HospitalInspections.org

Based on observation , interview, and record review, the facility failed to ensure current patients were protected from fire as evidenced by "space" heaters facility placed inside patient rooms.

16 of 19 occupied patient rooms had space heaters which were prohibited by the National Fire Protection Agency / Life Safety Code.


Cross reference tag A-0710

Based on observation, interview, and record review, the facility failed to provide and maintain a safe environment for patients during a facility renovation project.

The facility failed to conduct an Infection Control Risk Assessment (ICRA) prior to beginning a major renovation project per facility policy and the Centers for Disease Control (CDC) recommendations. The facility failed to:

a. identify the type of construction and the patient risk groups affected;

b. determine and implement the appropriate precautions necessary - prior to beginning the renovation project [i.e., critical barriers, negative air-pressure to work area, and other actions as stated in facility policy)

c. conduct and document daily "Infection Control Construction Rounds" per policy.


Deficient practices placed 17 patients at risk for illnesses due to air-borne dust dispersion. Ten (10) of the seventeen (17) patients had documented acute respiratory failure, pneumonitis, pleural effusion, and hypoxia.

Cross reference : Tag A-0749

Based on interview and record review, the facility failed to ensure nursing supervision for the care of three patients (Patient ID#2, #4, and #18).

Nursing staff failed to:

A. Perform skin and wound care assessments per facility policy.

B. Change IV (intravenous) site dressings per policy.


Findings:


Skin Assessments:

Review of facility policy titled "Wound Assessment," #AMC-WC-POL-012 (2), dated 12/5/18 showed the following: "B. Wound Assessment..Wound assessment will address the following: .....2. Location of wound(s), 2. Wound stage .....6. Exudate/drainage, amount and color ....11. Odor ...Note of odor is present ...".

Review of facility policy titled "REASSESSMENT: NURSING", policy # 102, dated 12/5/18 stated " ....4. .....each patient is reassessed on a routine basis each shift. The data is documented in the Nursing Flowsheet as the shift assessment".


In an interview on 12/11/19 at 1:15 PM, CNO Staff #B stated that skin assessments in their entirety were to be done by nursing once per 12 hour shifts. This included skin and wound assessments.


Review of facility document titled "Medical Nursing Flow Sheet" showed a section specific to skin/wound assessments. There was a diagram of several views of a human body (facing forward, backward, and sideways for each side) that was labeled "Number Lacerations/Bruises/Pressure Ulcers/Skin Tears/Excoriations" where the nurse was supposed to document by making markings on the diagram. Also present was a section underneath the diagram which was a chart to document: Number, Pressure Wounds/Other, Stage, Drainage, and Odor. This was to be completed each shift every day.


Record review of three sampled patients showed the following:

Patient ID#4:

Review of clinical chart revealed per Dr. #J's initial History & Physical Examination, this 68 year-old female patient was admitted with acute respiratory failure, pneumonia, acute renal failure, was bedbound, had severe anemia, protein calorie malnutrition, and multiple pressure ulcerations that included both heels and feet, and "significant sacral decubitus ulcer".

Review of nursing documentation for both day and evening shifts from 12/5/19 through 12/10/19, showed the skin assessments failed to contain one or more of the following components: Markings on the diagram indicating Numbered Lacerations/Bruises/Pressure Ulcers/Skin Tears/Excoriations, the Staging of skin ulcers present, Odor, and/or Drainage. Patient #4 was a current patient at time of survey.

Most entries had only one or two components present. Some were blank.



Patient ID #2:

Review of patient's clinical chart revealed per Dr. #K's initial History & Physical exam, showed that this 84 year old male patient was diagnosed with recurrent urinary tract infection, large perinephric (near kidney area) abscess with rectal fistula-drainage was placed, encephalopathy-toxic metabolic, Dementia, renal insufficiency, hypertension, and sacral would (bedsore ulcer) with anal fistula-underwent surgical intervention

Record review of nursing documentation for both day and evening shifts from date of admit 9/1/19 through date of discharge 10/14/19, showed that the skin assessments failed to contain one or more of the following components: Markings on the diagram indicating Numbered Lacerations/Bruises/Pressure Ulcers/Skin Tears/Excoriations, the Staging of skin ulcers present, Odor, and/or Drainage.

Most entries had only one or two components present. Many were blank.


Patient ID #18:

Record review of this 74 year old male's clinical records showed an initial History & Physical exam was performed by Dr. #J. The patient's diagnoses were quadriplegia from a stroke, Parkinson's disease, seizure history, Diabetes with the complications of retinopathy, polyneuropathy, gastroparesis, chronic respiratory failure, and Stage IV Sacral Decubitus Ulcer.

Record review of nursing documentation for both day and evening shifts showed that from date of admit 4/15/19 through date of discharge 5/23/19, the skin assessments failed to contain one or more of the following components: Markings on the diagram indicating Numbered Lacerations/Bruises/Pressure Ulcers/Skin Tears/Excoriations, the Staging of skin ulcers present, Odor, and/or Drainage.

Most entries had only one or two components present. Many were completely blank.


IV site dressings not being changed:

Record review of facility policy titled "IV THERAPY GUIDELINES," policy # 075, dated 3/2/18, stated: " ....Rules .....17. IV catheter/needle [dressing] site should be changed every 72 hours .....Central Line Catheters ... ...3. All central line catheter dressings are changed every Tuesday and whenever dressing is damped, soiled, or loose unless otherwise ordered by a physician."

In an interview on 12/11/19 at 1:25 PM, CNO #B stated that IV site dressings needed to be changed every 72 hours. When showed that there were numerous missed dressing changes as well as no documentation for the date(s) of IV insertions for the sampled patients, she stated that nursing did not handle this task appropriately and the form should have been filled out completely.


Patient ID #4:

Record review of nursing documentation for both day and evening shifts showed that from 12/5/19 through 12/10/19, on the Nursing Flow Sheet document where dressing changes and insertion dates of IVs are documented, there were no IV site dressings performed and there were no dates of insertion of IV documented.

The patient had a left upper arm PICC IV (Peripherally inserted central catheter). At time of survey, this was a current patient.


Patient ID #2:

Record review of nursing documentation showed that from date of admit 9/1/19 through date of discharge 10/14/19, the patient had a CVC (Central Venous Catheter).

Nursing was inconsistent naming this type of catheter, referring to it as a "Subclavian", a "Chest PICC line", a "Quentin" catheter, a "Permacath", a "Double Lumen catheter" and also a "Triple Lumen catheter".

During the patient's entire 44-day stay, his catheter dressing was changed only three times; on 9/9/19, 9/30/19, and day of discharge to another facility -10/14/19.

In addition, on the same form that documented dressing changes, there was also a place to document insertion dates of the IV. There were no insertion dates documented at all for the entire 44 days that patient had resided in the facility.


Patient ID #18:

Record review of nursing documentation from date of admit 4/15/19 through 5/7/19 showed that the patient had a Left Hand PIV (Peripheral IV). Nursing documented only once, the date of insertion on 4/17/19. All the other dates up to and including 5/7/19 failed to show the date of insertion. From 4/16/19 through 5/7/19, there were no IV site dressing changes (22 days).

On 5/8/19, records show that the Left Hand PIV was discontinued and a PICC line was inserted the same day, placed on the upper right arm. From 5/8/19 through the day of discharge on 5/23/19, the dressing was changed one time on 5/16/19.

Based on observation, interview, and record review, the facility failed to ensure current patients were protected from fire hazards as evidenced by the presence of "space" heaters in use inside patients room in 16 of 20 patient rooms (Room #'s 301, 303, 305, 306, 307, 308, 309, 310, 311, 312, 313, 315, 316, 317, 319, and 320).

Findings:

Review of the National Fire Prevention Agency (NFPA) 101 Life Safety Code, 2012 edition: Chapter 19 (Existing Health Care Occupancies), Section 19.7.8, read: "Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in nonsleeping staff and employee areas.

(2) The heating elements of such devices do not exceed 212°F (100°C)".


Review of facility policy titled "LIFE SAFETY MANAGEMENT PLAN," policy number 077, dated 12/5/18, stated "8.0 Miscellaneous Fire Hazards .....b) ATRIUM Medical Center Health has specific policies on the control of: the use of space heaters and like devices is banned through the facility".


Observation on 12/12/19, at 2:00 PM, of patient bedrooms showed there were 16 of 20 rooms that contained "Space-Heaters" which were plugged into electrical outlets and functioning (Room #'s 301, 303, 305, 306, 307, 308, 309, 310, 311, 312, 313, 315, 316, 317, 319, and 320).


In an interview on 12/12/19, at 2:45 PM, with Maintenance Director, Staff #D, he stated that he was unaware that the facility was not allowed to have space heaters in patient rooms.

Based on observation, interview, and record review, the facility failed to implement an effective system to control infections.

The facility failed to conduct an Infection Control Risk Assessment (ICRA) prior to the beginning a major renovation project per facility policy and the Centers for Disease Control (CDC) recommendations.

The facility failed to identify and implement appropriate precautions necessary prior to the beginning of the renovation project.

These deficient practices affected 17 of 17 current patients [Patient ID # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 , and 17].

a. All 17 patients were exposed to potential airborne illnesses carried by dust;

b. 10 of the 17 patients had documented respiratory failure/respiratory issues ( Patient ID # 1, 3, 4, 6, 7, 10, 14, 15, 16, and 17]

c. All 17 patients were exposed to patient care equipment that was dusty, dirty, and unclean.


Findings:

Facility Policy:

Review of facility policy titled "Construction & Renovations Risk Assessment," dated 12/2/2018 showed the following:

* An 'Infection Control Pre-Construction Risk Assessment' will be initiated prior to any construction project.

* The type of construction project would be identified as: A, B, C, D; the patient risk groups would be identified ( low, medium, high, highest).

* Precautions would be selected depending on type of construction project and risk of patients.

*A meeting with infection control, contractors, and facility engineering should take place before any demolition to determine risk and controls for Class lll or Class IV.

* For Class III/ IV projects ( removing walls, sanding, replacing floor coverings, etc), along with high-risk patients: required critical barriers, negative air pressure to work area; and other actions.


Centers for Disease Control (CDC):

Review of CDC "Guidelines for Environmental Infection Control in Health-Care Facilities," dated 06-06-2003, stated "ll. Construction, renovation...E. Implement infection-control measures relevant to construction , renovation...1. before the project gets under way, perform an Infection Control Risk Assessment (ICRA) to define the scope of activity and the need for barrier measures...2. Implement infection-control measures for external demo and construction activities...establish & maintain surveillance for airborne environmental disease (e.g. aspergillosis) during construction activities.."

CDC information on fungal disease: "Aspergillus fumigatus is a fungus that can be be found in soil, decomposing plant matter, household dust, building materials, plants, food, and water. Transmission occurs through inhalation of airborne conidia. Hospital-acquired infections...may be associated with dust exposure during building renovation or construction....The incubation period for aspergillosis is unclear and likely varies depending on the dose of Aspergillus and the host immune response..."


Observations during initial facility tour with Staff F, charge nurse, on 12-10-19, between 9:30 AM and 11 AM, showed the following:

West wing: there were 20 patient rooms, 17 were occupied with patients.

Observation near the end of a patient hallway showed a large plastic sheet taped across the entire hall opening. The plastic sheeting was secured with blue "painters tape." The top right corner of the plastic sheeting was pulled away from the wall with the plastic and the blue tape lying loose. There were several other areas noted on the hallway opening in which the plastic was not secured.

During an interview at the time of observation with Staff F, charge nurse, he stated there was a renovation project going on the other side of the plastic (East wing). He said the space was being renovated to become a skilled nursing unit. There was no posting of any type of construction permit or any type of signage.


East wing:

Surveyor requested to tour the East wing with the charge nurse. Observation on the East wing on 12-10-19, at 10 A.M., showed it was unoccupied and in the process of being renovated. Observations included:

* large areas with unfinished walls & flooring;

* large amounts of dust, dirt, and construction debris noted throughout the wing;

* rooms with stacks of sinks & other fixtures;

* rooms with paint cans, saw horses, tools, and other construction materials;

* multiple ceiling tiles missing throughout the wing;

* large, open , full construction trash bins;

* two (2) workers were painting; no personal protective equipment (PPE) worn.


Continued observation showed the East wing and the West wing were laid out in a rectangular configuration with double doors separating the two wings. The patient rooms were located on the periphery of each wing. The center portion housed offices, equipment storage, mechanical rooms, and elevators /stairwells.


Observation at the end of the East wing hallway showed an open alcove between the East/West wings. Further observation showed the alcove had the following equipment stored: a mechanical bed scale; a vital sign machine, and a patient bedside table. There was a thick layer of dust on the equipment.


During an interview with Staff F, charge nurse, at the time of observation, he said, the equipment was used on current patients. He went on to say he was unsure if the infection control nurse was involved with the renovation project. Staff F said, the Safety officer made daily rounds.


On 12-12-19, at 11 AM, surveyor reviewed the architectural plans with the Maintenance Director, Staff D. He explained that some walls had been removed to make a larger dining area, medical gases and electrical wiring were reconfigured to accommodate needed firewalls, and new fire doors were added.


During an interview on 12-12-19, at 10 A.M., with Staff C, facility Safety Officer, she stated, she conducted daily life safety rounds every day. She went on to say, this did not include the required infection control components as outlined in the facility policy ( e.g. posting of IC construction permit, negative air pressure, construction barriers, etc..)

Staff C stated she was also the facility Respiratory Director. She acknowledged that the construction dust could carry airborne illnesses. It was potentially harmful to patients, particularly those with underlying respiratory issues.



Observation on 12-13-19, at 10:45 A.M., on the West wing accompanied by Staff C showed the following:

Room 320:

Room 320 (located immediately adjacent to the plastic construction barrier): thick layer of dust was discovered by finger sweep on top of room signage.

Further observation directly across the hall from room 320 showed a large glassed-in bulletin board. A thick layer of dust was discovered by finger sweep on top of the bulleting board enclosure.


Review of the clinical record of the current patient (# 17) housed in room 320 showed documented physical exam findings that included :

* acute respiratory failure likely due to congestive heart failure;

* pneumonitis with dyspnea;

* diffuse crepitation all over the lungs.


Room 301:

Room 301 (located immediately adjacent to the plastic construction barrier): thick layer of dust was discovered by a finger sweep on top of room signage.

Review of the clinical record of the current patient ( # 1) housed in room 301 showed documented physical exam findings that included :

* acute respiratory failure secondary to congestive heart failure;

* recurrent pneumonitis;

* coarse crepitations with decreased breath sounds on the right as compared to the left.



Continued observations on 12-13-19 with Staff C on the 2 occupied hallways of the West wing showed several areas with dust identified to include behind computer monitors, equipment carts, and signage posted in the hallways.


Record review on 12-10-19 of 17 current patient records showed the following:

Patient # 1: 68 year old : acute respiratory failure secondary to congestive heart failure, recurrent pneumonitis.

Patient # 3: 95 year old: worsening of shortness of breath, respiratory failure diminished aeration at bilateral lung bases, coarse crepitation all over the lungs.

Patient # 4: 68 year old: worsening of shortness of breath, respiratory failure decreased aeration at the bases (lungs) both sides with crepitation and rales.

Patient # 6: 59 year old: pulmonary embolism, congestive heart failure, bilateral lobe pneumonitis, acute respiratory failure.

Patient # 7: 84 year old: worsening shortness of breath, management of respiratory failure.

Patient # 10: 89 year old: aspiration pnemonitis, bilateral pleural effusion - decreased breath sounds bilaterally.

Patient # 14: 68 year old: acute shortness of breath and respiratory distress with progressive acute respiratory failure, rales increased over the base of the lungs, coarse rales toward the bases, decreased aeration bilateral bases.

Patient # 15: 81 year old: significant worsening of shortness of breath, pneumonitis bilaterally, rales increased over the base of the lungs, decreased aeration at the base.

Patient # 16: 78 year old: endstage Chronic Obstructive Pulmonary Disease (COPD), chronic hypoxic respiratory failure, bilateral pneumonia.

Patient # 17: 79 year old: acute respiratory failure, pneumonitis with dyspnea, diffuse crepitation all over the lungs.


During an interview on 12-13-19, at 1:30 PM, with Staff A, facility administrator, he stated the facility did not follow their policy regarding construction & renovation. The administrator stated they should have formulated an ICRA prior to construction and put the infection control measures in place.