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Based on observation, staff interviews, and review of maintenance records between
July 13, 2015 and July 14, 2015, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. The cumulative effect of the environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.


Findings:

The facility was found to contain the following 12 deficiencies.
K 12: unprotected construction type for the building;
K 17: patient treatment areas open to the corridor
K 22: exit signs missing;
K 29: the facility did not enclose hazardous rooms with smoke tight walls.
K 33: exit stairs opening to unoccupied rooms
K 38: egress paths has too many delayed egress locks in the path of egress.
K 48: that staff were not familiar with their responsibilities in the event of a fire K 67: the facility did not provide neutral airflow between the corridor and rooms, and compliant fire dampers
K 75: the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes;
K 77: the facility did not provide proper medical gas piping by not clearly identifying piping and not having riser shut off valves.
K 144: facility did store items in emergency electrical generator room.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation and temperature control system in operating rooms and sterile processing areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect the operating room patients within these smoke compartments.

FINDING INCLUDE:
1. On 07/14/2015 at 10:05 AM, observation revealed in the Operating Room A that the ventilation to the space could not be confirmed to be compliant with accepted standards. The operating room shall be positive to the other rooms. Operating room A is negative to the scrubbing up room. This incorrect pressure relationship is not compliant with FGI Guidelines, ASHRAE 170, and 42 CFR 482.41(c)(4). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

2. On 07/14/2015 at 10:50 AM, observation revealed in the Sterile Processing area, that cleaning of endoscopy scopes and other surgical equipement was done in the same room as the sterilizing and packaging of sterile equipment. The cleaning of the dirty equipment requires the room to be negative pressure and the processing of clean equipment requires the room to have positive pressure. The air flow into this room is negative. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation, staff interviews, and review of maintenance records between
July 13, 2015 and July 14, 2015, the facility failed to construct, install and maintain the building systems to ensure life safety to patients. The cumulative effect of the environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.


Findings:

The facility was found to contain the following 12 deficiencies.
K 12: unprotected construction type for the building;
K 17: patient treatment areas open to the corridor
K 22: exit signs missing;
K 29: the facility did not enclose hazardous rooms with smoke tight walls.
K 33: exit stairs opening to unoccupied rooms
K 38: egress paths has too many delayed egress locks in the path of egress.
K 48: that staff were not familiar with their responsibilities in the event of a fire K 67: the facility did not provide neutral airflow between the corridor and rooms, and compliant fire dampers
K 75: the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes;
K 77: the facility did not provide proper medical gas piping by not clearly identifying piping and not having riser shut off valves.
K 144: facility did store items in emergency electrical generator room.
K 147: deficiencies in the electrical systems.

Refer to the the full description at the cited K tags.

Based on observation and interview the facility failed to ensure that medications were secured properly in 1 of 4 areas (Cardiac Rehab) where emergency carts were stored. This deficiency could potentially affects all patients and visitors at this facility.

Findings include:

Per review of facility policy titled Hospital Pharmacy Operations, index number TCMPhm-0060, dated 11/3/2014, the policy stated in part under storage; 3. Any other medications stored outside of pyxis or the pharmacy will be required to be locked when not in use. 4. Kits/crash carts that can be accessed in areas where staff are not always present will be additionally secured by tamper tags and/or tear away bags.
On 7/13/2015 at 1:45 PM entered the cardiac rehabilitation area, the door to the room was propped open. The cardiac rehabilitation area is located adjacent to the main entrance of the hospital. There were no staff or patients present in the room. Noted an emergency code cart containing medications (aspirin, nitroglycerin, epinephrine, diphenhydramine, glucose gel, and glucagon) stored in the corner of the cardiac rehabilitation room. This emergency code cart was secured with a plastic breakaway lock.

Per interview with Rehabilitation Manager (RM) G at time of observation, RM G confirmed that staff was not present in the area at time of tour.

Based on observation the hospital failed to maintain seperation of clean items from dirty items in 1 of X soiled utility rooms and failed to maintain cleanable ceilings in 2 of X exam rooms on _____ unit. This failure had the potential to affect all patients _______

Findings include:

Per observation of the Emergency Room (ER) on 7/14/2015 at 1:31pm, it was observed that the ER soiled utility room has clean mop heads in the room along with dirty toilet seats and partially full biohazard containers.
Director of Facilities A was interviewed regarding the storage of clean items with dirty items and Staff A, agreed the storage was not correct.

Per observation of ______ on 7/14/2015 at 2:17pm, it was observed that the two negative pressure exam rooms (5 and 6) had ceiling tile that was perforated and was not cleanable. This was confirmed with Director of Facilities A at the time of observation.

Based on observation, record review, and staff interview the hospital failed to follow proper food storage in 2 of 3 food storage areas (refrigerator and freezer). This failure has the potential to affect all patients at the hospital during the survey.

Findings include:

Per review of facility policy titled Purchasing, Receiving, and Storing Foods, index number TCMDi-0550, dated 11/3/2014, stated in part under storage, 2. Food items removed from the original package shall be identified with the common name of the food. Under special notes, 4. Leftover food items will be labeled and dated.

Per observation on 7/13/2015 at 11:40 AM of the kitchen was completed with Nutritional Service Director (NSD) H, the following was were noted in the freezer- 8 muffins wrapped individually- no label or date present. A bag holding 9 cookies were not labeled or dated. There were 6 covered individual plastic containers which appeared to be flavored jello however the containers were not labeled or dated.

The above findings were shared with NSD H at time of observations.

Per interview with NSD H on 7/13/2015 at 11:40 AM, NSD H stated "All food that is opened should be labeled and dated, the staff will need a reminder."

Based on record review and interview, the facility failed to ensure staff follow policy ensuring patients receive effective pain control in 3 of 20 patient medical records reviewed. This deficiency has the potential to affect all patients receiving pain medication.

Findings include:

Per review of policy titled Pain Management, index TCMNsg-4000 stated in part under details, "When an intervention is utilized, the patient will be reassessed for effectiveness of the intervention." Under Ongoing Assessments and Reassessments in part stated, "g. Reassessment is recommended to occur: i. As determined by the nature and severity of the pain, the interventions utilized. 1. As recommended in the Acute and Chronic Clinical Practice Guidelines: 2. Intravenous medication-30 minutes. 3. Intramuscular medications-60 minutes. 4. Oral medications-60 minutes.

Per review of pt. #14's medical record, pt. #14 received oral Tylenol for complaint of mild pain on 6/29/2015 at 10:23 PM. No reassessment was completed with follow up due to effectiveness until 6/30/2015 at 12:30 PM. Received intravenous morphine on 6/30/2015 at 10:28 PM and on 7/1/2015 at 12:45 AM, no reassessment of pain was completed.

Per review of pt. #15's medical record, pt. #15 received oral Tylenol of mild pain on 5/23/15 at 10:50 PM, reassessment was not completed until 5/24/2015 at 2:01 AM. Oral Tylenol was given on 5/24/2015 at 10:23 PM, reassessment was not completed until 5/25/2015 at 2:49 AM.

Per review of pt. #19's medical record , pt. #19 received oral morphine on 6/10/2015 at 10:05 PM, reassessment was not completed until 6/11/2015 at 12:39 AM. Oral morphine was given on 6/11/2015 at 2:36 PM and 7:24 PM, reassessment was not completed until 6/12/2015 at 12:29 AM.

Findings were shared with DON F on 7/15/2015 at time of medical record review and DON F stated in an interview on 7/15/2015 at 3:27 PM that "staff are expected to complete pain reassessment 30 minutes after giving a intravenous pain medication and 60 minutes after oral pain medication".

Based on record review and staff interview the staff failed to updated and individualize patient care plans in 4 of 20 medical records (pt. #14, 15, 18, and 19) reviewed. This deficiency potentially affects all inpatients at this facility.

Findings include:

Per review of policy titled Plan of Care, index number TCMNsg-6135, dated 9/15/2014, stated "The plan of care is a plan created to drive the care for the patient. This plan of care is developed by determining relevant patient problems and needs based on data and assessments, and using this information to plan, with the patient and/or family, care, treatment, and services that are appropriate and individualize to meet the needs, limitations and strengths of the patient."

Per interview with DON F on 7/15/2015 at 3:27 PM stated "Staff are expected to care plan all active problems, however staff would not be expected to care plan all existing chronic conditions."

Per review of medical record for pt. #14 on 7/15/2015 at 11:30 AM, pt. #14 was admitted to the hospital with a diagnosis of aspiration pneumonia. The care plan does not address alteration in airway addressing aspiration pneumonia or COPD (Chronic obstructive pulmonary disease).

Per review of medical record for pt. #15 on 7/15/2015 at 12:14 PM, pt. #15 was admitted to the hospital with a chief complaint of fall, and diarrhea. Per History and Physical for this hospitalization dated 5/23/2015 also stated pt. was seen 3 weeks ago due to episode of hypoglycemia. The care plan does not address risk for complications with diabetes.

Per review of medical record for pt. #18 on 7/15/2015 at 1:15 PM, pt. #18 was admitted to the hospital following a fall due to excessive alcohol intake resulting in a clavicle fracture. The care plan addressed only one problem, suicide risk, the care plan did not address risk for falls or pain.

Per review of medical record for pt. #19 on 7/15/2015 at 1:40 PM, pt. #19 was admitted to the hospital due to urinary retention and constipation. The care plan does not address the urinary retention problem or address that a foley catheter was placed increasing risk for potential infection.

Based on observation, record review and interview the hospital failed to ensure surgical scopes are stored in a clean manner in 1 of 1 cabinets, failed to ensure a clear separation of decontamination from sterile processing in 1 of 1 sterile processing area. The hospital failed to ensure written documentation confirms ABSP is dry prior to draping in 1 of 1 (pt.#1) record reviewed. The hospital failed to ensure proper PPE is worn during procedures in 1 of 4 staff observed (MD I). The hospital failed to ensure staff wear gloves when handling potentially hazardous materials and perform HH in 1 of 4 staff observed (RN J) and in 1 of 4 staff observed (MD I).
These failures had the potential to affect 3 patients scheduled for procedures from 7/13/2015 through 7/15/2015.

Findings include:

Per review on 7/15/2015 at 9:27 AM of P&P titled, Hand Hygiene, #TCMIP-0050, last revised 2/23/2015 the P&P states in part, "II. Indications for cleansing hands with an alcohol-based hand rub (use of soap and water is also acceptable) G. After removing gloves." "V. Other aspects of Hand Hygiene. 3. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur."

Per review on 7/15/2015 at 9:30 AM pf P&P titled, "Prevention of Transmissible Infections", #TCMSurg-0012 last revised 6/2/2015. The P&P states in part, "7. Protective eyewear must be worn when splatter is anticipated."

Endoscopy Cabinet
Per observation of OR B on 7/14/2015 at 10:23 AM with Director of Facilities A, 2 endoscopy scopes were hanging in a endoscopy drying cabinet in OR B. The doors to the cabinet were wide open and the scopes were visible.
Interview with OR Coordinator D, and CST E during the observation revealed that the cabinet had be left open and should be kept closed.

Decontamination & Sterile Processing
Per observation of Sterile Processing with, CST E on 7/13/2015 at 3:20 PM decontamination and sterilization of surgical instruments is completed in the same room. CST E explained the dirty instruments come in are cleaned per manufacturers instructions, then moved to the adjacent counter for wrapping for sterilization.

On 7/13/2015 a request was made for the P&P for completing Decontamination and Sterilization in the same room. On 7/14/2015 two P&P's were presented. Per review on 7/14/2015 of P&P's titled, Decontamination and Chemical Sterilization the P&P's reference Association of Surgical Technologists as the professional standard. The P&P's do not address procedures for decontamination and sterilization in the same room.

Per interview with CST E on 7/15/2015 at 8:02 AM, CST E explained not aware of what standards were followed when it was decided to have the sterile processing and decontamination in the same room.

ABSP

Per record review (pt. #1) on 7/15/2015 at 1:30 PM , pt. #1 was admitted to the hospital on 5/20/2015 for gall bladder removal under general anesthesia. The medical record indicates DuraPrep was the ABSP used. The record does not indicate the ABSP was dry prior to draping.

Per interview with OR Coordinator D on 7/15/2015 at 2:32 PM, after review of pt. #1's MR OR Coordinator D explained the ABSP dry time was not documented. Recently a change was made to the perioperative nursing record and the area to document the ABSP is dry, was left out.

PPE
Per observation of a colonoscopy for pt. #21 on 7/15/2015 at 8:12 AM in OR (operating room) B, MD I performing the colonoscopy was observed to not have eye protection on.

Per observation of colonoscopy for pt. #21 on 7/15/2015 at 8:12 AM, RN J was observed collecting polyp samples from CST E by having CST E place the samples in three separate Formalin containers while RN J held the containers without gloves. At 8:53 AM RN J changed the contaminated tubing from the full suction canister to an empty canister without wearing gloves.

HH
Per observation of a colonoscopy for pt. #21 on 7/15/2015 ay 8:56 AM, MD I was finished with the procedure, removed gown & gloves, retrieved the pictures taken of the polyps removed from pt. #21's colon, left OR B, sat at the desk in the restricted area, used the telephone, used the computer key board, did not immediately perform HH after glove removal.

Per interview with CST E on 7/15/2015 at 9:00 AM, CST E explained RN J should have been wearing gloves while collecting specimens and changing the suction canister tubing. MD I should have had eye protection on but doesn't wear any during procedures.

On 7/15/2015 at 11:28 AM the above findings were shared with Director of Patient Care K.

Based on record review and interview the hospital failed to assess the dental status and participation in the assessment in 5 of 5 Swing Bed patients (#8, 9, 11, 12 & 16). This has the potential to affect all patients with swing bed status during the survey, 7/13/2015 - 3pts., 7/14/2015 - 2pts., and 7/15/2015 - 2 pts.

Findings include -

Per review of medical records for pt.s #8, #9, #11, #12 and #16 on 7/15/2015 from 9:51 AM through 1:20 PM, dental status and paticipation in the assessment were not assessed and documented as part of the comprehensive assessment.

Per interview with Quality Coordinator L during the record reviews the dental status and participation pieces are missing from the assessments. Quality Coordinator L agreed they should be included and could not give a reason why it was not completed.