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At this Life Safety Code (LSC) survey, Franciscan Healthcare Rensselaer was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and
Franciscan Health and Fitness was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 39, Existing Business Occupancies.

The facility consisted of two separate buildings. Building 01 is the main hospital, a three story building with a basement. Building 02 is the Franciscan Health and Fitness Center, a one story building. The buildings were determined to be Type II (222) construction.

Building one is partially sprinklered with a fire alarm system, and with smoke detection in the corridors and areas open to the corridor. A long term Residential Care facility occupies the west side of the second floor with battery operated smoke alarms in the patient rooms. Sprinklered areas of the main building included the Emergency Room, Registration, main lobby and entrance areas located on the first floor north of the fire wall, basement of the 1983 addition, the boiler room, all environmental storage areas and offices, the water lab, equipment room # 2 and the corridor outside the pharmacy. Building 02 was protected by a fire alarm system and was not sprinklered.

The facility has the capacity for 46 patients and had a census of 9 patients at the time of the survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 9 of 12 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier and 3 of 4 ceiling smoke barriers were maintained to provide a one half hour fire resistance rating (see K 025), failed to ensure proper sprinkler coverage was provided for 4 of 4 stairwells (see K 056), failed to provide 1 of 1 fire damper inspections to show dampers were inspected and provided necessary maintenance at least every four years (see K 067), failed to ensure 7 (hydrocollator, scrubber, air handler, 3 wheelchairs and cryostat) of 7 pieces of equipment had preventive maintenance inspections per manufacturer recommendations and failed to ensure blanket warmer temperatures did not exceed the temperature range required per facility policy and procedure for 3 of 3 (Outpatient Department, Medical/Surgical Department and Oncology Department) (see C0222), failed to ensure appropriate storage conditions for medications according to facility policy and procedure for 1 of 7 (Surgery Department) areas toured (see C0224) and failed to maintain the hospital environment and equipment in such a manner that the safety and well-being of patients, visitors and/or staff are assured in 7 of 7 instances (see C0225).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the hospital failed to maintain the hospital environment in such a manner that the safety and well-being of patients, visitors, and/or staff are assured for 1 of 1 floor landing in the Franciscan Health and Fitness off-site facility.

Findings included:

1. Review of the Safety Plan indicated, "Those safety rules and precautions that will be required to provide a safe environment for those entrusted to our care, as well as to all of those who are employed at our facility and to those who may visit have been listed. It is necessary for you to assist in providing a safe and healthful environment." Franciscan Healthcare Rensselaer Safety Plan was last revised June 11, 2013.

2. At 9:13 AM on 4/20/2016, the floor landing above the steps that lead to the basement of Franciscan Health and Fitness off-site were observed to be uneven and posed a trip hazard. The uneven floor surface was visible under the carpet flooring.

3. In interview at 1:15 PM on 4/20/2016, staff member #1 (Director of Operations) confirmed the above and no other documentation was provided prior to exit.

Based on document review, observation and interview, the hospital failed to ensure 7 of 7 pieces of equipment (hydrocollator, scrubber, air handler, 3 wheelchairs and cryostat) had preventive maintenance inspections per manufacturer recommendations and failed to ensure blanket warmer temperatures did not exceed the temperature range required per facility policy and procedure for 3 of 3 (Outpatient Department, Medical/Surgical Department and Oncology Department) areas toured.

Findings included:

1. Review of the Operation Manual instructions for M-2 Master Heating Hydrocollator Unit indicated, "The thermostats are extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature was 160 to 166 degrees Fahrenheit. The temperature of the water should be checked before using the Steam Packs."

2. Review of Franciscan Health & Fitness offsite therapy Daily Hydrocollator Temperature log for April of 2016 indicated fourteen of fourteen recorded temperatures exceeded 172 degrees Fahrenheit. Review of the hospital in-patient Daily Hydrocollator Temperature log for January through April of 2016 indicated at least 27 days of 74 days the Hydrocollator recorded temperatures were recorded less than 160 degrees Fahrenheit.

3. Review of the Operation Manual Service Schedule for the Saber Compact Walk Behind Scrubber indicated the service schedule required: monthly, 100 hours and 200 hours operating usage for preventive maintenance.

4. Review of the documented preventive maintenance (PM) of the Saber Compact Walk Behind Scrubber indicated the previous three recorded preventative maintenance inspections were: 2/2/16, 7/8/15 and 7/6/14. The recorded preventive maintenance inspections lacked documented monthly, and hour usage preventive maintenance as required by the manufacturer.

5. Review of Preventive Maintenance Air Handler Report stated, "Motor greased every 6 months, filters replaced, belt tension, and coils cleaned as needed."

6. Review of the documented preventive maintenance (PM) of the Air Handler M12606 indicated the previous three recorded preventative maintenance inspections were: 7/6/2014, 6/14/2013 and 4/20/2012. The recorded preventive maintenance inspections lacked documented semiannual preventive maintenance and lacked a preventive maintenance inspection for 2015.

7. Review of the Clinical Engineering Preventive Maintenance schedule indicated the one wheelchair located at Franciscan Health & Fitness offsite facility and the two wheelchairs located at the Main Entrance of the hospital lacked documentation of preventive maintenance.

8. At 10:20 AM on 4/20/2016, staff member #26 (Clinical Engineer) indicated the wheelchairs are not on the preventive maintenance schedule to have routine inspections performed on them.

9. In interview at 1:15 PM on 4/20/2016, staff member #1 (Director of Operations) confirmed all the above and no other documentation was provided prior to exit.


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10. Review of letter revised/reapproved 12/22/14 related to cryostat confirmed once the pathologist has completed the processing of the frozen section, the Cryostat is to be cleaned of excess tissue/OCT fragments from the interior of the Cryostat to include vacuuming as needed using the Histovac.

11. Review of patient medical records confirmed patient:
A. 13 underwent a surgical procedure on 2/22/16 and a frozen section was processed using the Cryostat.
B. 14 underwent a surgical procedure on 2/22/16 and a frozen section was processed using the Cryostat.

12. Review of Cryostat maintenance Logs confirmed it was inspected/cleaned last on 10/22/15.

13. Staff 10 (Director of Operating Room/Post Anesthesia Care Unit/Central Sterile & Reprocessing/Outpatient Department) was interviewed on 4/19/16 at approximately 1328 hours and confirmed Cryostat Maintenance Log was last dated 10/22/15 for inspection and/or cleaning.

14. Policy #IC-26, Inventory, Cleaning, Maintenance of Supplies, Equipment, Medication and Food, revised/reapproved 8/14, indicated on pg. 2, under section V. Blanket Warmers, blankets can be warmed up to 130 degrees Fahrenheit. Temperatures are to be checked daily and documented on pertinent department form.

15. While on tour of facility on 4/18/16 at 1455 hours and 4/19/16 at approximately 1255 and 1426 hours, accompanied by staff 3 (Director of Patient Care Services), it was observed that the blanket warmer temperatures ranged between 134-138 degrees Fahrenheit.

16. Staff 10 (Director of Operating Room/Post Anesthesia Care Unit/Central Sterile & Reprocessing/Outpatient Department) was interviewed on 4/18/16 at approximately 1430 hours and confirmed blanket warmer temperatures have been exceeding the temperature range required per facility policy and procedure.

Based on document review, observation and interview, the facility failed to ensure appropriate storage conditions for medications according to facility policy and procedure for 1 of 7 (Surgery Department) areas toured.

Findings:

1. Policy #PH-41, High Risk or High Alert Medications, revised/reapproved on 3/31/13 indicated on pg:
A. 2, under Procedure section, points 4.iv. and v., employees will be mindful of high-alert medications. These medications will be sequestered and separated from the general medication inventory in a system that would reduce errors. Pharmacy will apply special auxiliary (High-alert) warning labels on the storage bins containing high-alert medications.
B. 4, Appendix A: High-Alert Medications...Zemeron (rocuronium).

2. While on tour of facility on 4/18/16 at approximately 1328 hours, accompanied by staff 10 (Director of Operating Room/Post Anesthesia Care Unit/Central Sterile & Reprocessing/Outpatient Department), high alert medication of Zemeron (rocuronium) was not stored separately from the general medication inventory or in a bin or with a High-alert warning label in the Surgery Department Medication Refrigerator.

3. Staff 10 (Director of Operating Room/Post Anesthesia Care Unit/Central Sterile & Reprocessing/Outpatient Department) was interviewed on 4/19/16 at approximately 1328 hours and confirmed the above-mentioned high risk/high alert medication was not stored according to policy.

Based on document review, observation and staff interview, the hospital failed to maintain the hospital environment and equipment in such a manner that the safety and well-being of patients, visitors and/or staff are assured in 7 of 7 instances.

Findings included:

1. Review of the Safety Plan indicated "Those safety rules and precautions that will be required to provide a safe environment for those entrusted to our care, as well as to all of those who are employed at our facility and to those who may visit have been listed. It is necessary for you to assist in providing a safe and healthful environment." Franciscan Healthcare Rensselaer Safety Plan was last revised June 11, 2013.

2. At 9:15 AM on 4/20/2016, the Franciscan Health and Fitness off-site storage room located in the basement adjacent to the racquetball courts was observed heavily cluttered and unsafe for easy access to assorted equipment. The room was observed with sporting equipment, filled storage boxes and maintenance tools.

3. At 9:20 AM on 4/20/2016, the Franciscan Health and Fitness off-site Therapy Department patient restroom was observed with assorted fitness equipment stored in the restroom that presented uneasy access to the patient's handwashing sink and the toilet.

4. At 9:30 AM on 4/20/2016, Franciscan Health and Fitness off-site was observed with at least six ceiling light fixtures with their light shielding cracked, broken and missing section of the plastic light cover.

5. At 11:20 AM on 4/20/2016, the hospital Laundry Department folding room ceiling paint was observed to be chipping and peeling directly above shelves of uncovered folded assorted linen items.

6. In interview at 1:15 PM on 4/20/2016, staff member #1 (Director of Operations) confirmed all the above and no other documentation was provided prior to exit.


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7. On 4-20-2016 at 12:25 PM, the following was observed in the morgue restroom:
a. The sink had orange streaks in it and the sink drain was a green color.
b. There was no hand soap in the soap dispenser near the sink.
c. The toilet bowl had a brown ring in it, approximately 6 inches wide.

8. In interview on 4-20-2016 at 12:25 PM, Staff Member #L1 acknowledged the sink and toilet were dirty, and the soap dispenser had no soap in it.

Based on document review, observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 9 of 12 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier and 3 of 4 ceiling smoke barriers were maintained to provide a one half hour fire resistance rating, failed to ensure proper sprinkler coverage was provided for 4 of 4 stairwells and failed to provide 1 of 1 fire damper inspections to show dampers were inspected and provided necessary maintenance at least every four years.

Findings:

1. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8-3. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames.

2. Observation during tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m. noted the following smoke barrier walls above the ceiling tiles had unsealed penetrations:
a) The 83/63 basement smoke barrier wall had an unsealed three by three inch hole and a six by six inch hole.
b) The smoke barrier wall by the director office has seven unsealed six to four inch penetrations around a wires.
c) The smoke barrier wall by the morgue had an unsealed hole measuring two feet by one foot and seven unsealed two inch penetrations around wires.
d) The smoke barrier wall by pharmacy had five unsealed four inch penetration around wires.
e) The smoke barrier wall by stairwell B had five unsealed one inch penetration around wires and an unsealed half inch gap from the top of the smoke wall to the ceiling.
f) The smoke barrier wall by X-ray had five unsealed one inch penetration around wires and conduits.
g) The smoke barrier wall by the lab had four unsealed two inch penetration around a conduit.
h) The smoke barrier wall by surgery had three unsealed one inch penetration around wires and a six inch hole.
j) The west hall smoke barrier wall on the second floor had an unsealed one inch penetration around a wire.

3. In interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.

4. Observation during tour of the facility with the Director of Operations and the Facilities Man #1 on 04/25/16 between 11:05 a.m. and 2:00 p.m. noted the following areas had unsealed ceiling penetrations:
a) In the basement IT office closet there were two unsealed five inch penetrations around a wires.
b) In the outpatient recovery electrical panel closet there were 20 unsealed fourth of an inch penetrations around conduit.
c) In janitor closet on the third floor there was an unsealed half of an inch penetration.

5. In interview at the time of observation, the Director of Operations and the Facilities Man #1 acknowledged and provided the measurements of the penetrations.

6. During tour of the facility with the Facilities Man #1 on 04/25/16 2:00 p.m., it was noted that stairwell "C" had a sprinkler at the first floor of the stairwell but not at the top and bottom of the stairwell.
7. During telephone call with the Director of Operations on 04/28/16 at 10:30 a.m., it was noted that stairwell "C" had a sprinkler at the first floor of the stairwell but not at the top and bottom of the stairwell.
8. In interview, this was acknowledged by the Director of Operations at the time of telephone call.
9. Record review with the Director of Operations on 04/25/16 at 10:30 a.m., and again at 2:00 p.m. indicated there were no inspection records available for review for any of the facility's fire dampers.

10. In interview during records review, the Director of Operations stated the facility had dampers, but did not know when the last inspection was conducted and there were no other records available to show completed maintenance on the facility's fire dampers.

Based on document review and interview, the facility failed to ensure patient care policies are reviewed at least annually by members of the professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists.

Findings:

1. Policy #:
A. IC-02, Surveillance of Infections, was last revised/reviewed 2/11/11.
B. IC-02, Infection Control: Human/Animal Bites (same policy # as Surveillance of Infections, was last revised/reviewed 3/25/11.
C. IC-04, Infection Control Committee Duties, was last revised/reviewed 6/19/14.
D. 08, Infection Control: Emergency Department, was last revised/reviewed 12/06.
E. IC-40, CHG Pre-Operation Baths, was last revised/reviewed 7/30/13.
F. IC-172, Infection Control: Central Lines Infections: Prevention, Diagnosis, Tracking and Treatment, was last revised/reviewed 12/30/14.

2. Review of the Infection Control Policies revision/review statement signed by staff 8 (Infection Prevention & Employee Health) and the Medical Advisor of the Infection Control Committee was dated 6/19/14 indicating all policies within the facility have been reviewed, revised, or added to as necessary by the Infection Control Committee.

3. Staff 8 (Infection Prevention & Employee Health) was interviewed on 4/18/16 at approximately 1245 hours and confirmed the above-mentioned policies had sections that related to patient care and were considered patient care policies related to infection control and were not reviewed at least annually.

Based on document review and interview, the facility failed to ensure properly executed informed consent for 2 of 4 (9 and 12) surgical patient medical records reviewed.

Findings:

1. Policy #NS-29, Health Information Management: Consent to Operation(s), Anesthetics, and Other Medical Services, revised/reapproval 2/12/16, indicated on pg. 1, under Procedure section, "To be filled out for all inpatients and outpatients who are to have any major or minor surgery. Must be signed before surgery...date and time consent obtained."

2. Review of patient medical records confirmed patient:
A. 9 underwent a surgical procedure on 1/29/16 and Surgical Consent lacked the time of the physician's signature.
B. 12 underwent a surgical procedure on 11/18/15 and Surgical Consent lacked the time of the physician's signature.

3. Staff 19 (Health Information Management) was interviewed on 4/18/16 at approximately ¿¿1300 hours, and confirmed the above-mentioned patients lacked the time the physician signed the Surgical Consent and these forms need to be signed, dated, and timed by the patient (if able) and the witness and the physician prior to the start of the procedure.

Based on document review and interview, the hospital failed to ensure 4 (Electroencephalography, Pediatrics, Infusion Therapy and Laundry) of 4 services were evaluated through the quality assessment and improvement (QA&I) program.

Findings included:

1. Review of the Franciscan Healthcare Rensselaer Quality Assurance & Performance Improvement Program Plan indicated "The Quality Plan shall be a coordinated, comprehensive and continuous effort of the Hospital Board of Trustees, Medical Staff, administration, departments and employees to monitor and improve the performance of all care and services provided at the Hospital." The QAPI Plan was last reviewed 11/6/2014.

2. Review of the Hospital Quality and Patient Safety committee dashboards and minutes for 2015 indicated the documents that were provided lacked evaluation or addressing the following services: Electroencephalography, Pediatrics, Infusion Therapy and Laundry.

3. In interview at 2:30 PM on 4/19/20176, staff member #6 (Director Quality Management) confirmed all the above and no other documentation was provided prior to exit.




Based on document review and interview, the hospital failed to ensure six (Electroencephalography, Pediatrics, Infusion Therapy, Biohazard Waste Hauler, Laundry and Security) of six services were evaluated through the quality assessment and improvement (QA&I) program.

Findings included:

1. Review of the Franciscan Healthcare Rensselaer Quality Assurance & Performance Improvement Program Plan indicated "The Quality Plan shall be a coordinated, comprehensive and continuous effort of the Hospital Board of Trustees, Medical Staff, administration, departments and employees to monitor and improve the performance of all care and services provided at the Hospital." The QAPI Plan was last reviewed 11/6/2014.

2. Review of the Hospital Quality and Patient Safety committee dashboards and minutes for 2015 indicated the documents that were provided lacked documentation of evaluating or addressing the following services: Electroencephalography, Pediatrics, Infusion Therapy, Biohazard Waste Hauler, Laundry and Security.

3. In interview at 2:30 PM on 4/19/20176, staff member #6 (Director Quality Management) confirmed all the above and no other documentation was provided prior to exit.

Based on document review and interview, the hospital failed to document an action plan to address the opportunities for improvement for 5 (blood bank, dietary, nursing medical/surgical, anewthesia and infection control [Wound]) of 5 services in the hospital's quality assessment and improvement (QA&I) program.

Findings included:

1. Review of the Franciscan Healthcare Rensselaer Quality Assurance & Performance Improvement Program Plan indicated "All departments and teams are required to submit performance indicator information in a timely manner, at least quarterly." The QAPI Plan was last reviewed 11/6/2014.

2. Review of 5 services of the hospital's QAPI program dashboards indicated there was no evidence of written action plans for areas that fell short of their goals.

A. Blood Bank - Charts meeting transfusion criteria targeted goal was 100% and in the 4th quarter of 2015, the hospital only met 96% of the target. The department dashboards lacked documented remedial action to address deficiencies.

B. Dietary - All food safety & sanitation audit monitors are being practiced. Criteria targeted goal was 100% and in the 4th quarter of 2015, the hospital only met 87% of the target. The department dashboards lacked documented remedial action to address deficiencies.

C. Nursing Medical/Surgical - Medication education aligns with primary diagnosis criteria targeted goal was 100% and in the 4th quarter of 2015, the hospital only met 68% of the target. The department dashboards lacked documented remedial action to address deficiencies.

D. Anesthesia - Pre/Post assessment completed and signed criteria targeted goal was 98% and in the 1st quarter of 2016, the hospital only met 80% of the target. The department dashboards lacked documented remedial action to address deficiencies.

E. Infection Control (Wound) - Documented on admitted from Emergency Department criteria targeted goal was 100% and in the 4th quarter of 2015, the hospital only met 17% of the target. The department dashboards lacked documented remedial action to address deficiencies.

3. In interview at 2:30 PM on 4/19/20176, staff member #6 (Director Quality Management) confirmed all the above and no other documentation was provided prior to exit.