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Based on observation and staff interview, the facility failed to ensure the rights of the patients are met.

Findings Include:

Observation during the tour of the Emergency Department(ED) on 04/23/18 at 11:00 a.m. revealed the ED had six (6) exam rooms. None of the exam rooms had an emergency call system.

At 11:15 a.m. the ED Manager confirmed none of the ED rooms had call lights. When asked how do the patients call if needed, the ED Manager stated, "The nursing desk is not far away and we can hear them if they call."

Observation of the Surgery Department made with the ED Manager on 04/26/18 at 12:25 p.m. revealed the pre-operative area and the post-operative area did not have an emergency call system.

During an interview on 04/26/18 at 1:30 p.m. the Hospital Administrator confirmed the ED and the Surgery Department did not have an emergency call system.

No other information was submitted at the Exit Conference on 04/25/2018.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the hospital environment was constructed, arranged, and maintained to ensure the safety of the patients on three (3) of three (3) days of survey.

Findings Include:

On 4/24/2018 observation of the Medical/Surgical floor from 11:41 a.m. to 12:20 p.m. revealed:

Room #106 had peeling paint on the walls above patient beds.
Room #109 had peeling paint above the entrance to the bathroom.
Room #112 had peeling paint above the door.
Room #113 had peeling paint above the door.
Room #114 had paint cracking on the walls.
Room #115 had peeling paint above the entrance to the bathroom door and walls.
Room # 116 had peeling paint above the entrance to the bathroom.

On the Senior Care Unit:
Room #120 had a ceiling tile which needed replacing
Room #124 had peeling paint on the walls and above the entrance to the bathroom.
Room #126 had paint cracking on the wall by the air condition unit.
Room #128 had paint peeling above the entrance to the bathroom, the walls and a ceiling tile needed replacing.
Room #130 had paint peeling and cracking behind patient beds.

At 1:01 p.m. requested policy and procedures on maintenance services and any requests on rooms that needed painting.

During an interview on 4/24/2018 at 1:01 p.m. the Administrator was asked for policy and procedures on maintenance services and any requests on rooms that needed painting. The Administrator stated, "I have a list that I sent to maintenance with the work that needs to be done. I will get that for you. We just painted, but it's started to peel."

On 4/25/18 at 9:00 a.m. a maintenance policy and a list of maintenance issues were received. The rooms that needed to be repainted were not on that list.


33119


Refer to K-221- The facility failed to properly maintain patient sleeping room doors as directed by NFPA Chapter 19 2.2.2.5. This condition practice affected the entire facility on the day of survey.

Refer to K-251- The facility failed to properly maintain exit discharge as per NFPA 19.2.5.2. This condition affected one (1) of eight (8) exits in the facility on the day of survey.

Refer to K-271- The facility failed to properly maintain exit egress as per S&C letter 05-38.
This condition affected five (5) of eight (8) exits in the facility on the day of survey.

Based on observation, staff interview, and document review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings Include:

Observation during a tour of the Emergency Department (ED) on 04/23/18 at 11:00 a.m. and the Surgery Department on 04/23/18 at 12:25 p.m. revealed the oxygen receptacles in all of the rooms had a nipple nut adapter (Christmas Tree) attached. The ED Manager confirmed these findings during the observations.

On 4/23/18 at 12:45 p.m. the Respiratory Manager confirmed all the rooms had Christmas Trees attached to the oxygen receptacles. When she was asked if the Christmas Trees were single use, she stated she was not sure.

Review of the package insert for the Christmas Tree confirmed they are for single usage.

Based on record review, staff interview, and policy and procedure review, the facility failed to notify the Organ Procurement Organization (OPO) in a timely manner of individuals whose death was imminent or who had died in the hospital. One (1) patient (in November 2017) out of the last 12 months was affected.

Findings Include:

Review of the facility's "Death Notification Report" from the OPO from the last 12 months (April 2017 through March 2018) revealed the facility had one untimely patient death referral in November of 2017.

During an interview on 04/25/18 at 9:45 a.m. the Chief Executive Officer (CEO) confirmed the facility was late in calling in one (1) patient death to the OPO, in November of 2017.

Review of the facility's "Tissue/Eye/Organ Donation" policy revealed: "Purpose: To establish a policy in accordance with state and federal law, which outlines the process and provides a mechanism by which families of deceased patients are routinely offered the opportunity to authorize tissue donation. The policy will provide a formal mechanism by which the health care providers can initiate the process of donation. Definitions:..2. Routine Referral - On every death regardless of age or disease, call the 24 hour referral number. Policy: It is the policy of North Oak Regional Medical Center to make a routine referral call on every death within one hour of death ...".

Based on observation and staff interview, the facility failed to ensure the patient's right to receive care in a safe setting.

Findings Include:

Cross Refer to A-0115 for the facility's failure to ensure the patients receive care in a safe setting.

Based on record review, staff interview, and Policy and Procedure review, the facility failed to ensure all orders, including verbal orders, were authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient, for three (3) of 30 patient medical records reviewed. (Patients #15, #16 and #29)

Findings Include:

Medical record review revealed three (3) patient medical records had telephone orders which had not been signed by the ordering practitioner or by another practitioner who is responsible for the care of the patient. Patient #15 had a telephone order, dated April 17, 2018; Patient #16 had a telephone order dated April 18, 2018; and Patient #29 had telephone order dated March 29, 2018.

During an interview on 04/25/18 at 10:00 a.m. the Chief Operations Officer confirmed these findings.

Review of the facility's "Medical Orders" Policy revealed: "Purpose: 1. To reduce errors in association with misinterpreted verbal/telephone orders. 2. To ensure the safety of the client, the institution, and the nurse delivering care. Policy:..2. Verbal/telephone orders shall be processed in accordance with Medical Staff Rules and Regulations ...Procedure:..6. The order must be signed by the appropriate physician within 24 hours of giving the order ...".

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the hospital environment was maintained and safe for patients on three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0700 for the facility's failure to ensure the hospital environment is maintained and safe for patients.

Based on observation, staff interview, and policy review, the facility
1. failed to avoid possible transmissions of infections and communicable diseases by using a biohazard waste receptacle as a table top for storage of non-latex exam gloves and a container of germicidal cleaning wipes in Operating Room #2 on one (1) of three (3) days of survey; and
2. failed to avoid the possible transmission of surgery-related infections during endoscopic procedures during one (1) of three (3) days of survey.

Findings Include:

Observation during operating room tour on 4/24/2018 at 7:30 a.m. revealed two (2) open boxes of non-latex exam gloves and an open container of Super Sani-Cloth Germicidal Disposable wipes which were stored on top of a large red plastic biohazard container in Operating Room (OR) #2. During the observation an OR staff member moved a box of open gloves off the lid of the biohazard container, discarded some materials, closed the lid and placed the box of gloves back on top of the biohazard container. Interview with an OR nurse and a surgical technician at 7:40 a.m. confirmed that the two open boxes of gloves and the container of germicidal wipes were currently used in OR #2. The OR Nurse stated, "We've always stored our gloves and wipes here. I will remove them right now."

On 4/24/2018 at 12:30 p.m. observation revealed an endoscope, which had been cleaned earlier that morning, in the decontamination room (dirty room) hanging on an endoscope rack near a sink which is used for washing dirty endoscopes and dirty surgical instruments. Interview with the surgical technician at 12:35 p.m. revealed that after the clean endoscopes are removed from the washer, they are hung on the endoscope rack near the sink in the decontamination room until dry. Once the scopes are dry, they are moved to a clean endoscope cabinet. Interview with the OR Nurse at 12:37 p.m. revealed, "The endoscope currently hanging on the rack in the dirty room will be re-cleaned and that from now on all clean endoscopes will be hung in a designated clean area for drying."

During interview on 4/24/2018 at 1:50 p.m. the Chief Executive Officer (CEO) these findings were discussed. The CEO stated, "I will make sure that is take care of immediately." All policies that addressed the storage of clean supplies were requested, but were not received by the end of survey.


Review of the facility's "Cleaning of Endoscopy Scopes At Point of Care" policy (approved 6/2/2017) revealed: " ...9) Clean scope per endoscopy cleaning policy.

Review of the facility's "Separation of Clean and Dirty Areas" policy revealed, "...Trays and other items that have been washed are to be laced in the sink in surgery dirty utility room where re-washed and pushed thru the window into Central Sterile ... ...All areas in Central Sterile are CLEAN areas. Only instruments that are clean/sterile shall be located and stored in Central Sterile ....Soiled / Contaminated items shall be handled in surgery dirty utility room ...."

Review of the facility's "Universal Precautions" policy revealed, "...C. Medical Devices or instruments that require sterilization or disinfection should be thoroughly cleaned before being exposed to the germicide, and the manufacturer's instructions for the use of the germicide should be followed ...."

At the exit interview on 4/26/2018 at 11:30 a.m. no additional information was submitted.

Based on observation, staff interview, and policy review, the facility failed to follow their policies and procedures governing surgical care to assure the achievement and maintenance of high standards of medical practice and patient care.

Findings Include:

Cross Refer to A748 for the facility's failure to follow their policies and procedures governing surgical care to assure the achievement and maintenance of high standards of medical practice and patient care.