HospitalInspections.org

Based on record review and interview with staff, it was determined the facility failed to:

(K0161) Building Construction Type and Height
Ensure the any area having a higher degree of hazard of the hospital was sprinkler protected or protected by one hour fire resistance rating. Failure to ensure the areas within the facility were protected has potential to harm patients and staff during a fire.

NFPA 101 2012 Edition, Section 19.1.6 "Minimum Construction Requirements." Section 19.1.6.1 "Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 (See 8.2.1)." Section 8.7.1.1 " Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: (1) Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3. (2) Protecting the area with automatic extinguishing systems in accordance with Section 9.7. (3) Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.3.1.2 " Fire barriers shall comply with one of the following: (1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

(K0907) Gas and Vacuum Piped Systems - Maintenance Program
Develop and implement a maintenance program for the piped medical gas system. The facility failed to establish inspection and maintenance schedules through risk assessment and manufacturer recommendations increasing the potential for undetected problems with the medical gas delivery system. Failure to conduct a maintenance program and inspect the medical gas systems, control valves, alarms, gas outlets etc has potential to harm patients;

NFPA 99 2012 Health Care Facilities Section 5.1.14.2.2 Maintenance Programs. Section 5.1.14.2.2.2* "Inspection schedules. Scheduled inspections for equipment and procedures shall be established through risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction." A.5.14.2.2.2 "In addition: to the minimum inspection and testing in 5.1.14, facilities should consider annually inspections equipment and procedures and correcting any deficiencies." Section 5.1.14.2.2.3 "Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment." Section 5.1.14.4.4 Medical Gas an Vacuum Systems Maintenance and Record Keeping Section 5.1.14.4.1 "Permanent records of all tests required by 5.1.12.1 through 5.1.12.14 shall be maintained in the organizations files."

(K0908) Gas and Vacuum Piped Systems - Inspection and Testing
Have the required maintenance and inspection for the medical gas and vacuum piped systems. Failure to have annual inspections of the gas and vacuum piped systems has potential harm to patients during system failures.

NFPA 99 2012 Edition, Chapter 5, Section 5.2.13 "Category 2 Operation and Management. Category 2 systems shall comply with 5.1.14." Section 5.1.14.4.3 "An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity." Section 5.1.14.2.4 "Central supply systems for nonflammable gases shall conform to the following: (1) They shall be inspected annually; (2) They shall be maintained by a qualified representative of the equipment owner; (3) A record of the annual inspection shall be available for review by the authority having jurisdiction;" and

(K 0914) Electrical Systems- Maintenance And Testing
Conduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility. Failing to test and document annually the receptacle testing of all patient care areas of the facility could lead to an ignition hazard in a patient care area, and potentially cause a fire and or injury to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 4, Section 4.6.12.4 "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected or operated as specified elsewhere in the Code or as directed by the authority having jurisdiction." NFPA 99, Health Care Facilities Code, 2012, Chapter 6, Section 6.3.4.1.1 "Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device." 6.3.4.1.2 "Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data." 6.3.4.1.3 "Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months."

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Physical Plant and Environment, for the Life Safety Code survey, which poses a potential risk to the health and safety of patients and staff related to potential harm if staff did not develop and implement a maintenance program for the piped medical gas system; cnduct, maintain and document electrical receptacle testing in all patient care areas annually throughout the facility; and conduct required electrical receptacle testing.



(K0907) Gas and Vacuum Piped Systems - Maintenance Program

(K0908) Gas and Vacuum Piped Systems - Inspection and Testing

(K 0914) Electrical Systems- Maintenance And Testing

Based on observation on tour of the facility, review of facility documents, review of policy and procedures, and patient/staff interviews, it was determined the facility failed to maintain both a housekeeping and preventative maintenance program to require housekeeping staff and pest control ensure that the facility premises was free from a cricket infestation. This deficient practice poses a potential risk to the health and safety of patients, visitors, and staff as such infestations can carry and spread diseases.

Findings include:

Observation on tour of facility conducted on 08/05/2019, 08/06/2019, and 08/07/2019, identified dead and alive crickets in the following areas/departments:

Administration/Hospital Entrance;
Administration small conference room;
Administration halls;
Emergency Department Lobby;
Emergency Department - Trauma Rooms one (1) and two (2);
Laboratory;
Medical/Surgical/Obstetrics; and
Swing Bed Room

Facility document titled, "Service Report, 04/05/2019," revealed: "...Inspection...Treatment...."

Facility document titled, "Service Report, 05/03/2019," revealed: "...Inspection...Treatment...."

Facility document titled, "Service Report, 06/14/2019," revealed: "...Inspection...Treatment...."

Facility document titled, "Service Report, 07/08/2019," revealed: "...Inspection...Treatment...."

Policy and procedure titled, "Infection Control Policies & Procedures, #IC-1, Reviewed: 07/2019," revealed: "...Patient Care Area Surveillance: Site surveillance will be done monthly in patient care areas including: Emergency Department, Med Surg OB, Laboratory, Radiology, Pharmacy and Surgery areas. These areas will be monitored for infection hazards or risks...."

Patient #9 revealed during an interview conducted on 08/06/2019, that s/he has seen a lot of bugs in his/her room, and when s/he walks around outside his/her room.

Employee #2 confirmed during an interview conducted on 08/05/2019, that the influx of crickets has recently occurred.

Employee #6 confirmed during an interview conducted on 08/05/2019, that the facility does not have a contract with any exterminating company. Pest extermination is provided by an exterminating company on a month-to-month basis, Treatment is provided every month, or if there is a problem the pest company will come out and provide another treatment. The current crickets are dead, and if they weren't dead the company would come again.

Employee #13 confirmed during an interview conducted on 08/06/2019, that s/he has heard a lot of comments regarding the bug problem.

Employee #3 confirmed during an interview conducted on 08/07/2019, that the next pest control treatment is scheduled for 08/09/2019.

Based on review of the hospital's Medical Staff Bylaws, Rules and Regulations, facility documents, and staff interviews, it was determined that the facility failed to ensure that a time-frame was established for a medical staff member to complete a patient's medical record.
Such failure poses the potential risk to patient safety, when the medical record is incomplete.

Findings include:

Hospital document titled "(name of facility) Medical Staff Bylaws, Rules & Regulations," revealed: "...All progress notes shall be dated, and signed by the author...Verbal or telephone orders must be signed by the ordering practitioner in a timely manner...Discharge summaries are to be completed within 30 days of discharge...."

The Corporate document titled "Bylaws of (name of facility)" revealed: "...Each Medical Staff member shall maintain complete, accurate and timely medical records for the member's Patients...."

Hospital document titled "The Minutes of the Board of Directors of (name of facility), Wednesday, March 27, 2019," revealed: "...Deficiencies (Incomplete provider documentation or unsigned orders) that are found by the coders...We will continue to track this measure weekly...."

Hospital document titled "Deficiency Reporting by Physician Summary Report," dated January 4, 2019, reporting on all physicians, revealed that on the Cerner system (the new electronic system) there were "540" total deficiencies in "364" charts, the oldest deficiency being "259" days for the hospital.
In the Paragon system (the old electronic system) revealed there were "497" deficiencies with "493" being older than "120" days.

Hospital document titled "Deficiency Reporting by Physician Summary Report," dated August 5, 2019, reporting on all physicians, revealed that on the Cerner system there were "193" total deficiencies in "155" charts, the oldest deficiency being "412" days for the hospital.

Employee #30 confirmed in interview on 08/07/2019, that the Deficiency Reporting by Physician Summary Report counts items improperly coded, also unsigned items such as orders, progress notes, discharge summaries, and etc. All of these items require the physician to attend to them in order for the medical record to be complete. The Paragon system was the old system and now they are using Cerner. The items listed in the Paragon system are not duplicated in the Cerner system. All charts listed in the Paragon system are now discharged patient encounters. When a provider signs on to the Cerner system there is an alert notifying that provider there are deficiencies in charts in the Cerner system that need their attention.

Employee #40 confirmed in interview on 08/06/2019, that this employee monitors the deficiencies and notifies the providers of the deficiencies on a weekly basis.

Employee #3 confirmed in interview on 08/06/2019, that this quality improvement measure has been presented to the Quality Committee in May and June of this year, and it was reported to the Board of Directors in their March meeting. Progress has been made since January of 2019, in reducing the deficiency numbers in Cerner at the hospital.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for tracking of staff and sheltered patients during an emergency. Failure to adequately track patients and staff during an emergency could lead to harm to both patients and staff if staff and patient location/whereabouts are not known.

Findings include:

The facility Emergency Plan specifically relating to the facility process for the tracking of sheltered/evacuated patients and staff during an emergency was requested on August 06, 2019. The emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

The Chief Operating Officer (COO) and the Support Services Manager confirmed during an exit conference on August 06, 2019, the emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency.

Based on review of the facility emergency plan, and staff interview, it was determined the facility failed to develop and implement a policy and procedure for sheltering in place during an emergency. Failure to adequately shelter in place during an emergency could potentially lead to harm for both patients and staff, if the facility does not have processes and supplies readily available to institute when patients and staff cannot leave the facility.

Findings include:

The facility Emergency Plan related to a process for sheltering patients and staff during an emergency was requested on August 06, 2019. The Emergency Plan (EP) did not identify a process for sheltering patients and staff during an emergency.

The COO and the Support Services Manager confirmed on August 06, 2019, the facility EP plan did not identify a process for sheltering patients and staff during an emergency.

Based on record review and staff interview, it was determined the facility failed to develop arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Failure to have arrangements with other hospitals and other providers to receive patients has potential to harm patients due to delay of care.

Findings include:

The policy and procedure to describe arrangements with other hospitals and other providers during an emergency was requested on August 06, 2019. The Emergency Plan did not have the documented policy and procedure to describe arrangements with other hospitals and other providers during an emergency.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review to describe its arrangements with other hospitals and other providers during an emergency.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop an emergency policy and procedure at alternative care sites may cause harm to the patients during an emergency if the needs of the patients are not met.

Findings include:

The policy and procedure to describe the facilitys' role in providing care at alternate care sites during an emergency was requested on August 06, 2019. The Emergency Plan did not have the documented policy and procedure to describe its role in providing care at alternate care sites during an emergency.

The COO and the Support Services Manager acknowledged during the exit conference on August 06, 2019, that there was no documentation to review to describe its role in providing care at alternate care sites during an emergency.

Based on review of the facility Emergency Plan, facility record review, and interview, it was determined the facility failed to develop and implement a method for sharing information and medical documentation for patients under the hospitals care, as necessary, with other health care providers to maintain the continuity of care.

Findings include:

The facility's Emergency Plan related to the requirements of providing a method for sharing information and medical documentation for patients under the hospitals care, as necessary, with other health care providers to maintain the continuity of care was requested on August 06, 2019. The plan did not include a method for sharing information and medical documentation for patients under the hospitals care, as necessary, with other health care providers to maintain the continuity of care.

The COO and the Support Services Manager confirmed during an interview on August 06, 2019, the facility Emergency Plan did not include a method for sharing information and medical documentation for patients under the hospitals care, as necessary, with other health care providers to maintain the continuity of care.

Based on review of the Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.

Findings include:

The facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center was requested on August 06, 2019. The Emergency Plan did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

The COO and the Support Services Manager confirmed during an interview on August 06, 2019, the EP plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.