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At this Life Safety Code survey, Pulaski Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This one story building with a partial basement was constructed of Type II (000) construction.

The facility was fully sprinklered with the exception of an emergency room canopy of protected construction. The facility has a fire alarm system with smoke detection in the corridors, hazardous areas and spaces open to the corridors.

Based on record review, observation and interview, the facility failed to ensure the penetration in 3 of 4 fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff and up to 7 patients (see tag K131) and failed to ensure 1 of 6 fire door sets were arranged to minimize air leakage. LSC, 7.2.4.3.9 requires all fire door assemblies in horizontal exit shall be designed and installed to minimize air leakage. This deficient could affect staff and up to 3 patients (see tag K226) and the facility failed to ensure the humidity in 1 of 4 anesthetizing locations were greater than 20 percent. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. This deficient practice could affect staff and up to 1 patient (see tag K323) and the facility failed to install gauge on 1 of 1 medical vacuum system. NFPA 99 2012 edition 5.1.8.2.3 states all pressure-sensing devices and mainline pressure gauges downstream of the source valves shall be provided with a gas-specific demand check fitting to facilitate service testing or replacement. This deficient practice could affect staff and all patients (see tag K903) and the facility failed to protect 4 of 4 wet location Operating Rooms in accordance with 6.3.2.2.8. 2012 Health Care Facilities Code 99 6.3.2.2.2.8.4 states that operating rooms shall be considered to be a wet location unless a risk assessment conducted by the health care governing body determines otherwise. HCFC 6.3.2.2.8 requires wet procedure locations shall be provided with special protection against electrical shock. This deficient practice could affect staff and up to 4 patients (see tag K913).

Based on observation and interview, the facility failed to ensure 1 of 6 fire door sets were arranged to minimize air leakage. LSC, 7.2.4.3.9 requires all fire door assemblies in horizontal exit shall be designed and installed to minimize air leakage. This deficient could affect staff and up to 3 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:15 p.m., the set of fire barrier cross-corridor doors by the Emergency Rooms had at least a ¼ inch gap along the center where the doors came together in the closed position. Based on interview at the time of observation, the Director of Plant Engineering confirmed the cross corridor doors were fire doors (see tag K226).

Based on record review and interview, the facility failed to install gauge on 1 of 1 medical vacuum system. NFPA 99 2012 edition 5.1.8.2.3 states all pressure-sensing devices and mainline pressure gauges downstream of the source valves shall be provided with a gas-specific demand check fitting to facilitate service testing or replacement. This deficient practice could affect staff and all patients and the facility failed to protect 4 of 4 wet location Operating Rooms in accordance with 6.3.2.2.8. 2012 Health Care Facilities Code 99 6.3.2.2.2.8.4 states that operating rooms shall be considered to be a wet location unless a risk assessment conducted by the health care governing body determines otherwise. HCFC 6.3.2.2.8 requires wet procedure locations shall be provided with special protection against electrical shock. This deficient practice could affect staff and up to 4 patients.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 between 9:30 a.m. and 11:30 a.m., the most recent medical vacuum inspection documentation by ARTEC Environment Monitoring indicated that "2nd Pressure Gauge Not On Gas Specific Demand Check Fitting." Based on interview at the time of observation, the Director of Plant Engineering acknowledged the aforementioned condition and confirmed no further documentation was available for review (see tag K903) and based on record review with the Director of Plant Engineering on 10/17/17 between 9:30 a.m. and 11:30 a.m., no risk assessment documentation was available for review. Based on interview at the time of record review, the Director of Plant Engineering confirmed no risk assessment had been performed and no electrical shock prevention was in place (see tag K913).

35731

Based on document review, observation and interview, the Critical Access Hospital (CAH) failed to provide a clean and orderly environment in 5 of 5 areas toured. (Decontamination, Emergency, Obstetrics, Medical Surgical, and Surgery areas)

Findings include:

1. Review of the CAH policy entitled "Treatment Plan for Exposure to Hazardous Materials" policy number 22-37, effective date 3/10/2008, indicated it is the role of the hospital to provide emergency medical treatment and to be prepared for patient decontamination.

2. Review of the CAH policy entitled "Cleaning Emergency Suite", policy number 13.3, effective date 12/29/2016, indicated the Emergency Department (ED) room cleaning should be "damp dusted", and "all protruding objects on the wall" should be cleaned.

3. Review of the CAH policy entitled "Infection Control Policy - ED", policy number 32.20, effective date
01/28/2014, indicated in section "General Cleaning" that housekeeping personnel would be responsible for the daily cleaning of "fixed lights" in the ED rooms.

4. Review of the CAH policy entitled "Infection Control for the Obstetrical (OB) Department", policy number 20-22, effective date 03/02/2010, indicated that the environmental service personnel duties and responsibilities for cleaning the rooms include "damp dusting all fixtures, and permanently attached equipment".

5. Review of the CAH policy entitled "Environmental Cleaning of Surgery and Central Sterile", policy number 4.20, effective date 12/29/2016, indicated that environmental services at the conclusion of the days schedule will clean the area "locker room".

6. Review of the CAH policy entitled "Dispensing Clean Linen-In House", policy number 14-8, effective date 08/02/2005, indicated that clean linen would be transported to designed areas of the hospital in "clean, covered shelved linen carts".

7. On 10/16//2017 at approximately 2:05 pm, while on tour of the ED designated decontamination area, accompanied by A # 3 (Chief Nurse Executive), N # 1 (ED Registered Nurse), and a second ISDH surveyor, the following areas were found to be unprepared to provide emergency medical treatment, and/or to perform patient decontamination:
A. The windows on the back wall of the three (3) different stations "Undress, Station One (1), and Dry and Dress", were not covered with anything to protect the patients privacy from the outside.
B. In the middle of the designated "Wait" station and "Undress" station was a "John Deer Parking Lot Sweeper" which would have impeded the tarp from completely dropping down to create the barrier to create the two (2) separate stations.
C. In the middle of the designated "Wait" station, and Station Three (3)" area was a pallet of thirty (30) bags of Calcium Chloride which would have impeded the tarp from completely dropping down to separate and create the "Wait and Undress" section from the "Station One (1), Two (2), Three (3)" wash sections.
D. In the middle of the "Dry and Dress" station there was a table saw with piles of saw dust surrounding it.

8. On 10/16/2017 at approximately 2:25 pm, while on tour of the ED area, accompanied by A # 3 and N #1 the following areas and/or equipment, in the patient care area rooms, were observed to have an accumulation of visable wipeable dust and/or dirt:
A. The top of the mobile overhead light fixtures in rooms one (1), three (3), four (4), and five (5).
B. The Electrocardiogram (ECG) monitor in rooms one (1), three (3), four (4), and five (5).
C. The Otoscope wall mount in rooms one (1), three (3), four (4), and five (5).

9. On 10/17/2017 at approximately 11:48 am, while on tour of the four (4) bed Obstetrics (OB) unit, accompanied by A # 3 and A # 11 (Manager OB), all four (4) patient care area rooms (48, 52, 54, and 62) mobile overhead lights were observed to have an accumulation of dust and/or dirt.

10. On 10/18/2017 at approximately 10:42 am, while on tour of the seventeen (17) bed Medical Surgical (MS) unit, accompanied by A # 3 and N # 3 (Clinical Leader Registered Nurse) the following areas and/or equipment were observed to have an accumulation of dust and/or dirt:
A. The inside bottom of the metal double door linen cart kept in the hallway.
B. The top of the "Medication Dispenser Tower" in the medication room.
C. Inside the medication room on the bottom of the "intravenous (IV) peg board" where patients IV solution and/or IV medications were hung prior to administration.

11. On 10/18/2017 at approximately 11:30 am, while on tour of the Surgery Department (Pre-Op, Post-Op, Surgical Suits, and Endoscopy Procedure room) accompanied by A # 3, N # 4 (Surgery Manager), and a second ISDH surveyor, the following areas were observed to have an accumulation of dust and/or dirt.
A. A mobile ECG machine and cart in the hallway of the back hall by the ED.
B. The shelving, above the lockers, in the female locker room.

12. Interview with A # 3 on 10/18/2017 at approximately at 2:50 pm, confirmed the following:
A. The decontamination area was not prepared to provide emergency medical treatment and/or perform patient decontamination at that time.
B. All of the above environmental areas and/or equipment were discussed throughout the tour, and all were in need of cleaning.

Based on record review and interview, the facility failed to ensure the humidity in 1 of 4 anesthetizing locations were greater than 20 percent. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. This deficient practice could affect staff and up to 1 patient.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 4:08 p.m., one operating room was under 20 percent on 3/17/17 and 11/19/16. No other further documentation was available to show what response was performed. Based on interview at the time of record review, the Director of Plant Engineering acknowledged the aforementioned condition and confirmed no policy was in place to documented responses for when the humidity in anesthetizing locations drops below 20 percent (see tag K131).

Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) failed to follow written policies for paraffin
therapy in four of four instances reviewed, and high level disinfection for transvaginal probes in three of three instances.

Findings include:

1. Review of policy titled: "Paraffin," policy number "12.316," effective "9/2/14" read: "Check paraffin bath temperature and assure that it is between 120 - 130 degrees."

2. Review of "Paraffin Temperature Log" indicated the paraffin bath temperature was below 120 degrees Fahrenheit (F) on the following dates: 3-13-2017 (108 F); 3-31-2017 (108 F); 4-3-2017 (108 F); and 8-10-2017 (110 F).

3. Review of patient records indicated the following patients received paraffin therapy on the following dates, when the paraffin bath temperature was below 120 F: Patient #18 (3-13-2017); Patient #19 (8-10-2017); and Patient #20 (3-31-2017 and 4-3-2017).

4. Review of policy titled: "Use Of Revital-Ox Resert XL HLD," policy number "18.18," effective "03/28/14" read: "A test strip device is used according the manufacturer's instructions to monitor Revital-Ox concentration daily before each use..." and "Items to be chemically disinfected are completely immersed in the disinfectant solution according to the recommendations of the product manufacturer..."

5. On 10-17-2017 at 2:00 PM, an opened bottle of "Revital-Ox Resert" and an open bottle of "Revital-Ox Resert Test Strips" were observed in the ultrasound room. The label on the "Revital-Ox Resert" bottle indicted the contact time for high level disinfection was eight minutes. The label on the "Revital-Ox Resert Test Strips" indicated test results should be read 60 seconds after the test strip is dipped into the "Revital-Ox Resert" solution.

6. Review of "Revital-Ox Resert High Level Disinfectant Technical Data" copyright "2014" by "STERIS Corporation, read: "Once the instrument has been immersed and all surfaces in contact with the disinfectant solution, soak the instrument for a minimum of eight minutes..."

7. Review of ultrasound transvaginal probe cleaning log did not indicate the probes were soaked for a minimum of eight minutes for the following dates: 8-24-2017; 9-1-2017; and 9-28-2017.

8. Review of patient records indicated the following patients had an ultrasound procedure performed using the transvaginal probe, when there was no documentation the probe was soaked in the disinfectant a minimum of eight minutes, for the following patients: Patient #15 (8-24-2017); Patient #16 (9-28-2017); and Patient #17 (9-1-2017).

9 In interview on 10-17-2017 at 2:10 PM, Staff Member #L10 acknowledged the paraffin temperatures were not within the acceptable range, as indicted by the hospital's policy, for the above mentioned dates when patient therapy was performed.

10. In interview on 10-17-2017 at 2:00 PM, Staff Member #L14 indicated transvaginal probes are disinfected by immersing in "Revital-Ox Resert," however the amount of time the probe remains in the disinfectant is not timed or documented. The staff member further indicated the "Revital-Ox Resert" concentration is tested by dipping the "Revital-Ox Test Strips" into the disinfectant for two seconds and then read immediately, instead of waiting 60 seconds, as required by the test strip manufacturer.