a safe temperature may result in harm to the patients, staff and visitors.

Findings include:

During the facility tour on 02/07/18 at 02:00 PM and 02/08/18 at 10:00 AM and 10:30 AM, it was observed that the hot water temperature exceeded 120 degrees Fahrenheit when tested in 3 of 3 patient care areas. The following was noted:

On 02/07/18, the hot water temperature in the patient toiletroom of the Ambulatory Surgical Unit (ASU) was 127 degrees Fahrenheit;
On 02/08/18, the hot water temperature in patient room #259 was 123 degrees Fahrenheit;
On 02/08/18, the hot water temperature in the patient room #217 was 122 degrees Fahrenheit;

Interview with Staff (J), Facilities during the above noted tours verified the findings.

Based on observation and staff interview, the facility does not ensure that 5 of 5 exhaust vents are maintained in the kitchen area.. Failure to maintain the exhaust vents may result in inadequate ventilation.

Findings include:

During the facility tour on 02/07/18 at 11:00 AM, it was observed that the mechanical exhaust vents in the kitchen area had a significant accumulation of dust and debris present. These vents were located above the grill/fryer area and in the janitor's area.

Interview with Staff (J), Facilities and (PP), Dietary on 02/07/18 verified this finding.

Based on observation, interview and policy review, the facility does not ensure biohazardous waste, specifically sharps containers, are properly secured and stored. Failure to properly secure sharps containers can place patients, staff and visitors at risk of injury and/or infection.

Findings include:

Review of policy #S-01, "Syringe and Needle Control" last revised 03/05/15 revealed the departmental users will be responsible for the security of needles and syringes within their department.

Observation on 02/05/18 at 11:30 AM in the Emergency Department medication preparation room revealed 4 unsecured tabletop sharps container.

Observation on 02/06/18 at 10:00 AM in the 2C Medical surgical unit medication preparation room revealed one unsecured sharps container standing on the floor.

Interview with Staff (D), Patient Care Services on 02/05/17 at 11:30 AM and on 02/06/18 at 10:00 AM confirmed the above noted findings.

Based on observation and staff interview, the facility does not ensure the isolation monitors are operational in 2 of 2 designated isolation rooms (room 213 and 217). Failure to ensure proper operation of the isolation monitors may result in patients, staff and visitors being exposed to communicable diseases.

Findings include:

During the facility tour on 02/08/18 at 10:45 AM, it was observed that the isolation room monitors, located in the corridor, did not indicate that the rooms were negative pressure when the rooms were activated for air borne infectious isolation (AII). When these rooms were activated for negative pressure, the lowest pressure reading was 0.012, indicating that the rooms were slightly positive air pressure with relation to the corridor. It was also observed that a self-closing device was not present on these rooms when they were activated for AII. These rooms must provide a visual indicator whenever the negative pressure differential is not maintained.

Interview with Staff (J), Facilities on 02/08/18 11:15 AM verified this finding.

Based on observation, policy review and interview, surgical staff has not followed facility policy related to emergency equipment, specifically the monitoring of the Malignant Hyperthermia cart in the Operating Room. This has the potential for emergency equipment and medication to be unavailable in emergent situations.

Findings include:

Review of facility policy titled " Malignant Hyperthermia" last reviewed 01/20/18, revealed the cart will be checked monthly for supplies and out-dates, and will be checked-off on a log as completed.

Review of the Malignant Hyperthermia (MH) cart in the operating room center core area on 02/05/18 at 1:30 PM revealed the MH cart does not have a log for documentation of monthly checks of cart contents and expiration dates.

Interview with Staff (L), Surgical Services and Staff (BB), Scrub Technologist on 02/05/18 at 1:45 PM revealed that the malignant hyperthermia cart is checked monthly for contents and expiration dates but verified that a log manual for recording monthly checks has not been maintained.



Based on document review, interview and observation, surgical staff failed to develop a policy and procedure or maintain a log book to address cleaning of sterilizers in central sterile processing. Furthermore, facility failed to remove outdated sterilizer supplies from storage area in sterile processing area. This has the potential to lead to infection control problems.

Findings include:

Review of Getinge Steam Sterilizer User Manual (400/500HC-E) on 02/06/18 at 11:00 AM revealed the interior chamber of sterilizer should be cleaned quarterly with Getinge Stainless Steel Chamber Cleaner. No log or documentation of sterilizer cleaning and maintenance found in sterile processing area.

Review of facility policy titled "Expired Supply and Medication Disposal" effective 02/2018 stated that supply inventories will be checked on a monthly basis for out-dates and expired supplies will be discarded.

Observation in cleaning supply room next to Getinge sterilizers on 02/06/18 at 11:30 AM revealed (2) of the (4) gallon bottles of Getinge Clean Stainless Steel Chamber Cleaner expired in 08/2015.

Interview with Staff (L), Surgical Services and Staff (M), Sterile Supply Technician on 02/06/18 at 11:45 AM revealed that the interior chamber of sterilizers are cleaned monthly with recommended Getinge cleaner but verified that a log is not maintained for documentation of monthly cleaning. Staff (L) stated that there is no facility policy and procedure regarding care and maintenance of sterilizers. Staff (L) and (M) verified the expiration dates of sterilizer cleaner.

Based on medical record review and interview, the facility did not provide a written copy of Resident Rights to the patient when their status changed from Hospital Inpatient to Swing Bed status in 3 of 3 patients. This could potentially confuse patients/families about hospital/long term admission status.

Findings include:

Review of medical records for Patient # 45, 46, 47 on 2/8-9/18 revealed no documentation of the residents having received a copy of the Residents Rights when the patient changes from hospital inpatient to swing bed admission status.

Review of Admission Procedure for a Swing Bed Policy No: A-02 last reviewed 4/17 revealed no procedure to provide a copy of Residents Rights for new Swing Bed residents.

Interview with Staff (KK), Clinical Practice on 02/09/18 verified this finding.

Based on medical record review and interview the facility does not provide an on-going program of activities directed by a qualified activities program director for 3 of 3 swing bed patients. (Patient # 45-47). Lack of an activities program could negatively impact the residents physical, mental and psychosocial well-being.

Findings include:

Review of medical record on 02/09/18 for Patient # 45-47 revealed no documentation of participation in or refusal of individual or group activities.

Interview with Staff (KK), Clinical Practice on 02/09/18 verified the lack of activities documentation. In addition it was noted that although any activities are usually lead by occupational or physical therapy and social work at times, there is not a designated qualified professional that specifically directs the swing bed activity program.