HospitalInspections.org

Based on medical record review, observation, review of the hospital's Professional Staff Rules and Regulations, it was determined the hospital failed to ensure patient medical records were completed within 30 days of discharge and failed to ensure hardcopy (paper) patient medical records were stored in a secure manner to protect from water destruction in the event of activation of the sprinkler system. The patient sample size was 34. The patient census was 86.

Findings include:

1. On 06/20/13 at 2:20 P.M. an interview was conducted with Staff I in the medical records department. Staff I stated at this time the hospital currently had 950 medical records that were over 30 days delinquent. Staff I confirmed the oldest delinquent patient medical record was 02/18/11. Staff I confirmed the delinquent patient medical record was Physician L who was currently an active staff member.

2. The hospital's Professional Staff Rules and Regulation were reviewed on 06/20/13. According to the Section J. Completion of Records: 1. Records should be completed within twenty-eight day. Records more than 28 days are considered delinquent. 2. Notice of pending relinquishment of admitting privileges will automatically be mailed to all physicians and dentists who have delinquent records. This notice will identify what records are delinquent.

3. Interview with Staff I and Staff K on 06/20/13 at 2:28 P.M. revealed there was no documentation available to review to demonstrate Physician L had been given written notice as per the rules and regulations. Staff K stated at this time they had sent the written notice to Physician L at least weekly but had not kept documentation of the sending of the notice. Staff K provided a report from the computer system that documented Physician L had a total of eight delinquent medical records past 30 days as of 06/20/13.



4. On 06/20/13 between 2:30 P.M. and 3:00 P.M. observations of the medical records department were made with Staff I. At least 100 patient medical records (records pulled for copying for information release requests) were observed stored on a large, open, metal cabinet. Observations revealed sprinkler heads (from the sprinkler system) were located in the ceiling directly above and beside the open, metal file cabinet. There was no means to cover or provide protection from water destruction in the event of the activation of the sprinkler system. This finding was confirmed by Staff I on 06/20/13 at 3:00 P.M.

5. Another open, metal cabinet was seen positioned against the wall across from the reception desk. Patients' paper medical records were stored in this open cabinet. There were at least 25-30 patient records. Staff I stated on 06/20/13 at 2:57 P.M., these patient records contained paper surgical reports, anesthesia reports, and signed consents. Staff I said these patients' records were active from 06/20/13 and mostly same day surgery charts that were waiting to be processed, coded, and filed. On 06/20/13 at 3:00 P.M. sprinkler heads were observed mounted in the ceiling directly in front of and beside this cabinet. There was no means in place to protect these medical records from water destruction in the event the sprinkler system was activated. This was confirmed by Staff I on 06/20/13 at 3:00 P.M.

Based on observation, interview and policy review it was determined the facility failed to ensure one anesthesia drug cart in one operating room (#4) of five operating rooms #1, #2, #4, #9 and #5) were locked. There was a total of 16 operating rooms. The total census was 86.

Findings include:

1. Observations were made on 6/19/13 from 1:20 PM to 1:45 PM of five (#1, #2, #4, #9, and #5) operating rooms in the surgical area. Observation of operating room number four on 6/19/13 at 1:27 PM revealed the second drawer of the Lionville cart (anesthesia drug cart) was not closed. Over 30 medications including atropine (anticholinergic and antagonist), lidocaine (antiarrhythmics), epinephrine (cardiac stimulant), and naloxone (antagonist) were observed in this drawer.

2. Interview with Staff E, RN, Administrative Manager of surgery on 6/20/13 at 8:16 AM., revealed it is the responsibility of the anesthesiology team to lock the Lionville cart (anesthesia drug cart) after the last scheduled surgical case in that operating room which would be considered the end of the day.

3. Review of the revised surgical schedule on 6/20/13 at 9:47 AM revealed the last surgical case for the day in operating four on 6/19/13 was from 10:40 AM to 11:10 AM.

4. Review of the policy and procedure "Medication Safety in the Operating Room" revised 1/12, revealed the purpose of this policy was to provide guidelines to ensure medications were labeled and secured when not under the direct control of anesthesia providers or nursing professionals in the preoperative environment. Medications must always be secured from those who do not have access authority.
The policy revealed at the end of the day, weekends, and holidays, the Lionville carts are locked.

This finding was confirmed by Staff E, RN, Administrative Manager of surgery on 6/19/13 at 1:25 PM., who revealed the second drawer should have been shut and when you shut the drawer the anesthesia drug cart locks.

Based on observation and staff interview the facility failed to ensure the director of dietary services maintained kitchen equipment and stored food in a clean and safe manner. This has the potential to affect all patients, employees and family members utilizing the dietary department. The facility census was 86.

Findings included:

Tour of the dietary department on 6/18/13, with the dietary manager and other facility staff at 10:00 AM revealed the following findings.

1. There were three large unmarked containers in the walk in refrigerator. One container held powdered cheese, two other containers held grated cheeses. There was a small unmarked container that held pesto.

2. The large mixer had dirty, greasy looking buildup on the controls.

3. One oven had a soiled substance on the outside, and

4. A cart holding large pans had a build up of dark substances on the legs of the cart.

5. The steamer had soiled handles and the table on which the steamer sat was dusty.

6. Upon entrance to the meat cooler a large pan containing 7 pieces of uncovered meat was sitting in the middle of the room.

7. The vegetable cooler had two large bags of mixed vegetable that were loosely open with no date marked on the bags to indicate when the bags had been opened.

8. The walk-in freezer contained two large pans of uncovered pasta and sauce.

9. Two large wooden cutting board tables in the spice room were partially stained with black marks and had cut areas on the surface of the tables.

10. There were four large dented food cans that contained pudding, diced tomatoes, water chestnuts and beans on the can shelf.

11. Review of the job description of the Food Service Director on 6/19/13 revealed his/her responsibility was to assure the preparation and safe food handling practices are provided and sanitation and disinfection oversight will be within the scope of his/her authority.

All findings were confirmed by Staff D on 6/18/13 at 10:00 AM.

Based on staff interview, observations, and policy review, the Condition of Participation of Physical Environment was not met in regard to cleanliness of facility and life safety from fire. Life safety from fire was in regard to fire walls and doors, corridor doors, smoke barrier doors, storage rooms penetrations, and exit access door, exit discharge lighting, exit signs, smoke detector locations, sprinkler head maintenance and clearance, fire extinguishers, fire damper testing, a kitchen hood extinguishing system, medical gas storage, sprinklers in off-site facilities, and generator testing. This could potentially affect all patients, staff, and visitors. The total patient census on the first survey day was 86.

Refer to A0701 in regarding to a soiled air vent cover.

Refer to A0709 for Life Safety from fire requirements not met.

Based on observation, policy review and interview, the facility failed to ensure the return air vents in the operating rooms' clean storage and other areas were kept clean. The facility failed to ensure the facility policy was followed related to environmental cleaning of the Cardiac Catheter Laboratory and Urgent Care Center. This had the potential to affect each patient treated in surgery. The total census was 86.
Findings include:
On 06/17/13 at 3:15 P.M. a tour was conducted of the second floor of the surgery building with Staff A1 and A2.
1. Observation of the clean storage room revealed a return air grill near door 2845.1 covered in dust within each laminar square.
2. Observation of the operating room storage room revealed a return air grill near door 2844.1 covered in dust within each laminar square.
3. Observation of the return air grill near in the hallway near door 2843.2 caked in dust within each laminar square.
During the tour staff A 1 and A 2 confirmed the observations.


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4. The Cardiac Catheterization Laboratory was toured on 06/19/13 at 10:30 AM. A layer of dust was noted on the bottom of the boom. This dust fell down in small clumps as a hand was swiped along the surface of the boom..

5. Dust was observed in three vents in the ceiling.

6. A dark brown colored substance was noted in a cabinet under a weight relieving belt. When the belt was lifted, one side of it was noted to be disintegrating, leaving a brown colored substance.

7. A thick layer of dust was noted inside the wall vent in the Equipment room. The dust formed a thick, brownish gray coating on the wall near the vent, on a keyboard, and on the door leading directly to the Cath Lab. Staff F was interviewed at the time of the tour. According to Staff F, staff from the Cardiac Cath Lab are responsible for cleaning immediately after procedures but staff from Environmental Services are responsible for daily terminal cleaning of the lab.

8. The Housekeeping Standards Policy for the Cath Lab was reviewed on 06/20/13 at 02:00 PM. According to the policy staff are instructed to dust in the Cath Lab weekly and to clean the vents on a monthly basis. A request was made for the facility to provide evidence of the weekly and monthly cleaning. No evidence was provided prior to the time of exit.

9. The facility's Outpatient Care Center was toured on 06/19/13 at 04:15 PM. A keyboard used for therapy was noted in a cabinet. The keyboard had a sticky residue and crumbs on it.

10. In the Cat Scan Room a mask, connected to an oxygen outlet. The mask had a coating of dust in it. According to Staff M, the masks are attached to the oxygen outlet prior to CT scans being completed in case of an emergency. Staff M confirmed the mask should have been removed after completion of the last CT scan, one week ago. Staff M said the mask should have been free from dust.

11. Dust was noted on the ledges where oxygen and vacuum outlets were attached in Exam Rooms #7, #8, #9, #10, #11, and #12.

12. Dust was noted on the procedure light in the room used for stabilization of critical patients. There was dust noted on an IV pole in this room.

13. A layer of dust was observed on the procedure light in Exam room #10. There was a heavy coating of dust observed on top of a cabinet in Exam room #10.
Staff M was interviewed on 06/19/13 at approximately 05:45 PM. According to Staff M an outside contractor is responsible for the cleaning of the Outpatient Care Center.

14. The Janitorial Agreement was reviewed on 06/20/13 at 02:15 PM. According to the agreement the outside contractor is assigned the tasks of cleaning the top of the cabinets.

These facts were confirmed with Staff M on 06/19/13 at 5:45 PM.

Based on observations, staff interviews, and review of the fire damper testing and generator maintenance logs, the hospital failed to ensure life safety from fire requirements were met. This was in regard to fire walls and doors, corridor doors, smoke barrier doors, storage rooms penetrations, and exit access door, exit discharge lighting, exit signs, smoke detector locations, sprinkler head maintenance and clearance, fire extinguishers, fire damper testing, a kitchen hood extinguishing system, medical gas storage, sprinklers in off-site facilities, and generator testing. This could potentially affect all patients, staff, and visitors. The total patient census on the first survey day was 86.

Findings include:

During this visit, on 06/17/13 through 06/21/13, a tour was conducted by two surveys with Staff A1, A2, A3, A4, A5, A6. The following were observed and verified by these staff during this tour and inspection:

1. The facility failed to ensure fire walls were free from penetrations and fire doors closed and latched. Corridor room doors failed to resist the passage of potential smoke. One set of smoke barrier doors failed to latch when tested. Storage rooms designated as a one hour fire enclosure contained penetrations in the fire barrier. A deadbolt was observed on one exit access door. The facility lacked adequate exit dischage lighting at exit discharges. The facility lacked exit signs in areas where the exit was not readily apparent. Smoke detectors were located too close to air supply and return vents. Sprinkler head clearance was comprised by medical record storage, and dirty sprinkler heads were present in the facility. Fire extinguishers were not located as to be highly visible. One kitchen hood extinguishing system was non-compliant with the life safety code requirements. Medical gases were not stored in a safe manner, and exceeded the permitted amount. Extra sprinkler heads and/or wrench were not kept in the off-site locations. Generator testing and maintenance logs were not available, and testing of the generators' automatic transfer switches exceeded the facility's designated standard of time.

These findings were confirmed per interview with the aforementioned staff during this survey.

Refer to A0710.

Based on observations, staff interviews, and review of the generator log, and fire watch plan, the hospital failed to ensure life safety from fire requirements were met. This was in regard to fire walls and doors, corridor doors, smoke barrier doors, storage rooms penetrations, and exit access door, exit discharge lighting, exit signs, smoke detector locations, sprinkler head maintenance and clearance, fire extinguishers, fire damper testing, a kitchen hood extinguishing system, medical gas storage, sprinklers in off-site facilities, and generator testing. This could potentially affect all patients, staff, and visitors. The total patient census on the first survey day was 86.

Findings include:

During this visit, on 06/17/13 through 06/21/13, a tour was conducted by two surveys with Staff A1, A2, A3, A4, A5, A6. The following were observed and verified by these staff during this tour and inspection:

1. Fire doors failed to latch and penetrations were observed in one fire barrier. Refer to K11.

2. Corridor doors were observed with gaps and failed to resist the passage of potential smoke. Refer to K18.

3. One set of smoke barrier doors equipped with latching hardware failed to latch. Refer to K27.

4. Designated one hour fire rated storage rooms were observed with penetrations in the barrier. Refer to K29.

5. One exit access door required more than a single step operation due to being equipped with a deadbolt sixteen inches over the door handle. Refer to K38.

6. Eight exit discharges were observed without adequate lighting at the discharges. Refer to K45.

7. Exits were clearly marked with visible exit signs in areas where the path of exit was not readily apparent. Refer to K47.

8. Smoke detectors were located too close to air supply and return vents. Refer to K52.

9. Sprinkler heads were observed dirty, and sprinkler head clearance was compromised with medical record storage in two areas. Refer to K62.

10. Fire dampers were not tested every 6 years in accordance with the Life Safety Code. Refer to K64.

11. Fire extinguishers were not visible in areas of the facility. Refer to K67.

12. One kitchen hood extinguishing system was not compliant with the Life Safety Code requirements. Refer to K69.

13. Medical gases were not stored in a safe manner, and exceeded the permitted amount. Refer to K76.

14. Extra sprinkler heads and/or wrench were not kept in off-site locations. Refer to K130.

15. Generator testing and maintenance logs were not available, and testing of the generators' automatic transfer switches exceeded the facility's designated standard of time. Refer to K144.