HospitalInspections.org

Based upon onsite observation and document review by Life Safety Code (LSC) surveyors on 10/13/2016, the facility does not comply with the applicable provisions of the 2012 edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 10/13/2016 for Life Safety Code:

Building 1
K-0018
K-0029
K-0033
K-0054
K-0072

Building 2
K-0025
K-0029
K-0062
K-0072

Building 3
K-0029
K-0062
K-0064
K-0069
K-0076
K-0147
K-0211

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR 482.41(b), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include;

See the individually and below cited K-tags dated October 12, 2016.
K-0018
K-0025
K-0029
K-0033
K-0054
K-0062
K-0064
K-0069
K-0072
K-0076
K-0147
K-0211

Based on observation and interview, the facility failed to ensure that equipment and supplies were maintained in an acceptable level of safety and quality resulting in potential patient harm. Findings include:

On 10/13/2016 at approximately 10 AM during the survey of the hospital, it was noted that the medication refrigerators on second floor Pharmacy (labeled as "Lab Rep Co Med"); in medication rooms located on the third, four and fifth floors of Cooper Campus; and the medication room on the seventh floor of Harrison Campus were not served by the electrical emergency generator. The observations were confirmed by staff SSSS and staff RRRR.

Based on observation, interview and record review, the facility failed to wear personal protective equipment while carrying used equipment/instrumentation in 1 of 2 observations resulting in the potential to spread infectious agents to all patients served by the facility. Findings include:

On 10/12/2016 at 0928, during observations in the endoscopy reprocessing room, Staff FFF was observed walking into the reprocessing room carrying a used endoscope which had a large blue water-resistant pad lightly wrapped around it. Staff FFF was not wearing gloves.

On 10/12/2016 at 0929, this observation was confirmed by Staff ZZ who was then queried as to if Staff FFF should be wearing gloves to which Staff ZZ replied, "Yes. She should be wearing gloves."

On 10/13/2016 at 1315, facility policy titled "Sterile Processing" last reviewed 9/10/2015 was obtained and read. On page 1, letter A, policy states, "1. During dirty pick-up rounds disposable gloves are worn when handling the equipment and instruments. 2. After dirty pick-up is completed and before proceeding to another unit or floor the gloves are discarded and hands washed."