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 with staff (EMP), it was determined that the facility failed to ensure the safety of patients and the public by continuing to utilize an entrance to a outpatient site that was currently under construction.

On 3/19/19, at 9:15 am, observation and interview with EMP1 revealed that an addition was built at this location in February, 2019, to relocate existing and expand the space available to provide various medical services to the public. One of these services was a family medicine practice which was located on the second floor of the building. According to interview with EMP1, this practice serves individuals of all ages and at times, patients required the assistance of an ambulance transfer to their appointment. Interview also indicated that facility staff were aware that individuals who arrived via ambulance could not be transported to the second floor office by gurney because the gurney could not fit in the one and only elevator in the building. A decision was made to instruct ambulance staff to bring patients to the original entrance to the practice which was currently under construction and that communication was delivered to ambulance staff.

Observation on 3/19/19, at 9:30 am, revealed the entrance which was being utilized by ambulances, was under construction. One of two double doors leading into the building was propped open and being used to bring supplies in and out for the job. Building materials and equipment were observed in the doorway and hallway leading to the family practice area. Temporary lighting was strung above. Electricians were onsite roughing in walls; sprinkler system was being installed; and drywall was being done. Although signs, approximately 8 1/2 by 11 inches, had been posted on the doors, observation and interview with EMP2 who supervised the construction staff, indicated that the public was not consistently deterred from entering the building. At 10:00 am, while standing at the construction entrance, OTH1 walked up to the entrance and tried to open the other set of doors despite the signage. Interview revealed that OTH1 had not seen the signs and was looking for a way to get into the building for a medical appointment. On 3/19/19, at 10:00 am, interview with EMP2 recalled a situation where an individual drove up to the construction entrance despite orange colored cones which had been placed in the parking lot opposite the entrance. The driver failed to stop and continued driving through the area and around the dumpster in order to find a parking space near the entrance. Interview further revealed that individuals who have tried to use this entrance have become "huffy" when told that this entrance is no longer being used as the main entrance to reach the practice.

On 3/19/19, at 10:30 am, interview with EMP1 confirmed that ambulances had delivered and continued to bring patients to and through the construction area to the family practice suite since February 18, 2019.
Based on a review of facility documentation and interview with staff, the facility failed to ensure that all construction projects are assessed during the planning and building phase to ensure that they are built to facilitate a safe delivery of care. Findings include:

An investigation completed on 3/19/19, revealed that an entrance to the facility continued to be used even though it was still under construction. Based on this observation, an interview was conducted with staff (EMP1) on 3/27/19 to request a copy of two safety assessments (Pre-Project Safety Risk Assessment Checklist for Renovations, Alterations, Demolitions, and New Construction and the Patient Handling and Movement Needs Assessment). Interview further revealed that the assessments were not completed for the Middletown Expansion Project HMFG-3917 because they are not completed for off campus projects. Based on a review of the FGI 2018 Guidelines for Outpatient Facilities section 1.2-4, safety assessments are to be initiated during planning and evolve so as to ensure hazards and potential risks are identified.