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Based on review of facility documentation, facility tour, and staff interview, the hospital failed to construct and maintained the facility to ensure the safety of the patients in regard to the facility's failure to ensure that; corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating (K17), to ensure all doors protecting corridor openings were maintained in a manner in which there was no impediments to the closing of the door (K18), to ensure vision panels in corridor doors were fixed window assemblies in approved frames (K19), to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3.(K25), to ensure door openings in smoke barriers had at least a 20-minute fire protection rating or were at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted (K27) to ensure that one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted (K29), to ensure the gift shop met the exceptions for gift shops not considered hazardous, did not exceed 500 ft2 (46.5 m2) and was protected throughout by an approved automatic sprinkler system or separated from a lobby or corridor by non-fire-rated walls if the gift shop was protected throughout by an approved automatic sprinkler system (K30), to ensure that stairways and smoke proof towers used as exit were in accordance with 7.2 with regards to access controlled egress doors (K34), to ensure that exit access was arranged so that exits were readily accessible at all times in accordance with 7.1. (K38), to ensure that exit directional signs were displayed in accordance with 7.10. (K47), ensure that medical gas storage and administration areas were protected in a accordance with NFPA 99,Standards for Health Care Facilities (K76), to ensure that no smoking or non-smoking signs were conspicuously displayed wherever supplemental oxygen was in use, or in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means, to ensure that required illumination of the means of egress was arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area and to ensure that access to exits was marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants (K130).

Based on review of documents of contracted services and staff interview, the facility's contracted services for respiratory care failed to follow their peer review process for medical staff reappointment. This affected one (Staff K) of one contracted medical staff file reviewed for credentialing.
Findings include:
Review of the medical staff file for credentialing revealed Staff K (Doctor of Medicine) was granted reappointment to the medical staff for two years on 03/08/14. The Physician Ongoing Professional Practice Evaluation Assessment and Recommendation Form for Staff K was reviewed. The committee chairperson signed the form on 02/26/14, but made no recommendation if privileges were granted, limited or revoked.
Review of the letter to Staff K from the Chief Executive Officer of the contracted services, dated 02/28/14, indicated the Medical Executive Committee approved Staff K's request for reappointment.
On 03/19/15 at 2:00 PM, Staff L confirmed these findings.

Based on observation and staff interview, the facility failed to provide the patient or the patient's representative a phone number and address for lodging a grievance with the state agency.

Findings include:

1. On 03/16/15 at 2:40 PM, the facility's admission folder was reviewed. The folder did not contain the phone number and address for lodging a complaint with the state agency.
The facility patient admission folder was reviewed on 03/16/15 and lacked evidence patients were being informed of how to contact the Ohio Department of Health (ODH) with grievance concerns. Tour of the Emergency Department (ED), including registration and waiting room, the South entrance of the hospital and its registration area, and the mental health units all lacked evidence patients were being informed of how to contact ODH or that information was available upon request.
The ED registration clerk was interviewed on 03/16/15 at 1:05 PM and asked what information regarding rights was provided to patients, and the clerk provided a copy of the hospital's " Written Acknowledgement of Receipt of the Joint Notice of Privacy Practice" and a document entitled "Your Information. Your Rights. Our Responsibilities". Neither contained contact information for ODH.
2. A visit to the hospital's outpatient St. Clairsville Community Health Center was conducted on 03/18/15 beginning at 7:30 AM. The registration clerk was asked what information regarding rights was provided to patients, and the clerk provided a copy of the hospital's " Written Acknowledgement of Receipt of the Joint Notice of Privacy Practice". This contained no mention how to contact ODH.
3. On 03/19/15 the hospital's outpatient Shiffler Oncology department was toured. A pamphlet entitled "Information for Outpatients and Visitors" was reviewed. Again, there was no contact information for ODH to provide to the patients.
4. On 03/19/15 at 1:15 PM, the facility's offsite Physical Therapy location was observed. The facility did not have the phone number or address for lodging a grievance with the state agency. On 03/19/15 at 1:20 PM, Staff V was interviewed and reported the offsite physical therapy location did not provide patient's the phone number and address for lodging a complaint with the state agency.

Staff F was made aware of and confirmed these findings on 03/19/15 at 1:20 PM.

Based on medical record review, policy review and staff interview, the facility failed to ensure nursing staff developed, and kept current, a nursing care plan for six (Patient #12, #14, #18, #33, #34 and #36) of 30 inpatient medical records reviewed.

Findings include:

1. The History and Physical for Patient #18 listed Patient #18 as having a seizure disorder. The nursing care plan did not include nursing interventions for seizure disorders.
On 03/16/15 at 3:18 PM, the findings were shared with Staff R and confirmed.
2. The History and Physical for Patient #36 listed the patient as having dysphagia (difficulty in swallowing) and showed Patient #36 was being treated for aspiration pneumonia (a lung infection caused by inhaling mouth secretions, stomach contents, or both). The nursing care plan did not include nursing interventions for dysphagia.
3. Patient #33 was admitted to the facility on 03/11/15 following a cerebrovascular accident (stroke). The History and Physical from 03/12/15 listed Patient #33 as having dysphagia and seizures. The History and Physical showed Patient #33 was taking Keppra (a seizure medication). The nursing care plan did not include interventions for seizures and did not include interventions for dysphagia.
4. The medical record review for Patient #34 showed the patient was taking the medication Warfarin (an anticoagulant). The nursing care plan did not contain nursing interventions for anticoagulation therapy or bleeding precautions.
Review of the possible care plan selections/interventions available for the nursing staff to select in the electronic medical system included an intervention for anticoagulation management: Warfarin.
5. The electronic medical records for Patient #12 and Patient #14 were reviewed with Staff J on 03/17/15 at 10:27 AM. Patient #12 was admitted to the behavioral health unit on 03/06/15 with diagnosis of bipolar type 1. Patient #14 was admitted to behavioral health unit on 03/02/15 with diagnoses of mood disorder and polysubstance dependence. A nursing care plan (hospital KBC Adult Plan of Care) for each patient was not initiated until 03/16/15.
Staff J confirmed these findings at the time of the record reviews.
Hospital policy Patient Care Plan (#3.3, last revised 09/2013) was reviewed. Per said policy, "based on the admission assessment and assessments thereafter, the Registered Nurse formulates the Plan of Care in the EMR".

Based on medical record review, staff interviews, and policy and procedure review, the facility failed to ensure medications were administered in accordance with orders of the practitioner or practitioners responsible for the patient's care for three patients (Patient # 17, #24 and #27) failed to ensure a medication injection was administered in accordance with the facility's procedures for one patient (Patient #16) of 30 inpatient medical records reviewed, and the facility failed to establish policies and procedures to identify time critical and non-time critical scheduled medications.

Findings include:

1. The medical record for Patient #24 contained an order which read " Insulin Regular Sliding Scale (BGM/30) - 3 = dose in Units " three times a day. The order did not contain parameters to hold the Insulin. The medication administration record showed the Insulin was held on 03/15/15 at 4:00 PM (blood sugar 150), 03/16/15 at 4:00 PM (blood sugar 166) and on 03/17/15 at 11:00 AM (blood sugar 174) and 4:00 PM (blood sugar 174).
2. The medical record for Patient #17 contained an order which read "Insulin Regular Sliding Scale (BGM/30) - 3 = dose in Units" three times a day. The order did not contain parameters to hold the Insulin. The Medication Administration Record showed the Insulin was held on 03/15/15 at 4:00 pm (blood sugar 199), 03/16/15 at 7:00 AM (blood sugar 192), 03/17/15 7:00 AM (blood sugar 157), 03/17/15 at 4:00 PM (blood sugar 135) and 03/18/15 at 6:05 AM (blood sugar 140).
The facility's Medication Management policy was reviewed and stated a physician's order is required to hold a medication because of lab/parameters.
3. On 03/19/15 at 9:23 AM, Staff T, a registered nurse, was observed administering a Lovenox (used to prevent deep vein thrombosis (DVT) which can lead to blood clots in the lungs) injection to Patient #16. Staff T was observed administering the injection with Staff T's right hand and not grasping the skin around the injection site with Staff T's left hand. Staff T's left hand did not contact Patient #16 during the injection.
The facility's procedure for subcutaneous injections was reviewed and stated the following: "With your non-dominant hand, grasp the skin around the injection site firmly to elevate the subcutaneous tissue, forming a one inch fat fold. Holding the syringe in your dominant hand, insert the loosened needle sheath between the fourth and fifth fingers of your other hand while still pinching the skin around the injection site".
4. Staff W, a pharmacist, was interviewed on 03/19/15 at 2:00 PM. Staff W reported the facility had not identified which medications were time-critical and reported the facility had not established time windows in which to administer scheduled medications.
The facility's Medication Management policy was reviewed, and the policy did not contain a time window in which to give medications, identify which medications were time-critical and which medications were non-time-critical.
5. The electronic medical record for Patient #27 was reviewed with Staff R on 03/18/15 at 11:22 AM. There was a 03/11/15 order for sliding scale Novolog insulin, four times per day , prior to meals and bedtime. The amount of insulin to be administered was determined per the calculation BG (blood glucose) /30 - 3.

On 03/12/15 at 11:19 AM, Patient #27's BG was 139. Staff failed to administer two units of insulin as per order. On 03/12/15 at 8:13 PM Patient #27's BG was 150. Staff didn't administer insulin until 9:31 PM, more than an hour later.

On 03/13/15 at 11:09 AM, Patient #27's BG was 163. Patient #27 should have received two units of insulin but didn't.

On 03/13/15 at 4:05 PM, Patient #27's BG was 178. The patient should have received three units of insulin but didn't.

On 03/13/15 at 8:14 PM, Patient #27's BG was 219. Staff didn't administer the patient's insulin until 9:11 PM, approximately one hour later.

On 03/14/15 at 3:57 PM, Patient #27's BG was 176. The patient should have received three units of insulin. At 7:41 PM, Patient #27's BG was 220. Patient #27 should have received three units of insulin but staff administered five units.

On 03/15/15 at 11:02 AM, Patient #27's BG was 191. The patient should have received three units of insulin but did not. At 4:01 PM, Patient #27's BG was 278, but the patient didn't receive six units of insulin until 5:47 PM, approximately two hours later.

On 03/16/15 at 11:21 AM, Patient #27's BG was 195. Patient #27 should have received four units of insulin but did not. At 4:01 PM, Patient #27's BG was 199. The patient should have received four units of insulin but didn't. At 8:23 PM, Patient #27's BG was 148, in which the patient should have received two units of insulin but did not.

On 03/17/15 at 4:00 PM, Patient #27's BG was 203. Patient #27 should have received five units of insulin but didn't. At 9:06 PM, Patient #27's BG was 197. Patient #27 should have received four units of insulin but did not.

On 03/18/15 at 12:06 PM, Patient #27's BG was 170. Patient #27 should have received three units of insulin but didn't.

Based on review of facility documents for delinquent medical records, policy and procedure review, and staff interview, the facility failed to ensure each medical record was promptly completed within 30 days after discharge. This had the potential to affect all patients of the hospital. The facility's active census was 22.

Findings include:

Review of the facility's demand incomplete suspension report, dated 03/17/15, revealed 11 medical records were delinquent. The dates of the delinquent records were 07/08/14, 09/06/14, 09/25/14, 11/10/14, 01/25/15, 01/16/15, two on 02/6/15, 02/08/15, 02/27/15 and 02/29/15.

Review of the procedure on Monitoring of Incomplete /Delinquent Record Procedure indicated the first day of the month the facility was to run an Incomplete/Delinquent Record Report. The tenth day of the month a letter was sent from chief of staff and chief executive officer requesting completion by a specific date or run risk of suspension of admitting and consulting privileges.

On 03/17/15 at 2:00 PM, Staff M confirmed the facility had not suspended any physicians for delinquent medical records. Staff M also confirmed the facility had no evidence the physicians received a letter requesting completion of their delinquent records.

Based on medical record review and staff interview, the facility failed to ensure all patient medical record entries were timed by the person responsible for providing or evaluating the service provided for one (Patient # 24) of 36 medical records reviewed.

Findings include:

The medical record for Patient #24 contained progress notes from 03/12/15 through 03/17/15. The progress notes did not contain the time in which they were written.
On 03/18/15 at 10:15 AM, the findings were shared with Staff E and confirmed.

Based on medical record review, policy review and staff interview, the facility failed to ensure a medical history and physical examination was completed and documented or 24 hours after admission for one (Patient #24) of 36 medical records reviewed.

Findings include:

Patient #24 was admitted to the facility on 03/12/15. The history and physical in the medical record was completed on 03/15/15.
On 03/18/15 at 10:15 AM, the findings were shared with Staff E and confirmed.
The facility's Medical Staff Rules and Regulations stated "the attending practitioner or her/his designee shall be responsible for recording and dating a complete admission history and physical within twenty-four hours of admission".

Based on policy review, staff interview, and observation, the facility failed to ensure technologists appropriately wore their radiation detecting device. This had the potential to affect all staff worked in the radiology department.

Findings include:

On 03/16/15 1:40 PM, Staff B, a radiation technologist was observed in the radiology department without a radiation badge on. Staff A confirmed the findings and Staff B immediately placed a radiation badge on Staff B's uniform at the time of discovery.
The facility's Personnel Radiation Monitoring policy was reviewed and stated "the film badge is worn at all times while the employee is working".

Based on review of facility documentation, facility tour and staff interview and verification, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. Potentially all persons utilizing the facility could be affected. The facility had a capacity of 99 patient beds with a census of 22 patients at the time of the survey completed on 03/19/15.

Findings included:

On 03/16/15 through 03/19/15 review of the facility schematics was completed and tour of the facility was conducted with Staff TT, UU, VV and WW. The following findings were noted in the main hospital and two offsite locations that provided ambulatory care services.

K17, which addressed the facility's failure to ensure corridors were separated from use areas by walls constructed with at least ½ hour fire resistance rating.

K18, which addressed the facility's failure to ensure all doors protecting corridor openings were maintained in a manner in which there were no impediments to the closing of the door.

K19, which addressed the facility's failure to ensure vision panels in corridor doors were fixed window assemblies in approved frames.

K25, which addressed the facility's failure to ensure smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3.

K27, which addressed the facility's failure to ensure door openings in smoke barriers had at least a 20-minute fire protection rating or were at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted.

K29, which addressed the facility's failure to ensure one hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protected hazardous areas. When the approved automatic fire extinguishing system option was used, the areas were separated from other spaces by smoke resisting partitions and doors. Doors were to be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted.

K30, which addressed the facility's failure to ensure the gift shop met the exceptions for gift shops not considered hazardous, did not exceed 500 ft2 (46.5 m2) and was protected throughout by an approved automatic sprinkler system or separated from a lobby or corridor by non-fire-rated walls if the gift shop was protected throughout by an approved automatic sprinkler system

K34, which addressed the facility's failure to ensure stairways and smoke proof towers used as exit were in accordance with 7.2 with regards to access controlled egress doors.

K38, which addressed the facility's failure to ensure exit access was arranged so that exits were readily accessible at all times in accordance with 7.1.

K47, which addressed the facility's failure to ensure exit directional signs were displayed in accordance with 7.10.

K76, which addressed the facility's failure to ensure medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities.

K130, which addressed the deficient areas in the business occupancy locations, if not addressed previously in this deficiency list. The facility failed to ensure that no smoking or non-smoking signs were conspicuously displayed wherever supplemental oxygen was in use, or in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. Additionally, failure to ensure that required illumination of the means of egress was arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area and to ensure that access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach the exit was not readily apparent to the occupants.

Please see the Life Safety Code report for more specific details.

Based on observation, medical record review, policy review, and staff interview, the facility failed to have a system in place to identify which endoscope was used on patients for each procedure for two (Patient #21 and #22), failed to ensure staff adhered to infection control guidelines for one patient in contact isolation (Patient #26), failed to ensure expired alcohol-based hand sanitizers were identified and replaced, failed to ensure cleaning agents to disinfect point of care devices were not expired, and failed to ensure proper dishwashing procedures for kitchen sanitation. This had the potential to affect all patients who received care at the facility.

Findings include:

1. On 03/17/15 at 6:10 AM, Staff C was interviewed and reported the facility did not have a system in place to identify which endoscopes are used on each patient. Staff C reported the facility is in the process of adapting a color coded system to identify which endoscopes were used on each patient.
On 03/17/15 at 9:00 AM, Staff Q was interviewed and reported the facility is in the process of color coding the scopes in order to be able to track which scope was used on each patient. Staff Q reported the facility did not have a system in place to track which scope was used on which patient.
The facility's Endoscope Reprocessing procedure was reviewed and stated a log must be maintained for each procedure including the patient's name and identification number, the procedure and the serial number of the endoscope to assist in outbreak investigation if necessary.
The medical records for Patient #21, who had a Colonoscopy on 03/12/15, and Patient #22, who had an Esophagogastroduodenoscopy on 03/12/15, did not contain information regarding the specific scope used on each patient during their procedures.
2. The medical record review for Patient #26 showed the patient tested positive for Clostridium Difficile (a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) on 03/10/15 at 2:18 PM.
On 03/18/15 at 3:55 PM, Staff S was observed entering Patient #26's room without a gown or gloves. Staff S assisted Patient #26 out of bed and to the bathroom. Staff S reported normally wearing a gown and gloves but needed to get to Patient #26 due to the bed alarm.
The facility's Transmission-Based Isolation for Resistant Organism's policy was reviewed. The policy stated patients with Clostridium Difficile will be placed in transmission-based isolation (Contact Precautions). The policy stated to wear isolation gown and gloves for contact with the patient or when working with or around the patient's bedding or personal items.
3. On 03/19/15 at 1:15 PM, an expired hand sanitizer (Lot # 12061302 expiration 12/2013) was observed at the facility's offsite laboratory.
The findings were shared with Staff U, a phlebotomist, at the time of discovery and confirmed.
4. On 03/18/15 at 11:05 AM, the facility's inpatient glucometer case was observed in the supply room. The case contained six packages of PDI Sani-cloth bleach wipes Lot # 11301122 with an expiration date of 01/2014. The findings were shared with Staff E at the time of discovery and confirmed.
5. The hospital's Shiffler Oncology building was toured with Staff H on 03/19/15 beginning at 9:30 AM. Staff G (RN manager) was present and interviewed. Staff G was asked to explain what types of services were provided in this part of the hospital and stated today oncology patients would come in for blood draws, medication administration and to have their mediport (central venous access device) accessed and flushed.
While touring with Staff H, seven wall mounted hand sanitizer dispensers were observed in the hallway. One of the seven hand sanitizers expired 02/2014, one expired 03/2014, two expired 08/2014 and three expired 02/2015.
Room #2 was toured and noted to have two containers of PDI sani-cloths (germicidal, disposable wipes) that expired 02/2014.
Room #3 was toured and contained one bottle of Dispatch hospital cloths (germicidal wipes) that expired 06/2011.
Rooms #4 and #5 were toured and each contained one bottle of PDI sani-cloths that expired 04/2014 and one bottle of bacti-stat antimicrobial hand soap that expired 02/2014.
Staff H confirmed the above findings during the tour.
At 11:04 AM, Staff I (RN oncology) prepared to provide care to Patient # AB. Patient # AB was observed to have a mediport. Staff I, with clean gloves, proceeded to remove the old dressing from the patient's mediport site. Staff I disposed of the dressing and gloves, then proceeded to put on sterile gloves and began to clean Patient # AB's mediport site without first performing hand hygiene between glove changes.
Hospital policy Hand Hygiene (#6, last revised 11/2013) was reviewed. The Hand Hygiene policy revealed indications for hand hygiene included "after removing gloves" and "before applying sterile gloves".
6. On 03/17/15 at 2:30 PM, observation was done of Staff N running a test load to view operation of the dishwasher. The temperature gauge of the dishwasher was observed, and the dial did not move. Staff N indicated the wash cycle temperature gauge was not working on 03/16/15, and the dishwasher maintenance company was notified. Staff N indicated wash cycle temperatures were not recorded, and the staff member was not sure when the wash cycle temperature gauge quit working. Routine preventive maintenance was done on 03/02/15, and the wash temperature was 160 degrees. Staff N confirmed the inability to determine the temperature of the wash cycle with the gauze not working.
Staff N confirmed kitchen staff used a temperature strip to determine temperature of the rinse cycle. The temperature strip was used for the last load of dishes for each meal every day. If the temperature strip turns dark, this indicated the rinse cycle was 160 degrees. Staff N confirmed this was the recommended temperature for the rinse cycle.
Staff N confirmed the facility had no policy for dishwashing procedures.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to notify a referral agency for discharge planning of outpatient services. This affected one (Patient #29) of five discharged medical records reviewed. This has the potential to affect all patients of the hospital. The facility's active census was 22.

Findings include:

Review of the medical record for Patient #29 revealed the patient was admitted on 12/15/14 and discharged on 12/31/14. Review of the physician discharge summary, dictated 12/31/14, indicated Patient #29 had intense physical, occupational and speech therapy for right sided hemiparesis (weakness), dysarthria (difficulty with speech) and dysphagia (difficulty with swallowing) during hospitalization. The discharge summary also indicated Patient #29 was on nectar thick liquids. The discharge summary indicated Patient #29 had refused home health therapy services for physical and occupational therapy services, but had agreed to outpatient speech therapy. The summary indicated Patient #29 was to follow aspiration precautions.

Review of the discharge instructions for Patient #29, dated 12/31/14, indicated he/she refused physical and occupational therapy. The instructions had not included outpatient speech therapy services were to be provided after discharge. On 12/31/14, the physician wrote an order for outpatient speech therapy services.

On 03/18/15 at 4:00 PM, Staff J confirmed the findings and was unable to find evidence the facility assisted the patient in making the referral for outpatient speech therapy services.

The policy and procedure on Interdisciplinary Discharge Planning, reviewed on 7/09, indicated the day of discharge appropriate referral agencies was to be notified.