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Based on Governing Body meeting minutes and interview, it was determined the institution did not have an overall institutional plan that included an annual operating budget and anticipated income and expenses. Failure to ensure the facility had an annual operating budget had the potential of under expenditures, over expenditures, unaccountability and lack of financial direction for the hospital. The failed practice had the potential to affect all aspects of patient care including in-patients and out-patients. Findings follow:

A. Review of the facility governing body meeting minutes from 01/26/10 through 01/25/11 revealed no annual operating budget review and approval.
B. Interview with the Corporate Regional Director on 02/17/11 at 1600, she confirmed there was no annual operating budget reviewed and approved by the hospital governing body.
C. No annual operating budget had been presented to the surveyor by the exit conference conducted on 02/18/11 at 0830.

Based on policy and procedure review, clinical record review, restraint reporting forms and log, and staff interview, it was determined the facility was unsure if a restraint related death was reported to CMS (Centers for Medicare and Medicaid Services) no later than the close of business the next business day following knowledge of the patient's death for two (#32-33) of three (#32-34) patients. The facility also failed to document in the clinical record for two (#32-33) of three (#32-34) patients that CMS was notified of the restraint related deaths. The failed practice had the potential of prohibiting the monitoring of restraint related deaths by the facility and CMS. Findings follow:

A. Review of Patient #32's nursing notes on 02/17/11 at 1000 revealed the patient expired on 11/24/10 at 0545.
B. Review of the facility's restraint reporting forms revealed there was no restraint related death form completed for Patient #32. Review of the nursing notes revealed "Post note 2-17-11 Report to CMS-Restraint c (with) death" and signed by the Quality Resource Coordinator.
C. Review of Patient #33's nursing notes revealed no documentation of CMS notification of a restraint related death.
D. Facility Policy/Procedure #100-35, titled Restraint and Seclusion, stated the facility would report to CMS Regional Office any death that occurred while a patient was restrained or in seclusion, within the close of the next business day following knowledge of the death. Policy #100-35 stated to document on the medical record the date and time any restraint or seclusion associated death was reported to CMS.
E. The above findings were confirmed in an interview with the facility Interim CNO (Chief Nursing Officer) and the Corporate Regional Director at 1605 on 02/17/11.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related to the use of maintenance free batteries on emergency generators and testing of line isolation monitors. Battery cells cannot be inspected on maintenance-free batteries, which assure batteries are capable of starting the generator if normal power is lost. Maintenance-free batteries are not allowed on Type 1 Essential Electrical Systems per NFPA 110, Section 3-5.4.5. The failed practice had the potential to affect all patients, staff, and visitors in the areas served by the generators with the maintenance-free batteries, which included the Medical-Surgical Unit, Critical Care Unit, Emergency Department, Laundry, Information Systems, Dietary Department, Medical Records Department, and the Maintenance Department. The census on 02/15/11 was 28 patients. Monthly testing of the Line Isolation Monitors ensures proper operation of the devices, which are utilized to prevent electric shock in the areas they serve. The failed practice had the potential to affect all surgical patients and intensive care patients, and staff and visitors in the Surgery Department and the Intensive Care Unit. On 02/15/11 the Surgery Department had seven patients and the Intensive Care Unit had five patients. See CMS 2567, K130.

Based on review of Infection Control Policy and Procedure #2-630, titled "Airborne Precautions," and review of the Maintenance Log, the facility failed to perform monthly negative air pressure checks for two of two isolation rooms Room 317 and Intensive Care Unit #6) when unoccupied. Failure to monitor the negative air pressure had the potential to allow the spread of airborne disease to patients, visitors and staff. The failed practice had the potential to affect any patient requiring isolation and any visitors and staff in the facility on the days the isolation rooms were being used. Findings follow:

A. Review of the facility policy and procedure #2-630, titled "Airborne Precautions," revealed the facility's isolation rooms were to be checked daily when occupied, and the Centers for Disease Control's "Guideline for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities" 2005 for additional guidance on environmental strategies for preventing transmission of tuberculosis in healthcare settings should be consulted. "Guideline for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities" 2005 stated the negative pressure should be checked daily when in use and monthly when unoccupied.
B. Review of the two isolation rooms (#317 and Intensive Care Unit (ICU) #6) check log provided by the Maintenance Department revealed the monthly negative air pressure checks were not performed prior to 11/09/10. Although, the log indicated the negative air pressure was checked on 11/09/10, 12/08/10, 1/18/11 and 02/15/11 there was no evidence which room(s) the results were for. Review of the form "Historical Work Request Summary" revealed the negative air pressure was checked on 02/24/10, 05/19/10, 08/16/10 and 11/23/10 but there was no evidence which room(s) the results were for. . Findings were confirmed by the Director of Maintenance on 02/16/11 at 1420. The isolation room checks that were done were the checking of monitors only, no visual testing was done. Findings were confirmed by the Director of Maintenance on 02/16/11 at 1427.
C. Observation on 02/16/11 at 1427 revealed the exhaust fans in #317 were not operating. Findings were confirmed by the Director of Maintenance on 02/16/11 at 1427.
D. Observation on 02/16/11 at 1427 revealed ICU #6 was being utilized as a storage room at the time of the survey. Findings were confirmed by the Director of Maintenance on 02/16/11 at 1427.