HospitalInspections.org

Based on closed medical record review, observation and staff interview the staff failed ensure a patient's right to privacy, respect, dignity, and comfort while in the hospital in 1 of 1 medical records reviewed (#34).

The findings included:

Medical record review of patient #34 revealed the patient was admitted on 1/28/2013 due to becoming "suicidal with plan to wreck car". Nursing documentation revealed on 1/28/2013 at 1329 the patient had "lacerations on wrist and ankles".Review of nursing documentation revealed on 1/30/2013 at 1458 the patient's mood became unstable and the patient "Reports feelings of SI (suicidal ideation). Was asked to sign written contract but refused. She was noted to be tearing pieces of paper and forming the pieces to spell "H-U-R-T". " At this time staff moved pt (patient) and mattress out in front of nurses station. Pt. then pulled up left sleeve to show staff where she had scratched at her wrist with a broken pencil (which she handed staff ). ...Pt ball up on mattress in hall and lightly tap forehead on wall. No injuries to note. mattress moved away from wall". Record review revealed a "Safety Contract" form dated 1/30/2013 with documentation noted the patient refused to sign the contract and "moved pt on mattress into hall in view of nurses station". Record review revealed documentation on 1/30/2013 the "psychiatric services frequent checklist" the patient was in the hallway on a mattress from 1000 until 1145, 1230 unit 1545 at 1800 until 1915 and 2115 until 2245.

Interview with the supervisory psychiatric staff and the director of psychiatric nursing during tour of the psychiatric women's unit on 6/5/2013 at 1115 revealed there are different observation levels for patient care. The interview revealed on all units patients may need to be observed in the level "line of sight". The interview revealed these patients must be able to be viewed by staff at all times. The interview revealed during the night shifts the patients that are line of sight are moved to the hall in front of the nurse's station so the staff can keep the patient in "line of sight". The interview revealed the mattress may be moved from the bed or the patient's bed may be moved in the hall in front of the nurse's station.

Interview with the supervisory psychiatric staff and the director of psychiatric nursing on 6/5/2013 at 1500 revealed on the women's unit the mattresses are removed from the bed and placed in the hall in front of the nursing station especially at night when the patient is on observation status "line of sight". The interview revealed this was done for patient safety so the staff would be able to see the patients. The interview revealed there may not be enough staff to ensure safety so the patient is moved.

Interview with the hospital director of nursing on 6/5/2013 at 1600 revealed the director was not aware of the patient's mattresses being removed on the psychiatric units and placed in the hall so the staff would able to observe "line of sight" patients.

Interview with supervisory psychiatric nurse on 6/6/2013 at 0930 revealed when the patients are moved in the hall at night in front of the nurse's station it is because the staff can not observe the "line of sight" patients in their rooms.

Based on observations and staff interviews the staff failed to maintain a safe environment for patients on the women's psychiatric unit.

The findings included:

During tour of the women's unit on 6/5/2013 at 1115 the door to the Activity room was observed open. Observation in the activity room revealed a pencil holder with more than three sharpened pencils in the holder. Observation while continuing the tour revealed in Room 205 a crochet needle was observed on the bedside table in the room. Interview during the tour with the supervisory psychiatric staff and the director of psychiatric nursing revealed the Activity room is opened to the patients without restriction. The interview revealed there were patients on the unit currently that were involuntarily committed (threat to themselves or others) that had unrestricted access to the Activity room. The interview revealed the staff did not view the sharpened pencils or crochet needle as a potential instrument that could be used for harm.

Based on observations as referenced in the Life Safety Report of Survey completed June 6, 2013, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

The hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.


2 .The hospital staff failed to maintain a sanitary and clean environment in the surgical suites.

~cross-refer to 482.41(c)(2) Physical Environment: Life Safety from Fire - Standard Tag A0724.

Based on observations as referenced in the Life Safety Report of survey completed June 6, 2013, the hospital staff failed to ensure the safety and well-being of patients, staff, and visitors by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building - 01

A. Observation on June 5, 2013 at approximately 8:00am onward, doors are imcomplete due to the following:

1. Lack of positive latching hardware - door between engineering office and corridor adjacent to materials management.

2. Lack of positive latching hardware - door serving C-section recovery room located on first floor Labor and Delivery Unit.

3. Door to nuclear medicine is wedged in the open position.

4. Louver in door to room 340B, pharmacy regional manager's office, is not installed to maintain required fire resistance rating. The facility is not equipped with a complete automatic sprinkler system that would allow a rating reduction.

5. Lack of positive latching hardware on Wickett doors located on resident room doors in second floor Psych unit - Women's Unit.

6. Lack of positive latching hardware on door to office in Med Psych Unit on second floor.

7. Dead-bolt lock serving social work office is greater than forty-eight inches above the finished floor - Second Floor Med Psych Unit.

8. Wedge under door to Clinical Dieticians office.(Second floor)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.


B. Observation on June 5, 2013 at approximately 8:00am onward, hazardous areas are imcomplete in the following areas:

1. Materials management located on ground floor - fire doors, adjacent to corridor, do not close and latch properly.

2. Biohazard storage room - holes in enclosure walls. Located beside loading dock area.

3. Radioactive materials room - no lead lining identified in door.

4. Transformer room - no self-closing device on door enclosing room. Located off corridor between outpatient surgery and operating suite.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.


C. Observation on June 5, 2013 at approximately 8:00 am onward, the exits are noncomliant due to the following :

1. The second exit route is not identified at the second floor elevator lobby formed by unit control doors.(Psych Unit)

2. There is no on/off master release switch for electromagnetic locks serving the Baby Place - the required switch is not provided at the nurse's station on first floor unit

Note: The facility must be protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7 of NFPA 101; 2000 LSC when utilizing special locking arrangements.

3. Cross corridor control doors are single leaf doors, not double egress, where egress is required in both directions.(Second floor psychiatric unit).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.


D. Observation on June 5, 2013 at approximately 8:00 am onward, exit access is incomplete due to the following:

1. Exit access door added between renovation area and ICU is less than forty-four inches - located on third floor.

2. Exit access area formed by control doors near second floor elevators contain a dead-end corridor greater than thirty feet.

3. Exit access area near control doors to the Baby Place create a dead-end corridor exceeding thirty feet - there is no exit sign above doors at time of survey.(located on first floor)

4. There is no guardrail between means of egress and loading dock area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.


E. Observation on June 5, 2013 at approximately 8:00 am onward, the emergency lighting is incomplete due to the following:

1. Exit discharge located on east wing of first floor Labor and Delivery unit - no emergency lighting extending from exit discharge to publicway.

2. East stairway exit discharge near front entrance - no emergency lighting extending from exit discharge to publicway.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0046.


F. Observation on June 6, 2013 at approximately 8:00 am onward, exit signs are incomplete in the following areas:

1. Materials management area - exit egress is not equipped with an exit directional sign at area near metal gate - direction to exit discharge is not obvious.

2. Women's unit, second floor - there is no exit sign above door leading from women's unit to main corridor near elevators.

3. Med Surg emergency exit on north wing - there is no exit sign above door leading through construction renovation area.(Third Floor).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.


G. Observation on June 6, 2013 at approximately 9:36 am onward, the fire alarm system is noncompliant due to the following:

1. Did not function with loss of normal power to the main fire alarm control panel.(Security station near ER)

2. Manual pull station is located behind a wooden dish rack - located in the serving area beside the kitchen.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0051.

H. Observation on June 5, 2013 at approximately 10:05 am onward, the sprinkler system in renovated areas is incomplete due to the following:

1. There is no sprinkler in transformer room - located beside corridor between outpatient surgery and main operating suite.

2. There is no sprinkler at base of lowest stair landing - west stair at ground floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.


I. Observation on June 5, 2013 at approximately 11:22 am, the main sprinkler valve is not equipped with electrical supervision-located in valve pit beside street intersections.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0061.


J. Observation on June , 2013 at approximately 9:12 am the upright sprinkler riser is not secured with strap or bracing - located in electrical room near the Baby Place.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.


K. Observation on June 5, 2013 at approximately 8:00 am onward, the mechanical sustems are incomplete due to the following:

1. There is no emergency shutdown switch for air handlers serving the second and third floors of the facility - switch could not be verified near supervised areas within either floor.

2. Smoke damper did not close properly at barrier between OR and Outpatient Surgery located on the first floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.


L. Observation on June 5, 2013 at approximately 8:00 am onward, the range hood supression is incomplete due to the following:

1. Air imbalance between the kitchen and adjacent egress corridor - doors to kitchen and dining are held in the open position due to air flow.

2. Electrical outlets behind the range hood cooking equipment is not arranged to shut-off power with activation of range hood pull station.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0069.


M. Observation on June 5, 2013 at approximately 8:00 am onward, the means of egress is noncompliant in the following areas:

1. Ground floor corridor near sterile processing - carts, furniture and other impediments are stored in the corridor.

2. Exit passageway located on first floor west wing near Labor and Delivery unit - a wheelchair equipped with oxygen cylinder is left unattended in front of the exit door serving the exit passageway.

3. Med Psych Unit located on second floor - furniture and other impediments stored in corridor near social work office.

4. Second floor Women's Psych Unit - furniture, and other impediments are stored in the exit corridor.

5. Second floor near room 232 - corridor is obstructed by chairs, and bedside tables.

6. Second floor Psych unit on west wing - corridor wall is equipped with large mirror and bracket that protrude inside required head clearance of six feet eight inches. The mirror and bracket extend greater than three and one half inches from wall surface.

7. Second floor corridor near Pharmacy storage, and old OB area - sink, plants, IV poles, and blanket warmer obstruct corridor.

8. ICU located on 300 hall - tables, receptacle junction boxes, and conduit obstruct corridor near renovation area.

9. Med Surg on third floor near room 333 - electric bug light protrudes greater than three and one half inches into required corridor.

10. Ground floor - corridor is obstructed by furniture beside dining and serving area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.


N. Observation on June 5, 2013 at approximately 8:00 am onward, the medical gas sustems are incomplete due to the following:

1. Oxygen bank near loading dock - cylinders are not protected from extremes of weather. Cylinders are in direct contact with concrete slabs and are covered with rust.

2. Oxygen bank near loading dock - cylinders are not secured individually to support brackets.

3. Compressed air cylinders are intermingled with full oxygen cylinders - storage room beside loading dock.

4. Oxygen bank between main hospital and medical office building is not equipped with covers to protect cylinders from extremes of weather.

5. Ultrasound room #1 - piped medical gas systems are not identified on zone alarm panel behind nurse's station.(located in radiology area).

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.


O. Observation on June 5, 2013 at approximately 8:00 am onward, the central electrical system is incomplete due to the following:

1. Life Safety branch panelboard contains devices not permitted on the Life Safety Branch of the essential electrical system. Circuit directory has not been updated to include the exclusion of devices not in service.(Panel ISL located on first floor)

2. There is no means for testing the required audible signaling devices for generator annunciator panels located in the engineering office and security station near ER.

3. There is no required signaling, audible and visual, for less than three hour fuel operating supply in the main fuel tank serving the emergency generators of the essential electrical system.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0106.


P. Observation on June 5, 2013 at approximately 1:42 pm onward, the medical gas alarms required greater than a twenty percent drop in pressure to activate signaling device - alarm panel at Radiology nurse's station.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0140.


Q. Observation on June 5, 2013 at approximately 8:00 am onward, the facility electrical systems are incomplete due to the following:

1. standard duplex receptacles facing loading dock are not identified as ground fault interrupter protected.

2. Massage room located near the first floor Baby Place - there is a multioutlet power tap used to distribute power. The device is not listed for use in patient care areas of health care facilities.

3. Life Safety Panel 1SHA in first floor electrical equipment room located near the spa - equipment grounding conductor number six and smaller is not equipped with continuous green insulated conductor.

4. Electrical Panel 1NH in first floor electrical room located near the spa - equipment grounding conductor number six and smaller is not equipped with green insulated conductor.

5. There are no minimum #10 green insulated conductors for bonding emergency and normal power panelboards serving the same patient vicinity - panelboards located in first floor electrical equipment room near the spa.

6. Lack of tamperproof receptacles for all receptacles used in patient rooms - located in the second floor Psychiatric Women's Unit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0147.


Building - 02

A. Observation on June 4-6, 2013 hazardous areas are incomplete in the following areas:

1. Medical Office Building - room containing hyberbaric chamber(s) is not enclosed with a minimum one hour enclosure that extends to the floor deck above.

2. Medical Office Building - room containing hyberbaric chamber(s) is not equipped with self-closing, 90 minute fire doors with required hardware.

3. Medical Office Building - storage room 001 has approximately a one inch gap between meeting edge of fire doors. The room greatly exceeds one hundred square feet in area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.


B. Observation on June 6, 2013 at approximately 8:00 am onward, there are no stair identification signs provided within stair enclosures at each landing in accordance with section 7.2.2.5.4 of NFPA 101; 2000 LSC.(Medical Office Building)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0034.


C. Observation on June 6, 2013 at approximately 8:00 am onward, the emergency light at the base of north stairway did not function during loss of normal power - Medical Office Building, near electrical room 003.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0046.


D. Observation on June 6, 2013 at approximately 8:00 am onward, there are no exit signs to direct occupants at basement level to the appropriate level of exit discharge - Medical Office Building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.


E. Observation, on June 6, 2013 at approximately 8:00am onward, the fire alarm system is incomplete in the Medical Office Building due to the following:

1. fire alarm system strobe lights would not function with loss of normal power to the main fire alarm control panel.

2. Circuit and panelboard supplying normal power to main fire alarm panel are not identified on fire alarm control panel - located in room 003 electrical room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0051.

F. 1. Observation, on June 6, 2013 at approximately 8:00am onward, the sprinkler standpipe in south stairway, fifth floor, has no pressure reading on gauge.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.


G. 1. Observation, on June 6, 2013 at approximately 8:00am onward, there is no manual shutdown switch for air handler serving wound care center and other hospital based provider spaces within the Medical Office Building - the switch shall be located at a supervised area within a designated hospital based provider space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 67.

Based on hospital policy review, observations during tours, and staff interview, the hospital staff failed to maintain a sanitary and clean environment in the surgical suites.

Review of the hospital's policy and procedure, "Environmental Services" revised on 06/10/2011 revealed, "Purpose: To create a clean environment for patients, staff and visitors. Definitions: Cleaning: The removal of all visible debris. Policy: ...Procedure & (and) operating rooms: ...6. Each day, at the conclusion of the operating schedule, furnishings and equipment are cleaned."

Observations during tour of the preoperative area conducted on 06/04/2013 at 1540 revealed lint/dust on the lower part of a stretcher.

Observations during tour of operating room #4 conducted on 06/05/2012 at 1345 with the surgery manager and the charge nurse revealed lint/dust on storage equipment and furnishings.

Interview during tour of the preoperative area conducted on 06/04/2013 at 1540 with the surgery manager revealed, "terminal cleaning (cleaning all equipment, furniture, and floors) expection is daily and after each surgical case." The interview confirmed that there was lint/dust on the lower portion of the stretcher.

Interview during tour of operating room #4 conducted on 06/05/2012 at 1345 with the surgery manager and the charge nurse revealed, "terminal cleaning (cleaning all equipment, furniture, and floors) expection is daily and after each surgical case." The interview confirmed that there was lint/dust on storage equipment and furniture in the operating room .