HospitalInspections.org

Based on observation, staff interviews, and review of maintenance records on October 31, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 17: did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 29: hazardous areas improperly enclosed;
K 48: training of staff on response to fire
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records on October 31, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K 17: did not meet the permitted exceptions for spaces open to a corridor;
K 18: corridor doors that did not latch;
K 29: hazardous areas improperly enclosed;
K 48: training of staff on response to fire
K 51: fire alarm system without manual pull stations at all required locations;
K 56: deficiencies in the sprinkler system;
K 75: improper storage of trash and soiled linens;

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, record review and interview, the facility failed to follow aseptic technique in 1 of 2 medication administrations observed (Patient #8).

Findings include:

Facility policy "Hand Hygiene" states: "Decontamination/Handwashing indications include but are not limited to: -Before and after all direct patient/resident cares including when touching intact skin...Remove gloves after caring for a patient/resident."

On 10/31/2016 at 12:15 PM, RN I gloved and administered intravenous medication to Patient #8 via Patient #8's left arm. After administering the medication, RN I documented on the computer in Patient #8's room without removing the contaminated gloves or performing hand hygiene.

During an interview with on 10/31/2016 at 12:30 PM, RN I stated "I would have washed my hands before touching the patient, I was just logging off [the computer]."






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Based on record review and interview, facility staff failed to perform surgical skin site preparation and documentation per policy for 7 of 7 surgical patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7).

Findings:

Facility policy "Perioperative Skin Antisepsis" dated 9/2016 states: "8. If a flammable prep agent is used, additional precautions should be taken to minimize the risk of a surgical fire and patient burn injury. With alcohol based preps, 3 minutes need to pass before the draping may begin. The RN will monitor the time. The surgical site will be visualized as being dry before draping is started and then documented as such in the Fire Safety Checklist...12. Skin preparation will be documented on the intraoperative record..."

During an interview with Chief Clinical Officer H on 10/31/2016 at 11:15 AM, H stated the electronic health record includes a Fire Safety Checklist for all surgical patients. Per H, the process in the surgery department is that staff visualize prepped skin as dry prior to draping and this is reflected on the Fire Safety Checklist. Chief Clinical Officer H stated this process was in place prior to the previous survey in August.

During an interview with Surgery RN E on 10/31/2016 at 1:00 PM, RN E stated the Fire Safety Checklist is completed prior to prepping and draping a patient's surgical skin site and provides staff with a fire risk score based on the fire risk safety assessment.

On 10/26/2016 Patient #1 received surgical services for a cesarean section. The patient's surgical site is documented as prepped with an alcohol-based solution at 10:08 PM and draped at 10:14 PM. The record does not specify which prepping agent is used. The Fire Safety Checklist is completed at 9:58 PM, prior to the skin prepping time. There is no documentation in the chart that the prepped site was visualized as dry prior to draping.

On 10/26/2016 Patient #2 received surgical services for a laparoscopic appendectomy. The patient's surgical site is documented as prepped with Chloraprep solution at 7:29 AM and draped at 7:34 AM. The Fire Safety Checklist is completed at 7:18 AM, prior to the skin prepping time. There is no documentation in the chart that the prepped site was visualized as dry prior to draping.

On 10/25/2016 Patient #3 received surgical services for a left knee arthroplasty. The patient's surgical site is documented as prepped with Duraprep solution at 12:31 PM and draped at 12:35 PM. The Fire Safety Checklist is completed at 12:09 PM, prior to the skin prepping time.

On 10/27/2016 Patient #4 received surgical services for a right leg open reduction internal fixation. The patient's surgical site is documented as prepped with Chloraprep solution at 2:29 PM and draped at 2:31 PM, less than the 3 minutes required. The Fire Safety Checklist is completed at 2:14 PM, prior to the skin prepping time. There is no documentation in the chart that the prepped site was visualized as dry prior to draping.

On 10/27/2016 Patient #5 received surgical services for a right shoulder arthroscopy. The patient's surgical site is documented as prepped with Chloraprep solution at 12:00 PM and draped at 12:06 PM. The Fire Safety Checklist is completed at 11:46 AM, prior to the skin prepping time.

On 10/31/2016 Patient #6 received surgical services for a laparoscopic cholecystectomy. The patient's surgical site is documented as prepped with Chloraprep solution at 8:54 AM and draped at 8:58 AM. The Fire Safety Checklist is completed at 8:44 AM, prior to the skin prepping time. There is no documentation in the chart that the prepped site was visualized as dry prior to draping.

On 10/31/2016 Patient #7 received surgical services for a diagnostic laparoscopy. The patient's surgical site is documented as prepped with Chloraprep solution at 1:51 PM and draped at 1:55 PM. The Fire Safety Checklist is completed at 1:32 PM, prior to the skin prepping time.

The medical record findings were confirmed at the time of the review on 10/31/2016 between 1:00 PM and 1:45 PM with Surgical Services Director F, Surgery Manager G and Surgery RN E. At 1:45 PM, the facility's corrective action plan was reviewed: "...every surgical case has a mandatory 'Fire Safety Documentation.' In this documentation screen, the nurse must check to affirm that the surgical site has been visualized as being dry before draping is started. This documentation would meet the correction criteria..." Review of the facility's policy states: "The surgical site will be visualized as being dry before draping is started and then documented as such in the Fire Safety Checklist." When asked how the current process of completing the checklist prior to skin preparation is an accurate documentation of the nurse visualizing the site prior to draping, RN E stated "we have to fill out the checklist beforehand to get a fire risk score." Director F stated the surgical staff was re-educated on this process on 10/13/2016. Manager G stated chart audits were started on 10/24/2016 which showed compliance with the completion of the checklist. Manager G stated "we will have to do something to show the nurse is visualizing the prep site is dry."