HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain the patient call bell system in a manner to ensure patient safety.

Findings include:

The patient bathroom in Cardiac Catheterization Suite did not emit an audible signal upon activation and testing on 10/02/15, at approximately 10:30AM.

During the tour of the Geriatric Emergency Room, on 10/05/15 at approximately 10:15AM, the surveyors noted that the the patient call bell in Treatment Bay #20 did not emit an audible signal when activated.
The patient call bell system was also tested at Treatment Bay#19. No audible alarm was produced upon activation.

At interview with Staff #19, surveyors were informed that the console for the Emergency call bell system was missing from the nurses station, and therefore, it did not emit an audible signal upon activation.

Based on observation, interview, and review of document, it was determined the facility failed to develop and implement policies to ensure appropriate surgical attire is worn in the Cardiac Catheterization Procedure Rooms.

Findings include:

During observation of care in Cardiac Catheterization Lab #3, on 10/02/15 at approximately 12:30 PM, the surveyors noted Staff #17, Surgical Technician, opening sterile instrument packs and arranging them on the surgical cart. It was noted at that this staff member's facial hair was uncovered.

Upon interview of Staff #18, Clinical Manager, it was revealed that the Cardiac Catheterization Suite did not have its own supply of beard coverings and they were obtained them from the Surgical suite.

Review of the policy and procedure, "Cardiac Catheterization and Electrophysiology Laboratories," revealed that the policy does not mention the wearing of beard coverings during procedures.
Review of infection control audits on 10/06/15 revealed that the facility does not have documented evidence of audits conducted on staff practice, including the wearing of personal protective equipment (PPE).