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.

Based on observation and interview the facility failed to ensure patient's right to personal privacy in 4 of 21 observation
in the Adult Emergency Department (ED).

Findings include:

On 3/22/18 at approximately 10:30 AM, during a tour of the Adult Emergency Department two patient bays were occupied by four (4) patients. In both Bays, there were no privacy screen between patients.

During interview on 3/22/18 at 10:35 AM with Staff J, Emergency Department Nursing Director, the staff acknowledged the lack of privacy for the four patients and reported that he did not know why the patients were doubled up in the two ED bays when there are available beds in other bays.
Based on record review and staff interview, the facility failed to ensure that the medical staff documented the attempt to secure Autopsies as required by Hospital policy in one (1) of five (5) medical records reviewed (Patient #1).

Findings include:

Review of the medical records for Patient #1 revealed a 7-year-old female who expired at the facility on 1/14/18.

There was no documented evidence that the physician attempted to obtain permission for an Autopsy.

Review of the Death Certificate determined it was incomplete, the section that notes, "Objection to an autopsy - YES or NO " was not filled out.

Review of the facility's policy titled "died in the emergency room (DIE Cases)" dated 12/19/16, revealed that, "the emergency room Physician will request consent for an Autopsy from the family in the event that the Medical Examiner refuses the case and will complete and sign the death certificate if the Medical Examiner refuses the case and the family refuses an Autopsy."

This finding was acknowledged and confirmed on 3/26/18 at 12:15 PM with Staff D, (the Emergency Department Medical Director) and
Staff G (the Director of Quality Management). Staff D stated at 12:15 PM, "the patient's mother initially said that she wanted an autopsy done, she said it twice, but then later, she changed her mind and she didn't want one."

There was no documentation of the mother's refusal in the medical record.
Based on observation and staff interviews, the facility failed to ensure that water temperature was maintained at an acceptable range in accordance with generally accepted standards.

Findings include:

During tour of the Emergency Department (ED) on 3/22/18 at approximately 10:30 AM, the water in the Trauma/Critical section of the ED was cold. The temperature of the water was 70.3 degree Fahrenheit when it was measured by Staff L, Supervisor Plumber.

During tour of the Operating Room on 3/22/18 at approximately 11:15 AM, the temperature of the water in the two scrub sinks located by two operating suites were 51.9 degree Fahrenheit.

The hospital policy titled "2005.2 Hot Water Temperatures noted under Procedures, "The domestic hot water temperature will be maintained at 110 degrees Fahrenheit or less in all patient and staff areas". However, the facility's policy does not provide guidance on the temperature range for domestic hot water.

Review of CDC recommendation notes:

C. When state regulations or codes do not allow hot water temperatures above the range of 105F--120F (40.6C--49C) for hospitals or 95F--110F (35C--43.3C) for nursing care facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow either of these alternative preventive measures to minimize the growth of Legionella spp. in water systems. Category II

1. Periodically increase the hot water temperature greater or equal to 150F at the point of use (153). Category II
2. Alternatively, chlorinate the water and then flush it through the system (153--155). Category II

D. Maintain constant recirculation in hot-water distribution systems serving patient-care areas (1). Category IC (AIA: 7.31.E.3)

During interview on 3/22/18 at approximately 11:45 AM with Staff K, Senior Associate Director of Facilities Operation and Staff L, both staff members acknowledged findings.