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272 HOSPITAL ROAD

CHILLICOTHE, OH 45601

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on review of the medical record and review of the policy and procedures related to administration of blood products and interview with staff it was determined that the facility failed to obtain a consent prior to the administration of blood products. This involved 1 out of 2 inpatients who received blood products, Patient 11. The census was 160.

Findings include:

The medical record for Patient #11 was reviewed on 11/1/11. Patient #11 was admitted on 10/31/11 with fluid around his/her lungs and oxygen deprivation. A physician's order was written on 11/1/11 for Patient# 11 to receive five units of fresh frozen plasma. This plasma was administered to the patient on 11/1/11 at 11:00 PM by Staff J. Review of the medical record did not reveal a signed informed consent by the patient prior to administration of the fresh frozen plasma.

An attempt was made to interview Patient #11 on 11/2/11 at 3:45 PM. Patient #11 declined to speak with this surveyor. While this surveyor waited outside the hospital room door of Patient #11, the patient was asked if he/she signed a consent prior to receiving the fresh frozen plasma. Patient #11 loudly stated to the surveyor that he/she had not signed a consent to receive plasma. This patient was assessed as being alert and oriented.

An interview was conducted with Staff H on 11/3/11 at 12:55 PM. Staff H stated that Staff K was the nurse that cared for Patient #11 on 11/1/11 and administered the five units of fresh frozen plasma. Staff H stated that Staff K was contacted and questioned about the missing consent. Staff K stated that he/she had received a report at the beginning of the shift that the consent was signed and never checked to see if it had been prior to administration. Staff H stated that Staff K did not follow policy and will be disciplined as a result.

The policy titled "Administration of Blood and Blood Components" policy #15.2, reviewed on 06/10 stated that a "blood transfusion consent form must be signed by patients with an order for a type and cross or blood transfusion".

This was confirmed by Staff H on 11/3/11 at 12:55 PM.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observation and staff interview the facility failed to meet the condition of Environment based on the Health and Life Safety Code findings. The facility census was 160 patients.

Findings include:

Please refer to A709 regarding the life safety code violations

Please rever to A724 regarding the facility's failure to ensure that all areas and equipment used for patient caare was clean and well maintained.

LIFE SAFETY FROM FIRE

Tag No.: A0709

Based on interview and observation the facility failed to ensure that the life safety requirements were met.

Adena Regional Medical Center has a capacity of 261 beds with a census of 160 patients.

Findings include:

Please refer to K20 regarding the facility's failure to ensure that vertical openings between floors were enclosed with construction having a fire resistance rateing of at least one hour.

Please refer to K25 regarding the facility's failure to ensure that smoke barriers were maintained to provide at least a one-hour fire resistance rating.

Please refer to K29 regarding the facility's failure to ensure that two hazardous areas were enclosed with a one hour fire-rated barrier.

Please refer to K46 regarding the facility's failure to ensure all battery operated emergency lights were tested annually and documented.

Please refer to K62 regarding the facility's failure to ensure the sprinkler system and all its components were maintained in reliable operating condition at all times.

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on a tour conducted of the facility, staff interview and review of the facility's polices and procedures it was determined that the facility failed to ensure that all areas and equipment used for patient care was clean and well maintained after each patient use. This was observed in the inpatient physical rehabilitation area, laboratory, kitchen and the Emergency Department.

Observation of the laboratory suite on 11/01/11 with Staff E revealed cardboard boxes were stored directly on the floor in all areas of the laboratory including the supply room. The Chemistry area had useable laboratory equipment stored on the floor under the desk. Observation on 11/03/11 at 11:05 AM with Staff B revealed the previous cardboard boxes plus additional cardboard boxes were stored in the laboratory area on the floor. These findings were confirmed by Staff E on 11/03/11 at 11:10 AM.


07973

Tour of the Emergency Department on 11/02/11 at 9:10 AM revealed a reclining patient chair in treatment room A and in room B. Both chairs had cracked seats. The cracks in the plastic seat caused the two chairs to have unclean surfaces. This was confirmed by Staff M at 9:15 AM.


27700

A tour was conducted of the inpatient rehabilitation department on 11/01/11 at 1:30 PM. During this tour it was noted that the mats that were used for physical therapy located in Room 1 and in the Pediatric Swing Room were heavily soiled with a dark black substance. A request was made for information regarding the cleaning schedule of these mats and this was not provided to this surveyor. An interview conducted with Staff F during this tour revealed that the mats were not cleaned by housekeeping and were to be cleaned after patient use by the therapist.

A revisit was completed by two surveyors on 11/03/11 at 10:55 AM. The mats on the floor located in Room 1 and the Pediatric Swing Room remained heavily soiled and unchanged from the previous visit on 11/01/11. Staff G was asked to attempt to remove some of the substance from the mats with a moistened wipe. It was noted that the mat was easily cleaned with the moistened cloth and following removal the cloth was visibly soiled. The physical therapy table in Room 1 and the therapy ball were also wiped with the moistened cloth and the cloth after each use was visibly soiled. Staff G stated at this time that a sheet is used over the mats on the floor when in use and changed after each patient.

The policy and procedure titled "Rehabilitation Department Infection Control Policy", last reviewed 5/2002 stated that "after each patient, treatment tables and mats are cleaned with hospital-approved disinfectant, unless they were covered with a sheet. If a sheet is used, the equipment is cleaned at the end of the shift, or when visibly soiled.

The dietary department was toured on 11/02/11 at 11:30 AM with Staff L. During the tour the cooler located outside the kitchen was inspected. This cooler was used for storage of foods that were "in process" or foods that were to used for the next days meal. This cooler contained a large container of raw carrots that was uncovered and a group of shelves that held long strips of uncooked bacon that was uncovered. This was confirmed with Staff L who stated at this time that these should have been covered while stored in the cooler.

This was confirmed with Staff A and B at 11:10 AM.