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Based on observation, it was determined there were no doors or privacy curtains to provide patient privacy between Trauma Room #1 and Trauma Room #2 in the Emergency Department. Failure to provide privacy between Trauma Room #1 and Trauma Room #2 did not afford the patient privacy during the healthcare examination and treatment. The failed practice had the potential to affect the patient in Trauma Room #2 and all patients provided treatment in Trauma Room #1 and Trauma Room #2. Findings follow:

A. During a tour of the Emergency Department on 12/28/10 at 0935, there were no doors or privacy curtains between Trauma Room #1 and Trauma Room #2. During the tour, a patient was brought in by ambulance and placed in Trauma Room #2 and was visually observed by the Surveyor from Trauma Room #1.
B. The Emergency Department Supervisor confirmed the above findings during an interview at 0940 on 12/28/10.

Based on observation, clinical record review, and interview, it was determined the facility failed to assure a nursing care plan was developed for each patient, that included interventions to meet the identified patient needs for 11 of 11 (Patient #1-10, #16) current inpatients on 12/27/10. The failure to have interventions for identified needs had the potential to prevent progression to the achievement of identified goals for the delivery of care and allowed needs to remain unmet. The failed practice affected all 11 inpatients on 12/27/10 and had the potential to all admissions to the facility. The findings were:

A. Review of Patient #1's clinical record revealed the patient was admitted on 12/21/10 at 0910 with a diagnosis of Mental Status Change, Deconditioning, and Decubiti wound care. The nursing care plan problem listed "confusion" and "altered breathing pattern" but did not include interventions for either of the problems identified. In an interview with Medical Surgical Registered Nurse on 12/27/10 at 1055, she confirmed the findings and stated "there are no interventions documented for the care plan. I would document what I did for the patient based on what I identified as appropriate for that patient. That is what is supposed to be documented in the electronic record."
B. Review of Patient #2's clinical record revealed the patient was admitted on 12/26/10 at 2200 for induction of labor. Care Plan problems identified were "pain, potential for infection, and potential for adverse effects related to labor process." The care plan did not include interventions for the problems identified. The findings were confirmed by interview with the Maternal Child Supervisor on 12/28/10 at 1040.
C. Review of Patient #6's clinical record revealed the patient was admitted on 12/27/10 and had a Cesarean Section with Bilateral Tubal Ligation. Care Plan problems identified were "pain" and "intravenous therapy related to fluid, electrolytes and acid bases are balanced and WNL (within normal limits), Intake and Output are balanced." The care plan did not include interventions for the problems identified. The findings were confirmed by interview with the Maternal Child Supervisor on 12/28/10 at 1045.
D. Review of Patient #5's clinical record revealed the patient was admitted on 12/27/10, newborn. Care Plan problems identified were "knowledge deficit: r/t hypo/hyperglycemic events, body temperature altered." The care plan did not include interventions for the problems identified. The findings were confirmed by interview with the Maternal Child Supervisor on 12/28/10 at 1040.
E. Review of Patient #16's clinical record revealed the patient was admitted 12/27/10, newborn. Care Plan problems identified were "altered body temperature." the care plan did not include interventions for the problems identified. The findings were confirmed by interview with the Maternal Child Supervisor 12/28/10 at 1040.

Based on observation and interview, it was determined the facility did not maintain floors, walls, and ceilings in patient care areas in a good state of repair due to damaged seam welds and scratches on floors in two of two operating rooms and two of two trauma rooms, mold growth on ceiling tiles and damaged walls in patient sleeping areas, and in Operating Room #1, rust accumulation on a cart and a chair with torn covering. Those conditions presented hazards to the health and safety of patients, staff, and visitors due to the inability to effectively clean and sanitize the areas. The failed practice had the potential to affect all current 11 patients on census on 12/27/10, all patients admitted to the facility (average daily census of 17 patients), all patients admitted for surgery and to the Emergency Department, staff, and visitors. The findings follow:

A. On a tour of the surgical suite on 12/27/10 at 1300 with the Director of Support Services, the following observations were made:
1) In Operating Room #1, the welded seam joints of the floor was separating throughout the room. One chair was observed with rips and tears. The wall by the return air grille was damaged. The metal wheel castors on the cart holding the coagulator had an accumulation of rust.
2) In Operating Room #2, the welded seam joints of the floor was separating throughout the room. The wall by the return air grille was damaged.
B. On a tour of the facility on 12/29/10 at 0930 with the Director of Support Services, the following observations were made:
1) Two ceiling tiles located in the corridor near the nourishment room had an accumulation of black mold.
2) In Patient Room 214, the wall base was pulling away from the wall at one location.
3) In Patient Room 216, the wall was damaged and had chipped paint.
4) In the Emergency Department, the floors in Trauma Room #1 and Trauma Room #2 were damaged with scratches throughout.
5) In Patient Room 209, the wall was damaged and had chipped paint.
6) In Patient Room 206, the wall was damaged and had chipped paint.
7) In the anteroom serving airborne isolation Rooms #224 and #226, the ceiling had 2 tiles that had an accumulation of black mold. The wall was damaged leaving deteriorated wall material and chipped paint from what appeared to be water damage.
8) In Patient Room 226, the wall base was pulling away from the wall at one location and the wall was damaged with chipped paint.
C. The Director of Support Services verified and confirmed each of the above in an interview conducted at the time of observation.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements related roller latches. Roller latches are prohibited by CMS regulation.
Failure to replace roller latches with positive latching devices increased the possibility of closed doors opening during a fire situation, exposing building occupants to the spread of fire and smoke. The failed practice had the potential to affect all current 11 patients on census on 12/27/10, all patients admitted to the facility (average daily census of 17 patients) and all staff and visitors. See CMS2567, K-18.

Based on observation and interview, it was determined the facility had roller latches installed on a total of 21 corridor doors. Failure to replace roller latches with positive latching devices increased the possibility of closed doors opening during a fire situation, exposing building occupants to the spread of fire and smoke. The failed practice had the potential to affect all current 11 patients on census on 12/27/10, all patients admitted to the facility (average daily census of 17 patients) and all staff and visitors. See CMS2567, K-18.

Based on interview with the Infection Control Nurse and written documentation provided by the hospital Epidemiologist, it was determined the hospital failed to monitor and record the airflow in the airborne isolation Rooms # 225 and #226. Failure to monitor and record airflow in the airborne isolation room had the potential to allow the spread of communicable respiratory disease to all patients, staff and visitors. The failed practice had the potential to affect all patients hospitalized on the Medical Surgical Unit, any staff who worked on the Unit, and any visitors on the Unit on 12/15/10 through 12/17/10. Findings follow:

A. Review of the facility policy and procedure titled Tuberculosis Identification and Control stated the airborne isolation room was checked by Maintenance, House Supervisor, or the Infection Control Nurse prior to a patient being admitted to the room for airborne isolation, then daily for the length of time that the patient remains in the room.
B. During an interview on 12/29/10 at 1030 with the Infection Control Nurse, she stated monitoring and recording of air pressure checks in the airborne isolation rooms had been assigned to her one week ago.
C. During tour of the isolation rooms on 12/29/10 at 1000, #226 was found to contain an over bed table that had white Styrofoam trays of partially eaten food with mold on them. The tray had a label for Patient #22 with an admit date of 12/15/10. The Director of Support Services was present during the tour and confirmed the findings.
D. Review of Patient #22's clinical record on 12/29/10 revealed documentation on 12/15/10 at 1725 in the "Initial Interview" that "Airborne precautions initiated/MD (Medical Doctor) notified," Pt (Patient) is on droplet precautions for possible TB (Tuberculosis)" and at 1956 "Airborne Isolation, room set-up completed-Type specific. Isolation instructions posted, Keep door closed. Appropriate protection worn in room, Isolation explanation given to patient. Family/visitors instructed on PPE (Personal Protective Equipment) use, Patient verbalizes understanding."
E. Documentation provided by the hospital Epidemiologist on 12/29/10 at 1330 indicated there had been no monitoring and recording of air pressure checks in the airborne isolation rooms and the task had been assigned to the Infection Control nurse this month.

Based on observation, policy and procedure review, and interview, it was determined the facility failed to assure policies and procedures were documented and implemented for: the use of alcohol containing surgical skin preps that included fire safety measures, labeling and dating of sterilized items, and storage of sterilized items. Failure to document and implement policies placed patients at risk of injury from fire and increased risk of infection. The failed practice had the potential to affect one of one patient who had surgery on 12/27/10 and had the potential to affect 77 patients who had surgery from 11/29/10-12/27/10. Findings follow:

A. The Surgery Supervisor confirmed by interview on 12/27/10 at 1325 the facility used Duraprep (an alcohol based skin preparation solution). Review of the policies and procedures "Pre-Operative Skin Preparation", "Operation of Electrosurgery Unit" and "Fire Safety in the OR (Operating Room)" revealed the policies did not include measures for fire safety when alcohol containing skin preparations were in use, such as: assure alcohol based skin prep solution was not allowed to soak into the patient's hair or linens, place sterile towels to absorb drips and runs and then remove from the anesthetizing location prior to draping the patient, and to ensure the alcohol containing skin prep solution was completely dry prior to draping the patient or when cautery was used.
B. A tour of R.R. #1, #2, Cysto Room, Central Sterile, and storage area in the R.R. was conducted on 12/27/10 at 1300. In R.R. #1, #2, Cysto Room, Central Sterile, and Storage area, items in a dust cover had two different dates with the inner wrap date expired. Examples include the following: R.R. #1, one of one wire retractor with an expiration date located inside the dust cover on the blue over wrap of 06/28/08 and the dust cover had a label with an expiration date of 06/28/12; 14 of 14 cannulas with an expiration date of 06/28/08 on the blue overwrap inside the dust cover and the dust cover had a label dated 06/28/12. R.R. #2 contained two items in a clear plastic dust cover, with a date inside the dust cover on the blue overwrap of 02/20/10. The dust cover did not include the statement that contents were sterile unless package damaged. Items in dust covers had two different dates, therefor the policy and process for assuring items were used within the allowed time frame was not evident. A review of the Surgical Policy and Procedure manual on 12/27/10 -12/28/10 revealed the practice for the use of two separate dates in dust covered items was not addressed. The findings were confirmed in an interview with the Surgery Supervisor on 12/27/10 at 1345, she stated "items without a dust cover are sterile for 30 days, and items in a five year dust cover were considered sterile for five years." A specific policy for the use of a "five year dust cover" was requested at the time of the interview and not provided prior to the end of the survey.
C. Observation of an area identified by the Surgery Supervisor as a storage room on 12/27/10 at 1410 revealed a collection of sterile, used and unsterile items stored intermingled throughout the room. Contents of the room included a cart of sterile supplies, identified by the Surgery Supervisor as a Laparoscopic Cart, a Wilson frame which was stored on the floor surface, five pieces of an "eggcrate" type foam product noted on top of a wrapped sterile pack. The Surgery Supervisor was questioned regarding the eggcrate items. She stated they were used and confirmed the items were single use. The room also included a cast cart, orthopedia cart, Endotracheal tubes, sterile and unsterile gloves. Items were not segregated by sterile, unsterile, clean, or dirty. The Facility Policy "Infection Control in the R.R." stated "Sterile items are maintained in a sterile condition until their point of use." The findings were confirmed by interview with the Surgery Supervisor 12/27/10 at 1420.