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Based on observation, policy review and staff interview, the facility failed to ensure standard precautions were maintained per policy for two of seven patients observed during the medication pass observation (Patient #6 and #18). This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

Review of the facility's Standard Precautions Policy Number IC-105 revealed staff were to "Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluid, secretions, excretions and contminated items. Put on gloves just before touching mucous membranes and non-intact skin." The policy further revealed, "Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces...". Additionally the policy revealed, "if multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile."

1. During medication pass observation with Staff A and Staff B on 07/31/18 at approximately 9:05 AM, Staff B administered a Lovenox 40 mg (medication used to reduce the risk of blood clots) subcutaneous injection to Patient #18's left lower abdomen . Staff B performed hand hygiene and donned gloves before the injection administration, but Staff B did not remove the gloves before entering the patient's information using the keyboard on the roll around computer.

An interview with Staff A on 07/31/18 during the tour confirmed the finding.

2. An observation was conducted with Staff D of Staff E on 08/02/18 at 9:25 AM. Staff E was observed to wipe the rubber stopper of a multidose vial of Humulin 70/30 insulin that had already been opened, insert an insulin syringe needle, and withdraw 28 units of insulin. Staff E then removed the cap of a new multidose vial of Humulin 70/30 insulin, wiped the rubber stopper with an alcohol wipe, inserted the same insulin syringe needle into the vial, and withdrew an additional 12 units of insulin from the new multidose vial. Staff E then confirmed the dosage with staff D.

Interview with Staff D on 08/02/18 at 9:40 AM, confirmed the above finding.

3. An observation was conducted along with Staff D of Staff E on 08/02/18 at 9:32 AM of the medication administration for Patient #6. Staff E was not wearing gloves when he/she administered a subcutaneous dose of Lovenox and a dose of insulin.

Interview with Staff D on 08/02/18 at 9:40 AM confirmed the above finding.

Based on policy review, medical staff rules and regulations review, and staff interview, the facility failed to ensure all it's patients medical records were completed within 30 days after discharge. The census was 27.

Findings include:

Review of the facility's Delinquent Medical Record Policy Number ADM-IM-025 revealed "Inpatient records are considered delinquent if they are not completed within (30) days after discharge".

Review of the facility's Medical Staff Rules and Regulations revealed "Medical records shall be completed within thirty (30) days of discharge; provided, however, that certain components of the medical record shall be required to be sooner completed in accordance with applicable law and/or accrediting standards."

Review of the facility's delinquent rate revealed four delinquent records, three from one phyician and one from another physician.

This was confirmed with Staff D and nursing administrative staff on 08/02/18 at 1:30 PM.

Based on staff interview, record review, and observation, the facility failed to ensure its two hour fire barrier contained a two hour fire protective construction (K133). The facility failed to have emergency lighting comply with NFPA 101, 2012 edition, 7.9 (K291). The facility failed to ensure exit signage complied with NFPA 101, 2012 edition, 7.10 (K293). The facility failed to comply with NFPA 101, 2012 edition, 4.6.12.3 for life safety code features (K300). The facility failed to ensure door to hazardous areas were in compliance with NFPA 101, 2012 edition, 7.2.1.8 (K321). The facility failed to ensure compliance with NFPA 72, 2010 edition, 14.4.5 and 14.6.2.4 (K345). The facility failed to have a fire watch policy for when the fire alarm system was out of service (K346). The facility failed to comply with NFPA 13, 2010 edition, 24.6 (K351). The facility failed to ensure its sprinkler system had full functionality and complied with NFPA 25, 2011 edition, 13.3.2.1 (K353). The facility failed to have a fire watch policy for when the sprinkler system was out of service (K354). The facility failed to ensure doors protecting corridor openings that had self closing and latching hardware, closed and latched (K363). The facility failed to ensure smoke barriers were free of penetrations (K372). The facility failed to inspect the function of the smoke dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition (K521). The facility failed to ensure portable space heaters were not in use (K781). The facility failed to comply with NFPA 99, 2012 edition, 5.1.4.8 (K902). The facility failed to have a remote annunciator in accordance with NFPA 99, 2012 edition, 6.4.1.1.17 (K916). The facility failed to comply with NFPA 99, 2012 edition, 10.5.2.1 (K921).

Based on observation, staff interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The facility census was 27.

Findings include:

K133 Failed to ensure its two hour fire barrier contained a two hour fire protective construction.
K291 Failed to have emergency lighting comply with NFPA 101, 2012 edition, 7.9.
K293 Failed to ensure exit signage complied with NFPA 101, 2012 edition, 7.10.
K300 Failed to comply with NFPA 101, 2012 edition, 4.6.12.3 for life safety code features.
K321 Failed to ensure doors to hazardous areas were in compliance with NFPA 101, 2012 edition, 7.2.1.8
K345 Failed to ensure compliance with NFPA 72, 2010 edition, 14.4.5 and 14.6.2.4.
K346 Failed to have a fire watch policy for when the fire alarm system was out of service.
K351 Failed to comply with NFPA 13, 2010 edition, 24.6.
K353 Failed to ensure its sprinkler system had full functionality and complied with NFPA 25, 2011 edition, 13.3.2.1.
K354 Failed to have a fire watch policy for when the sprinkler system was out of service.
K363 Failed to ensure doors protecting corridor openings that had self closing and latching hardware, closed and latched.
K372 Failed to ensure smoke barriers were free of penetrations.
K521 Failed to inspect the function of the smoke dampers within the heating, ventilating, and air-conditioning (HVAC) system in accordance with 9.2 of NFPA 101, 2012 edition.
K781 Failed to ensure portable space heaters were not in use.
K902 Failed to comply with NFPA 99, 2012 edition, 5.1.4.8.
K916 Failed to have a remote annunciator in accordance with NFPA 99, 2012 edition, 6.4.1.1.17.
K921 Failed to comply with NFPA 99, 2012 edition, 10.5.2.1.