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Based on interview and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility failed to ensure there was emergency lighting around generators at the facility located on 1087 Dennison Avenue, Second and Third Floors, Columbus, Ohio 43201; and failed to maintain the sprinkler heads and ensure the coverage of the sprinklers was not limited by supplies/shelving. This has the potential to affect all 86 patients at this facility.

Findings include:

Please refer to V710.

Based on medical record review, staff interview, and review of policy and procedures; the hospital failed to ensure the orders for restraint use to ensure the physical safety of non-violent patients were renewed according to the hospital policy. This affected one (Patient 24) out of four restrained patients reviewed at the 793 West State St. Columbus Ohio 43222 location. The patient census at this location was 16 patients. A total of seven medical records were reviewed with restraint use.

Findings include:

The hospital's policy entitled Clinical Services Policy and Procedure, Number R02-N Restraints and Seclusion was reviewed on 05/22/13 at 1:30 PM. The policy stated, "If a patient is removed from restraint before the current order expires and must be returned to restraints a new physicians order is required."

Review of the medical record for Patient 24 was completed on 05/22/13 at 10:25 AM. Patient 24 was admitted on 04/23/13 at 4:00 PM after being transferred from another hospital. Patient 24 was a 69 year old male who recently suffered a stroke and was treated for hypertensive urgency. The patient had acute-on-chronic respiratory failure and required tracheostomy placement. The patient had been placed in medical restraints on multiple dates since his admission on 04/23/13 due to pulling tracheostomy and Foley catheter. The medical record revealed on 04/25/13 at 10:45 PM a physician's verbal order was obtained by the registered nurse for bilateral wrist restraints. The medical record revealed the patient was placed in bilateral wrist restraints at 11:00 PM on 04/25/13. Further review of the medical record revealed no physician's order for restraints the morning of 04/26/13 and the nursing care plan/progress notes lacked sufficient documentation of interventions for restrained patients from 7:00 AM through 6:00 PM. Nursing documentation on the care plan indicated two hour restraint checks being conducted by nursing staff beginning at 5:00 PM on 04/26/13. The hospital failed to ensure a new physician's order was obtained for restraints at this time. This was confirmed with Staff A on 05/22/13 at 10:42 AM.

Based on observation and staff interview the facility failed to ensure the overall hospital environment was maintained in such a manner that the safety and well-being of patients was assured in regards to finding used patient care items found in a patient room identified as clean and ready to receive a new patient, three bulk food storage bins in the kitchen area being unlabeled as to the date the products were placed in the bins, and the surfaces of three of three patient cart/chairs observed were non-intact and unable to be properly disinfected. The hospital census at the time of the survey was 16 patients at the satellite location and 76 patients at the main campus.

Findings include:

On 05/22/13 at 9:30 AM, an observation was made on the long-term acute care unit of the satellite location. The empty patient room marked as "5S47" revealed an armoire with a basin full of used patient supplies apparently from the patient that previously occupied the room. On 05/22/13 at 9:30 AM, Staff A verified this finding and stated that this room had been cleaned by environmental services and was ready for a new patient. Staff A stated that the basin should not be in the armoire, he/she threw away the basin containing the used patient supplies, and called the environmental services personnel to come and clean the room again.

On 05/23/13 at 11:00 AM, an observation was made in the kitchen at the main campus location of the long term acute care unit. There were three bulk storage bins with lids, one with what appeared to be flour, one appeared to be sugar and one was marked as cornmeal. None of these bins were labeled as to the date the product was placed in the bin. On 05/23/13 at 11:00 AM, Staff C verified this finding and stated the bins should be completely cleaned out and then labeled with the product name and the date the product was placed in the bin every time they are filled.


32059

A unit tour was conducted on 2 South on 05/21/13 at 12:53 PM with the nursing manager. The medical surgical unit was a twenty five bed unit with a total active patient census of twenty two. The unit had approximately eleven patients on contact precautions due to microbial infections.

During the walk through tour of the unit, observation of the medical equipment room and the shower room revealed three large cart chairs used to transport patients that had rips and tears in the footboard with exposed foam. Interview with the nurse manager on 05/21/13 at 1:30 PM confirmed the equipment was currently being used for patient transport. The nurse manager immediately pulled the three chairs and tagged them as out of service/needing repair during the survey process.

The non-intact surfaces are a potential infection risk to patients by not being able to properly disinfect contaminated surfaces. The hospital's policy for Environmental Care Policy and Procedure, Number 254 for Defective And/Or Unsafe Equipment stated, "All equipment suspected or known to be defective shall be immediately taken out of use and reported to Materials Management. Under no circumstances is a device suspected of being defective be used. All devices shall be appropriately labeled to ensure it is not used until repaired or replaced." This policy was reviewed onsite on 05/23/13 at 1:18 PM.

Based on observation and interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 86 patients in the facility.

Findings include:

The facility located at 1087 Dennison Avenue, Second and Third Floors, Columbus, Ohio 43201 was found to not have emergency lighting around all generators. Please see K 46.

The facility failed to maintain sprinkler heads and failed to ensure the coverage of the sprinklers was not limited by supplies/shelving.
Please see K 62.