HospitalInspections.org

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all physician orders are timed and dated using complete dates when they are entered into the medical record for 18 of 35 random records reviewed.

Findings include:

1. Fifteen discharged records were selected at random from a list of discharges for the past 2 months, along with 20 inpatient medical records These were reviewed for a total of 35 medical records.

2. On 18 of 35 medical records reviewed, all physician orders had not been timed and/or dated using complete dates when entered into the medical record. These orders included orders written by the physician, those taken by a nurse, and routine order sheets.

The hospital failed to be constructed, aranged and maintained to ensure the safety of the patients.

Refer to A 709, facility failed to comply with the provisions of the Life Safety from fire.


Refer to A 710, The facility failed to meet the the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation, staff interview and policy review, the facility failed to maintain bathing water temperatures in such a manner that the safety and well-being of patients was assured.

Findings include:

1) On May 11, 2010, at 11:05 a.m., during the initial tour on the 3rd floor with the Facilities Director, observation in patient room #321 revealed water temperatures of 120 degrees Fahrenheit (F) at the tub faucet and 119.6 degrees (F) at the sink.

On the 2nd floor, observation in patient room #224 revealed water temperatures of 120 degrees (F) at the tub faucet and 119 degrees F at the sink.

During the observations the Facilities Director noted that the temperature should not exceed 115 degrees (F).

Review of the Hospital water temperature policy revealed an acceptable range from 100 degrees (F) to 115 degrees (F).

2) On May 14, 2010, from 9:15 a.m. through 11:15 a.m., inspection of patient room water temperatures from 5th, 4th, 3rd and 2nd floors by the Hospital Safety Director, Plant Operations Engineer and the two (2) Life Safety Code (LSC) Surveyors revealed the following:

Room #574- Tub 119.8 degrees F Sink 119.8 degrees F

Room #575- Tub 118 degrees F Sink 118 degrees F

Room #458- Tub 117 degrees F Sink 117 degrees F

Room #480- Tub 120.6 degrees F Sink 120.6 degrees F

Room #475- Tub 120 degrees F Sink 120 degrees F

Room #422- Tub 119.8 degrees F Sink 119.8 degrees F

Room #374- Tub 118.6 degrees F Sink 118.6 degrees F

Room #326- Tub 119.3 degrees F Sink 119.3 degrees F

Room #325- Tub 118 degrees F Sink 118 degrees F

Room #224- Tub 120 degrees F Sink 120 degrees F

Room #221- Tub 120.4 degrees F Sink 120.4 degrees F

3) Facilities Director reported:
On Tuesday, May 11, 2010, at approximately 7:00 a.m. the primary boiler was shut down to prepare for the annual inspection conducted by FM Global.

The inspection was scheduled and conducted on May 12, 2010.

The boiler was typically shut down for a total of 48 hours and during the inspection period services are transitioned to the secondary back up boiler.

When this utility transfer occurred there was a fluctuation in water temperature due to boiler performance and variations in the domestic water loop.

The boiler inspection identified the refractory insulation on the rear door was compromised and required replacement.

For the temperatures to return to acceptable range will take eight (8) to 10 hours.

4) Hospital Database Worksheet noted the daily average census as 88.75

5) An acceptable Plan of Correction, with systems in place and attachments, was obtained from the hospital on May 13, 2010, at approximately 2:40 p.m..

The facility failed to comply with the provisions of the Life Safety from fire.

Refer to A 710, the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The facility failed to meet the the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Refer to K 12, the failure to provide the required 1 hour fire protection rating for structural steel. Refer to K 20, the facility failed to provide the required 2 hour fire rating for vertical shafts in a building 5 stories in height. Refer to K-29, the facility failed to provide the required 1 hour fire protection rating for hazardous areas in non-sprinkled portions of the facility. Refer to K 51, the facility failed to provide approved audio and visual notification devices for the fire alarm system in accordance with NFPA 72.

Based on record review, staff interview, and written statement, the Infection Control Nurse failed to ensure that the hospital had an accurate system in place for identifying, investigating, and controlling infections for Patient #1, one (1) of three (3) patients observed in isolation.

Findings include:

Record review revealed that Patient #1 was a 77 year old male admitted to the Intensive Care Unit (ICU) of the hospital on 05/04/10 complaining of chest pain and shortness of breath.

Review of ICU records revealed that on 05/04/10 this patient received a thoracentesis to rule out Myocardial Infarction and possible Pulmonary Edema. A culture of pleural space fluid was obtained at that time. Review of Patient #1's ICU record for the dates May 4th through 10th, 2010 revealed no documented evidence of culture results for the pleural space fluid obtained on 05/04/10 during the thoracentesis procedure.

Review of Patient #1's nurse's notes (NN) revealed that a non-productive cough was noted on May 8, 2010.

Review of the hospital policy "Nursing Service Critical Results and Diagnostic Procedures" (last reviewed and approved on 01/15/10)
revealed:
"Scope: This is a hospital-wide policy that applies to all clinical departments, clinic network, and physicians.
Purpose: To ensure immediate reporting of tests and diagnostic procedures are reported to the responsible licensed caregiver."

Observation made while touring the medical floor on 05/11/10 at 11:30 a.m. revealed a Licensed Practical Nurse (LPN) going into Patient #1's room to give medication. Prior to the LPN entering Patient #1's room a "Contact Isolation" sign was noted posted on the patient's room door. When asked, "Why is this patient on Contact Isolation?" the LPN replied, "He has MRSA in his pleural space." When asked, "Why is the patient not also on Droplet Precaution?" she replied, "I don't know."

On 05/11/10 at 1:00 p.m. an interview with Patient #1's attending physician revealed that Patient #1 was transferred to the medical floor on 05/10/10 at approximately 3:30 p.m. She stated that the patient had MSRA in his plural space, and had been on Droplet and Contact Isolation while in the ICU from 05/04/10 through 05/10/10. She did not know why he was not on Droplet Isolation at the present time. She stated, "I will put him on Respiration Isolation right now and start a round of antibiotics he is sensitive to."

On 05/11/10 at 1:30 p.m. a phone interview with the ICU Registered Nurse (RN) who discharged Patient #1 on 05/10/10 at 3:30 p.m. to the medical floor revealed, "He was not on any type of isolation while he was a patient in the ICU from 05/04/10 through 05/10/10."

Review of a NN dated 05/11/10 at 8:30 a.m. revealed that Patient #1 had been placed on Contact Isolation. The patient's family was taught about MSRA and the correct technique for hand washing.

On 05/11/10 at 3:00 p.m. an interview with the Infection Control Nurse revealed that she did not know how Patient #1 failed to have Droplet Isolation started. She stated, "I feel that (Patient #1) was not placed on Droplet Precaution because he did not have a cough. I received a computerized notice from the lab (laboratory) at 8:30 a.m. on 05/11/10 which stated that (Patient #1) had MSRA in the pleural space. I called the floor and let the RN in charge of (Patient #1) know about this and told her to place him in Contact Isolation."

On 5/11/2010 the Infection Preventionist RN provided a written statement which stated, "(A) The identified patient was changed from contact to droplet precautions. (B) Medical Staff were educated at the Medical Conference (Completed 5/12/10). (C) The IC nurse educated the involved nursing staff and counseled the physician."