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Based on observations, review of the facility's building plans, and facility's documentation, and staff interview during the life safety code inspection it was determined the facility failed to ensure the facility was maintained in a manner safe from fire, or to ensure the building construction type and height met the requirement of having a complete fire suppression system, in regard to providing services to inpatients within an area designated as a business occupancy, or to ensure a hazardous area was protected in regard to self-closing doors (C231). The facility failed to ensure all exit discharges had safe access to a paved common way, or to ensure all exit discharges were equipped with illumination arranged so failure of any single lighting fixture will not leave the area in darkness (C231). The facility failed to ensure the sprinkler system was inspected quarterly, or to ensure all portable fire extinguishers were mounted so the top of the fire extinguisher was not greater than five feet from the floor, or to ensure the testing of fire/smoke dampers was conducted, or to ensure the medical gas storage room door had proper signage displayed, or to ensure that smoke detectors were not located where the airflow patterns could prevent the normal operation of the detectors. (C231). The cumulative affects of these life safety deficiencies resulted in the facility's inability to ensure the facility was maintained in a manner safe from fire.

Based on tour of the surgical suites and an offsite outpatient area and staff interviews, the facility failed to follow current facility policies related to the cleaning of the surgical suites. This had the potential to affect all patients undergoing surgical procedures and receiving outpatient services. The sample size was 20. The facility census was 10.

Findings include:

1. Surgical Suite #1 was toured on 06/24/13 at approximately 03:30 PM. A thick layer of dust was noted on top of both of the surgical lights directly above the operating table. Clumps of dust were noted to fall to the floor as a hand was wiped over the surface. Dust was also noted on the anesthesia cart in this surgical suite. Visible dust, which was not disturbed, was noted on the boom in the surgical suite.

2. Surgical Suite #2 was toured on 06/24/13 at 04:00 PM. A sign that read: "This room has been terminally cleaned" was taped to the outside of the door. The light control panel on the wall next to the entrance was noted to have a layer of dust on it. A thick layer of dust was noted on top of both of the surgical lights directly above the operating table.

3. The facility policy entitled Sanitation, Operating Room Environment was reviewed on 06/25/13 at 10:00 AM. According to the policy, before the first scheduled procedure of the day, furniture, surgical lights, and equipment should be damp dusted with a hospital approved disinfectant. These facts were verified by Staff C on 06/25/13 at 11:30 AM.

4. The facility offsite outpatient services building was toured with Staff F, on 06/25/13 at approximately 02:20 PM. A thick layer of dust was noted on top of the soap dispenser next to the sink, on the paper towel dispenser,and on the fire alarm in the Physical Therapy/Speech Treatment Room Dust was noted on top of a storage cabinet in the treatment room. An exercise mat was observed on the floor of the treatment room. A layer of dust was noted on the mat. Staff F confirmed the mat was used for direct patient care.

5. An infant high chair was noted in a storage room in the Physical Therapy Gym. Particles of food and a sticky substance was noted in the cushion of the high chair. Two dead flies were observed on the window sill in this storage room. There were clean toys, used during physical therapy treatment, noted on the window sill.

6. The facility cleaning policy was requested at this time. A Housekeeping Checklist was provided by Staff F on 06/27/13 at 02:45. Review of the Housekeeping Checklist lacked indication that dusting was a required task of the cleaning staff. Staff F confirmed, on 06/27/13 at 02:50 PM the patient care areas should be free of dust and debris.

Based on tour observations, facility's policy review, and staff interview, the facility failed to follow current facility protocol related to surgical suite humidity monitoring and monitoring of the temperature of the drug, Mannitol. This had the potential to affect all patients receiving care in the surgical suites and all patients who were given the drug, Mannitol. The sample size was 20. The facility census was 10.

Findings include:

1. The Surgical Suites were toured on 06/24/13 at approximately 03:30 PM. The humidity log was observed in a binder. A copy of the Association of PeriOperative Registered Nurses (AORN) was observed in the binder. According to the AORN guidelines, the humidity reading in operating rooms (OR) should be monitored daily and should be maintained between 20% to 60%.

2. According to the humidity log for June, 2013, there were no humidity readings documented for 06/03/13, 06/21/13, or 06/24/13. On 06/10/13, the humidity reading was 64% in OR #2 and 62% in OR #3. On 06/12/13, the humidity reading in OR #2 was documented as 66% and in OR #3 the humidity was 62%.
3. The humidity log for the months of March through November of 2012, were also reviewed. The humidity readings in March, 2012, were documented as greater than 60 % in OR #2 on 03/16/12, on 03/19/12, and on 03/20/12, and in OR #3 on 03/22/12.

4. The humidity reading in April, 2012, was documented as greater than 60% in OR #2 on 04/16/12 .

5. The humidity readings in May, 2012, were documented as greater than 60% in OR #2 on 05/01/12, 05/02/12, and 05/03/12, 05/14/12, 05/15/12, and 05/16/12, 05/21/12, 05/23/12, 05/24/12, and 05/30/12.

6. The humidity readings in June, 2012, were documented as greater than 60% in OR #2, on 06/11/12, 06/12/12, 06/18/12, 06/20/12, 06/21/12, and 06/28/12.

7. The humidity readings in July, 2012, in all three ORs were greater than the acceptable range of 20% to 60%. In OR #1, on 07/02/12, 07/03/12, and 07/05/12.
In OR #2 on 07/02/12, 07/03/12, 07/05/12, 07/18/12, and 07/19/12.
In OR #3 on 07/05/12.

8. On 07/18/12, the humidity reading in OR #2 was documented as 82%.The log contained a note that maintenance was notified on that date. However, on 07/19/12, the humidity reading for OR#2 was documented as 72%.

9. Elevated humidity readings above 60% were documented in the months of August, 2012. September, 2012, October, 2012 and through November 2012.

10. Staff C was interviewed on 06/25/13 at 11:30 AM. According to Staff C, there is no written policy for monitoring the humidity in the OR suites, it is facility protocol to follow the AORN recommendations. Staff C verified that other than on July 18, 2012, there were no other days documented that maintenance was notified of humidity levels outside of the AORN recommended range of between 20% and 60%.

11. The Pharmacy Department was toured on 06/26/12 at 10:30 AM. A small cabinet with a hand written sign on it that read "Mannitol Warming Cabinet" was observed. A Mannitol Temperature Chart was further noted. A note on the chart read "acceptable temps are 86 to 98 degrees." On 06/06/13, 06/07/12, 06/08/13, 06/09/13, and 06/10/13 the temperatures were noted to be 106 degrees, 106 degrees, 100 degrees, and 101 degrees. Staff E was interviewed on 06/26/13 at 11:00 AM. It was verified that the temperature should be kept within the facilities acceptable temperatures.

Based on observations, review of the facility's building plans, facility's documentation, and staff interviews during the life safety code inspection, it was determined the facility was not maintained in a manner safe from fire. This had the potential to affect all patients, visitors, and staff members. This facility census at the beginning of the survey was 10.

Findings include:

1. Observation during the facility tour, review of the facility's schematics and other facility documentation and staff interview revealed the facility failed to ensure the building construction type and height met the requirement of having a complete fire suppression system, specifically in regard to providing services to inpatients within an area designated as a business occupancy. Please refer to K12.


2. The facility failed to ensure the hazardous area was protected as such in regard to self-closing doors. Please refer to K29.

3. The facility failed to ensure all exit discharges had a safe access to a paved common way for all patients, visitors and staff in the event of an emergency. Please refer to K38.


4. The facility failed to ensure all exit discharges were equipped with illumination arranged so that failure of any single lighting fixture will not leave the area in darkness. Please refer to K45.


5. The facility failed to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-. Please refer to K62.


6. The facility failed to ensure all portable fire extinguishers were mounted so the top of the fire extinguisher was not greater than five feet from the floor. Please refer to K64.

7. The facility failed to ensure the heating/ventilation and air conditioning (HVAC) system inspections complied with the National Fire Protection Association (NFPA) 90A, Chapter 3-4.7 in regard to testing of fire/smoke dampers. Please refer to K67.

8. The facility failed to ensure the medical gas storage location was protected in accordance with the National Fire Protection Association (NFPA) 99, Chapter 8-3.1.11.3, specifically in regard to signage. Please refer to K76.

9. The facility failed to ensure that smoke detectors placed in spaces served by air-handling systems were not located where airflow patterns could prevent the normal operation of the detectors, or to ensure the sprinkler system was inspected quarterly as required by the National Fire Protection Association (NFPA) 25, Chapter 2-1, or to ensure all battery operated lights were tested monthly for 30 seconds and a 90 minute annual test was performed according to the NFPA 101, Chapter 7.9.3. Please refer to K130.

Based on observations during tour, policy review, and staff interview, the facility failed to follow current facility policy related to the checking for outdated medications and supplies. This had the potential to affect patients receiving care in the Surgery Services area and the Respiratory Therapy area.

Findings include:

1. The Surgery Services area was toured on 06/24/13 at approximately 01:35 PM. In a locked cabinet in the Medication Preparation area a tackle box was observed with an expiration sticker with the date of 04/30/13. noted. Four vials of Ephedrine were noted. All four vials were noted to have an expiration date of 04/30/13.

2. A container with 43 bubble packs of Acetaminophen was noted on the second shelf of a cabinet. The expiration date was 01/30/13. Sterile swabs were also observed on the second shelf of this cabinet had expiration dates of 05/20/13. Three bottles of Hydrogen Peroxide were noted under the sink in the soiled utility room with an expiration date of 09/08 for all three bottles. An opened bottle of Hydrogen Peroxide on the cleaning supply cart in the soiled utility room was observed with an expiration date of 09/08 on the bottom.

3. The cleaning supply cart contained three containers of soap dispenser, used to wash surgical instruments, were observed with an expiration date of 02/12.

4. The second drawer of a locked difficult airway cart observed in the corridor of the Surgery Services area contained a can of topical anesthetic spray with an expiration date of 11/2012. The third drawer of the difficult airway cart contained a tube of Lidocaine Hydrochloride Jelly with an expiration date of 05/13. Also in the third drawer were three size 4 laryngeal tubes labeled with an expiration date of 08/2012, two size 3 laryngeal tubes labeled with an expiration date of 06/2012, a size 4.5 and a size 3.5 single use intubating laryngeal airway with an expiration date of 07/2012.

5. A Dantrium kit contained 11 vacutainers with expiration dates of 09/2012.

6. The first drawer of a locked anesthesia cart in the corridor contained two vials of Robinul with an expiration date of 04/01/13. The fourth drawer contained seven insulin syringes, four had expiration dates of 07/2012 and three had expiration dates of 01/2013. The fifth drawer contained a bottle of Aminophylline in a brown ziploc bag. The bottom of the bottle was labeled with an expiration date of 06/01/13. The fifth drawer contained two vials of Propranolol with expiration dates of 03/2013, two vials of Adenosine with expiration dates of 01/2013, a bottle of Lidocaine HCL with an expiration date of 06/01/13, two bottles of Lidocaine HCL with expiration dates of 05/01/13, and a vial of Atropine Sulfate with an expiration date of 12/12.

7. The facility Policy to Establish Guidelines for Storage of Drugs and Supplies for the Surgery Services Department was reviewed on 06/25/13 at approximately 11:30 AM. According to the policy outdated drugs should be removed from storage and replaced by the Pharmacy Department on a monthly basis.
These findings were confirmed with Staff C on 06/25/13 at 11:30 AM.

8. The Respiratory Department was toured on 06/26/13 at 10:30 AM. An atrial blood gas kit with an expiration date of 09/2011 was observed in a cabinet in the Outpatient Room.

9. A locked crash cart was observed in the Stress Lab. A 22 gauge IV catheter was noted in the first drawer. The catheter was labeled with an expiration date of 10/2011. 11 packets of alcohol swabs were observed stacked in the corner of the first drawer. The packets were tied together with a rubber band. When the stack of alcohol swabs was lifted, the rubber band was noted to disintegrate. Nine of the packets of alcohol were noted to be labeled with an expiration date of 02/2013, and the remaining two had expiration dates of 01/2013. A cuffed tracheal tube was was labeled with an expiration date of 04/2013. A bottle of antiseptic handrub was labeled with an expiration date of 10/2008.

10. The facility policy for the Cardiopulmonary Crash Cart was reviewed on 06/26/13 at 01:15 PM. According to the policy, staff from Pharmacy Services are responsible for ensuring the integrity of the crash cart. The policy instructs pharmacy staff to make routine checks for medication expiration and lock security.

11. Staff G was interviewed on 06/26/13 at 01:15 PM. Staff G confirmed the policy instructs pharmacy staff to check for outdated medications and the lock integrity. The policy does not assign to the pharmacy the task of checking for outdated supplies.


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12. On 06/25/13 between 1:00 P.M. and 3:00 P.M. a tour of the Emergency Department was taken with Staff B and Staff H. In the supply room observations revealed on 06/25/13 between 2:30 P.M. and 3:00 P.M. two bottles of Phisohex were dated as being opened on 04/21/13. Interview with Staff H on 06/25/13 at 2:30 P.M. revealed the facility policy is to discard all drugs and biological's within 30 days of opening. Staff H stated all drugs and biological's are to be dated with the staff initials and the date when items were first opened. Staff H confirmed at this time the bottles of Phisohex should have been discarded. In addition, a bottle of brown-orange liquid was seen in the overhead cabinet and did not contain any information to identify what was in the container. Staff H identified this solution as being Betadine and verified there should have been a label on the container that identified the solution and had corresponding information such as lot number, type of solution, and the date when opened. A third container of Phisohex was seen stored in the overhead cabinet that had been opened and was not labeled with any staff initials or the date when first opened, On the shelf in the supply room a 250 milliliter bottle of Sodium Chloride bottle was determined to have been opened. There was no staff initial or date the bottle had been opened. Also observed on the shelf was a bottle of 70% isopropyl alcohol that had been opened and was without a date of opening or staff initial.

Based on medical record review, policy review, and staff interview, the facility failed to follow current facility policy related to care of the PACU patient. This affected Patient #10. The sample size was 20. The facility census was 10.

Findings include:

1. Patient #10 was admitted to the pre-operative area on 02/28/13 for an elective hysteroscopy and Essure sterilization. The procedure was completed without any noted complications and the patient was noted to be in PACU for recovery at 11:00 AM.
The Obstetrical Physician ordered Morphine 2 mg IVP as needed every 15 minutes for a maximum of 4 doses for pain. The patient was noted to complain of pain, rating it a 10 on a 0-10 scale at 11:00 AM. The patient was medicated with 2 mg of Morphine at 11:10 AM. A Nursing Note at 11:20 AM read: "Patient whining of pain. Verbalized to patient that she will experience pain from procedure. And that pain will not go away completely." The patient's blood pressure was noted to be elevated at 171/101 at 11:20 AM. The patient was discharged home at 11:45 AM. The medical record lacked documentation to determine if the patient was medicated with the other 3 doses of Morphine as ordered by the physician.

2. The facility policy related to Care of the PACU Patient was reviewed on 06/27/13 at 02:40 PM. According to the policy staff are instructed to medicate patients for pain as directed by the physician. These facts were confirmed by Staff C on 06/27/13 at 03:00 PM.