The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| BAPTIST HEALTH CORBIN | ONE TRILLIUM WAY CORBIN, KY 40701 | March 4, 2011 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on observations, interviews, and record review, the facility failed to ensure patients received care in a safe setting. Patients exposed to chemical contaminants and presented to the facility were required to undergo a chemical decontamination process. Observation and interview revealed an area located outside of the facility, enclosed by two (2) walls of the facility and two (2) privacy screens, was utilized for decontamination regardless of the outdoor temperature. In addition, interviews revealed only cold water was provided at the decontamination area. Record review revealed nine (9) patients presented to the facility due to chemical exposures from December 4, 2010 thru February 3, 2011. The outside temperatures from December 4, 2011 thru February 3, 2011 ranged from 30 degrees to 36 degrees Fahrenheit. The facility failed to ensure patients received care in a safe setting during the chemical decontamination process. Refer to A144. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure patients received care in a safe setting for nine (9) of nine (9) patients (patients #1, #2, #3, #4, #5, #6, #7, #8, and #9) exposed to chemical contaminants and presented to the facility for decontamination. Observation and interview revealed an area located outside of the facility, enclosed by two (2) walls of the facility and two (2) privacy screens, was utilized for decontamination regardless of the outdoor temperature. In addition, interviews revealed the water source in the decontamination area provided only cold water for decontamination. Record review revealed the nine (9) patients presented to the facility and were decontaminated in the outside decontamination area on December 4, 2010, December 11, 2010, and on February 3, 2011. The outside temperatures obtained from the National Weather Service revealed the outside temperature was 30.9 degrees Fahrenheit on December 4, 2010; 36 degrees Fahrenheit on December 11, 2010, and 30 degrees Fahrenheit on February 3, 2011. The facility failed to ensure patients received care in a safe setting during the chemical decontamination process in cold temperatures. The findings include: A review of the facility's policies and procedures on March 1, 2011, revealed a "Chemical/Biological Decontamination" policy had been developed to ensure facility personnel were properly prepared to respond to hazardous chemicals and/or biological incidents that required patient decontamination, and to handle all measures of decontamination in accordance with "OSHA, HIOSH, MSDA" recommended procedures. The policy had been reviewed/revised on August 2, 2010. Continued review of the policy revealed the location of the decontamination area was to be within a "decon (decontamination) trailer," or any other outdoors site deemed appropriate. The policy was not specific as to where the outdoor site would be located. A review of the medical record of patient #1 revealed the [AGE]-year-old patient presented to the Emergency Department (ED) on December 4, 2010, and was at the decontamination area at 7:10 a.m. Documentation revealed the patient's clothing was removed prior to the decontamination process. The temperature on the day patient #1 presented to the ED was 30.9 degrees Fahrenheit. A review of the medical record of two-year-old patient #2 and nine-month-old patient #3 revealed the patients had presented on December 11, 2010, at approximately 6:00 a.m., due to a report that the patients had been exposed to chemical substances. Documentation revealed the patients had undergone the facility's decontamination process at the facility prior to entering the ED. The temperature on the day the patients presented to the ED was 36 degrees Fahrenheit. Documentation revealed patients #4, #5, #6, #7, #8, and #9 presented on February 3, 2011, from 3:20 to 3:25 p.m., due to an exposure to chemicals. Documentation revealed the decontaminating process had occurred prior to the patients' entrance into the ED. The temperature obtained from the National Weather Service for February 3, 2011, at 2:53 p.m., was noted to be 30 degrees Fahrenheit. Interview with Decontamination Officer #1 on February 28, 2011, at 10:30 a.m., revealed a trailer had previously been used for decontamination purposes, but the trailer became broken and could not be used. Decontamination Officer #1 stated an area outside of the Emergency Department (ED) had been developed to be used as the decontamination area because the area had a drainage system that allowed contaminated water to be contained separately from the facility's water system as required by federal guidelines. Officer #1 stated on the day six (patients #4, #5, #6, #7, #8, and #9) of the nine patients presented to the facility, February 3, 2011, the outside temperature was "cold." Interview with Decontamination Officer #2 on February 28, 2011, at 12:50 p.m., confirmed the facility had previously utilized a trailer for the purposes of decontamination of individuals that had been exposed to chemical contaminates and that presented to the facility. Officer #2 stated the trailer used for decontamination had developed three water leaks and could not be used due to federal guidelines that required contaminated water be contained in a separate drainage system than the facility. The officer stated an area located outside of the ED had been designated as the decontamination area because the area had a separate drainage system and met the federal guidelines. Interview with Officer #2 revealed the decontamination area had two brick walls and one of the walls had two water faucets that provided cold water for decontamination purposes. The officer was reportedly present when six (patients #4, #5, #6, #7, #8, and #9) of the nine patients presented on February 3, 2011, and stated the outside temperature was "cold." Interview with the Emergency Department Director of Nursing (DON) on February 28, 2011, at 11:45 a.m., also revealed the facility's decontamination area was located outside the facility near the ambulance entrance, was enclosed on two sides by brick walls, and had two water faucets to be used in the decontamination process. Interview with the DON revealed only cold water was available from the water faucets located in the decontamination area. The DON stated the decontamination process was required to be completed prior to the patient entering the ED. The DON also stated during the decontamination process, the patient's clothing, including shoes, would be removed and the patient would be cleansed with water to remove any possible decontaminate from the body. According to the DON, cold water was routinely used during the decontamination process due to the possibility that warm/hot water had the potential of opening the pores of the patient's skin which could allow chemical contaminates to absorb quicker into the patient's body. Interview with the Chief Nursing Officer (CNO) on March 1, 2011, at 9:40 a.m., revealed a local agency had donated a "trailer" to the facility to be used for decontamination purposes. According to the CNO, the trailer had been determined to be out of service due to a water leak on August 23, 2010, and the facility had utilized the outside decontamination area since that time. Observation of the facility's decontamination area on March 1, 2011, at 10:20 a.m., revealed an area located outside the ED of the facility. The area was adjacent to two exterior brick walls of the facility and had no overhead enclosure. Two water faucets with water hoses were observed to be located on one of the exterior brick walls. The facility failed to ensure patients received care in a safe setting during the chemical decontamination process in cold temperatures. |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on a review of documentation, interviews, and observations conducted on February 28, 2011-March 4, 2011, the facility failed to provide adequate facilities to ensure the safety of patients who had been exposed to chemicals and presented to the facility for decontamination. The facility failed to provide patients protection from the elements during the decontamination process and to ensure the decontamination area had a water supply that could be controlled during the decontamination process. Interviews and observation revealed the facility's decontamination area was located outside the facility and only had a cold water source available. A review of documentation revealed nine (9) of nine (9) sampled patients (patients #1, #2, #3, #4, #5, #6, #7, #8, and #9) had been exposed to a chemical contaminant, presented to the facility, and underwent a decontamination process in an area exposed to the elements that did not have a water supply that could be controlled. Refer to A722. |
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| VIOLATION: FACILITIES | Tag No: A0722 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of documentation, interviews, and observations conducted on February 28, 2011-March 4, 2011, the facility failed to provide adequate facilities to ensure patient safety. Although the facility offered decontamination for patients exposed to chemical contaminates, the facility failed to provide patients protection from exposure to the elements during the decontamination process and to ensure the decontamination area had a water supply that was temperature controlled. Interviews and observation revealed the facility's decontamination area was located outside the facility and only had a cold water source available. A review of documentation revealed nine (9) of nine (9) sampled patients (patients #1, #2, #3, #4, #5, #6, #7, #8, and #9) who had been exposed to a chemical contaminant, presented to the facility, and underwent a decontamination process in an area exposed to the elements that did not have a water supply that was temperature controlled. The findings include: A review of the facility's policies and procedures on March 1, 2011, revealed a "Chemical/Biological Decontamination" policy had been developed to ensure facility personnel were properly prepared to respond to hazardous chemicals and/or biological incidents that required patient decontamination, and to handle all measures of decontamination in accordance with "OSHA, HIOSH, MSDA" recommended procedures. The policy had been reviewed/revised on August 2, 2010. Continued review of the policy revealed the location of the decontamination area was to be within a "decon (decontamination) trailer," or any other outdoor site deemed appropriate. The policy was not specific as to where the outdoor site would be located. Interview with the Chief Nursing Officer (CNO) on March 1, 2011, at 9:40 a.m., revealed a local agency had donated a "trailer" to the facility to be used for decontamination purposes. According to the CNO, the trailer had been determined to be out of service due to a water leak on August 23, 2010, and the facility had utilized an outside decontamination area adjacent to the Emergency Department since that time. Interview with Decontamination Officer #2 on February 28, 2011, at 12:50 p.m., confirmed the facility had previously utilized a trailer for the purposes of decontamination of individuals that had been exposed to chemical contaminates and that presented to the facility. Officer #2 stated the trailer used for decontamination had developed three water leaks and could not be used due to federal guidelines that required contaminated water be contained in a separate drainage system than the facility. The officer stated an area located outside of the ED had been designated as the decontamination area because the area had a separate drainage system and met the federal guidelines. Interview with Officer #2 revealed the decontamination area had two brick walls and one of the walls had two water faucets that provided only cold water for decontamination purposes. Observation of the facility's decontamination area on March 1, 2011, at 10:20 a.m., revealed an area located outside of the facility adjacent to two exterior brick walls of the facility and visible to public view. The decontamination area was observed to be approximately three to four feet wide and 20 to 25 feet long. The area had a concrete floor with a drain and had no overhead enclosure. Two water faucets with water hoses were observed to be located on one of the exterior brick walls. Interview with the Director of Nursing (DON) of the Emergency Department (ED) on February 28, 2011, at 11:45 a.m., revealed only cold water was available from each water faucet. In addition, the DON stated two privacy screens were utilized during the decontamination process to enclose the decontamination area. Based on observation of the privacy screens, each screen was noted to be 12 feet and ?-inch wide and failed to completely cover the length of the decontamination area. The panels of the screen were noted to be 12 inches from the ground and, as a result, the lower portion of the patient's body was exposed to the elements. Interview with the Director of Nursing (DON) of the Emergency Department (ED) on February 28, 2011, at 11:45 a.m., confirmed the facility provided decontamination of patients exposed to chemical contaminates in an area located adjacent to the ED near an ambulance entrance. The DON stated the area was enclosed on two sides by brick walls and had two water faucets that provided only cold water available for use during the decontamination process. Also, interview revealed following the decontamination process, patients were required to walk from the decontamination area to the entrance of the ED, an area that was approximately 30 to 35 feet in length and exposed to the elements. The DON stated the patient's clothing, including shoes, were completely removed during the decontamination process regardless of the outside temperature. Based on a review of documentation, nine patients (patients #1, #2, #3, #4, #5, #6, #7, #8, and #9) had presented to the ED due to chemical exposure and had been decontaminated in the facility's outside decontamination area. A review of the medical record of patient #1 revealed the [AGE]-year-old patient presented on December 4, 2010, and was at the decontamination area at 7:10 a.m. Documentation revealed the patient's clothing was removed prior to the decontamination process. The temperature on the day patient #1 presented to the ED was 30.9 degrees Fahrenheit. A review of the medical record of two-year-old patient #2 and nine-month-old patient #3 revealed the patients had presented on December 11, 2010, at approximately 6:00 a.m., due to a report that the patients had been exposed to chemical substances. Documentation revealed the patients had undergone the facility's decontamination process at the facility prior to entering the ED. The temperature on the day the patients presented to the ED was 36 degrees Fahrenheit. Documentation revealed patients #4, #5, #6, #7, #8, and #9 presented on February 3, 2011, from 3:20 to 3:25 p.m., due to an exposure to chemicals. Documentation revealed the decontaminating process had occurred prior to the patients' entrance into the ED. The temperature obtained from the National Weather Service for February 3, 2011, at 2:53 p.m., was noted to be 30 degrees Fahrenheit. Interview with the family member of patients #4, #5, #6, #7, #8, and #9, on February 25, 2011, at 4:45 p.m., revealed the family member was present when the patients underwent the decontamination process at the facility. According to the family member, the weather was "cold" on February 3, 2011, when the patients had their clothing removed and underwent the decontamination process in the outside area of the facility. |
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