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Based on observation, interview, and documentation review, the facility failed to ensure cooking facilities were closed to the corridor, ensure monthly fire alarm testing included transmission and receipt of the signal by the supervising station within 90 seconds of fire alarm actuation, ensure smoke detection was installed in all areas open to the corridor, ensure fire hydrants connected to the facility's private fire line were tested and maintained annually, ensure forward flow testing was performed on the facility's fire line backflow device annually, ensure testing of the retention force of the grounding blade of all receptacles at patient bed locations, ensure power strips and flexible power cords were used properly(A709) and failed to maintain a policy regarding out of service sprinkler system that included notification of the insurance carrier and all authorities having jurisdiction other than the fire department (A717). This has the potential to affect all patients receiving services from the facility. The facility census was 21.

Based on observation, record review and staff interviews the facility failed to provide documentation the facility's negative pressure rooms used for prevention of the spread of respiratory illness were monitored and maintained in working order, failed to develop testing protocols and acceptable ranges for control measures to avoid the transmission of and exposure to Legionella in all areas identified in its policy for the water management program and failed to ensure staff followed policy and procedures for wound management. (A 0749) The cumulative effect of these systemic problems resulted in the facility's inability to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility census was 21.

Based on document review and interviews the facility failed to ensure patients were given contact information for the state agency in order to file a complaint or grievance. This finding had the potential to affect all patients receiving services at this facility. The facility census was 21.

Findings include:

Review of the facility's patient admission documents revealed an information folder that included the Patient Rights and responsibilities along with information related to Complaints and Grievances. The documents failed to provide patients with the Ohio Department of Health toll free complaint hotline number or agency address.

Interview with Patient #7 on 04/24/19 at 9:45 AM revealed they were unaware of the state's complaint hotline number but was interested in having the contact information.

Interview with Staff A on 04/24/19 at 4:10 PM confirmed the facility had failed to provide patients with the required Ohio Department of Health toll free complaint hotline number or address.

Based on document and policy review and interview, the facility failed to take preventive actions and implement mechanisms to reduce automated medication dispenser overrides that go against facility policy. The facility census was 21.

Findings include:

On 04/23/19 a review of the overrides to the automated medication dispenser to retrieve medications revealed the machine was overridden 14 times in January, 15 times in February, and 23 times in March. The override was medications that included insulin, narcotics, valium, and blood pressure medications. The reasons included "not loaded," "new order" and "per MAR."

A review of the facility's "automated dispensing cabinets" policy was completed on 04/22/19. The review revealed, "Overrides are not permitted as a convenience or to expedite availability of medication to a patient, but only in a truly emergent clinical crisis."

A review of the facility's medication variances (errors) policy was completed on 04/22/19. The review revealed a medication order includes those of omission, ie not administered before next scheduled dose due.

On 04/22/19 at 4:35 PM in an interview, Staff H confirmed the automated medication dispenser can be overridden for reasons other than a "truly emergent clinical crisis" and that those reasons include if the order is new or if the patient is new and it is after hours, ie in the evening and at night. She explained in the off hours nurses fax over the orders to an off site pharmacist, who reviews the order, and then electronically activates it in the facility's automated medication dispenser. She explained this sometimes takes awhile.

On 04/22/19 at 4:35 PM both Staff A and H confirmed the night nurse is confronted with a decision to override the automated medication dispenser, or allow a medication error to occur because too much time has elapsed because the off site pharmacist took too long to review the order.

Based on record review and staff interview the facility failed to provide care as ordered by the physician. This finding affected four patients (Patients #11, 15, #17, and #24 ) of 30 reviewed for compliance with physician orders. The facility census was 21.

Finding include:

Review of the facility's policy and procedures titled "Plan of Care-Individualized and Interdisciplinary" with a most recent review date of 01/2019 directed that each patient's individualized and interdisciplinary plan of care is appropriate to the patient's individualized assessed needs, strengths, limitations and goals. The care and treatment are provided according to the plan by an interdisciplinary team, led by a physician. Item lettered V directed care and services are provided to meet the needs of the patient, either through internal or external resources or through external resources under contractual arrangements.

1. Patient #15 was admitted to the facility on 04/12/19 with diagnoses which included traumatic brain injury, history of a recent fall with heamtoma to left scalp (bleeding into tissue), subarchnoid bleed and history of a right fractured ulna ( right arm). Patient #15 physician's order from admission on 04/12/19 directed the right upper arm splint was to be maintained until follow up. Review of the Treatment Administration Record (TAR) and medical record failed to record any monitoring that the splint was maintained per physician's orders.

This finding was confirmed on 04/24/19 at 8:49 AM with Staff C.

2. Patient #24 was admitted to the facility on 04/23/19 with diagnoses which included history of a recent cerebral accident. The medical record revealed the patient had an open blister on the right shin. A physician's order date 04/24/19 at 10:30 AM directed staff to apply A&D ointment to both patient's legs daily.

The Treatment Administration Record (TAR) and medical record review lacked evidence that the ointment was applied per physician's orders.

This finding was confirmed on 04/25/19 at 11:31 AM with Staff B.



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3. On 04/24/19 a review of Patient #11's medical record was completed on 04/24/19. The review revealed the patient was admitted to the facility for physical rehabilitation following a laminectomy. On 04/08/19 the patient was ordered blood work on 04/08/19. The medical record review revealed blood was collected on 04/08/19, 04/15/19 and 04/22/19.

On 04/24/19 at 1:30 PM in an interview, Staff G confirmed the lack of order for blood work on 04/15/19 and 04/22/19.



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4. On 04/25/19 between 10:00 AM and 12:00 PM, a medical record review was conducted with Staff B for Patient #17. The patient had physician orders for bilateral heelers (boots) in bed and a left hand splint at all times. The nursing notes and treatment administration record lacked evidence that the heeler boots and left hand splints were in place as ordered on the day shifts of 04/10/19 and 04/18/19.

This finding was confirmed with Staff B during the medical record review.

Based on record review and staff interview the facility failed to update the patient's plan of care for one of 30 patients reviewed. The facility census was 21.

Findings include:

On 04/25/19 at 9:45 AM a medical record review was completed for Patient #16. This review revealed on 02/16/19 the patient's physician ordered bilateral TED Hose (compression stockings used to prevent blood clots) to be worn during the day and off at bedtime. Per care plan review, the care plan was not updated for the TED hose.

This finding was confirmed with Staff B at the time of the record review.

Based on record review and staff interview the facility failed to administer medications in accordance with physician orders or to notify physicians of refusals of medications by patients. This finding affected five patients (Patients #6, # 7, #9, #14 and #24) of 30 reviewed for medication administration compliance. The facility census was 21.

Findings include:

Review of the facility's policy and procedure titled "Electronic Medication Administration" (eMAR) with a most recent review date of 01/2019 directed that drugs were to be administered were compared the eMAR to ensure that the dose and label are correct and that the drug is not contraindicated by allergy, sensitivity or diagnosis. Before any administration of of any drugs, the five rights should be reviewed: the right patient, the right drug, the right dose, the right route, and the right time.

1. Review of the medical record revealed Patient #24 was admitted to the facility with diagnoses which included history of a cardiac vascular accident on 04/23/19. Review of the patient's medication reconciliation form revealed the physician ordered Patient #24 to have acetaminophen 500 milligram every four hours as needed for a pain level between 1 and 5, and also provided an order for Tramadol 50 milligram ( a synthetic opiate narcotic medication) every six hours as needed for pain levels of 6-10.

Review of the electronic Medication Administration Record (MAR) dated 04/25/19 at 6:17 AM revealed Patient #24 complained of back pain at a pain level of "5" on the facility's pain scale. The MAR revealed the nurse administered Tramadol and not acetaminophen per the physician's order.

This finidng was confirmed in interview with Staff C on 04/25/19 at 1:47 PM.


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2. On 04/24/19 a review of Patient #9's medical record was completed. The review revealed the patient was admitted to the facility on 04/09/19 with diagnoses of diabetes mellitus, coronary artery disease, and liver disease. The medical record review revealed on 04/17/19 at 5:30 PM the patient's blood sugar was 58 milligrams/dl. The medical record review revealed oral glucose was given.

The medical record review did not reveal the physician was notified of the low blood sugar.

Further review revealed a physician's order dated 04/09/19 at 8:45 PM that stated if the blood sugar was below 70 milligrams/dl to give oral glucose and notify the physician and request new insulin orders.

On 04/17/19 at 9:30 PM the patient's blood sugar was 167 milligrams/dl and the patient was given four units of rapid acting sliding scale insulin.

On 04/24/19 at 11:36 AM in an interview, Staff G confirmed the physician had not been notified.

3. On 04/24/19 a medical record review for Patient #14 was completed. The review revealed the patient was admitted to the facility on 04/15/19 with a diagnosis of heart bypass surgery with aortic valve replacement, congestive heart failure, and type two diabetes mellitus.

The record revealed a physician's order dated 04/15/19 at 3:30 PM that stated to give a rapid acting sliding scale insulin at meals.

On 04/15/19 at 10:54 PM the patient was given six units rapid acting insulin.

On 04/18/19 at 9:49 PM the patient was given two units rapid acting insulin.

On 04/20/19 at 10:18 PM the patient was given two units rapid acting insulin.

On 04/21/19 at 9:40 PM the patient was given four units rapid acting insulin.

On 04/24/19 at 3:00 PM in an interview, Staff G confirmed the order was to give insulin at meals.


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4. On 04/24/19 between 2:00 PM and 4:00 PM a medical record review was conducted with Staff B for Patient#7.

An interview and the medication administration record review was conducted on the same date at 4:04 PM with registered nurse Staff F. Staff C was present during the record review and interview with Staff F.

Per the medication administration record (MAR), Patient #7 refused a constipation medication which had been ordered by the physician for one time a day (Miralax). The refusal dates were 04/22/19, 04/23/19 and 04/24/19. Staff F stated when the patient refuses a medication ordered by the physician, the staff nurse will report the refusal to the charge nurse, who will notify the physician.

Staff F confirmed the medical record lacked evidence of notification of the charge nurse and physician of the patient's refusal of this medication.

5. On 04/24/19 between 2:00 PM and 4:00 PM Patient #6's medical record including the medication administration record was reviewed with Staff B. There was a physician's order for a respiratory inhaler (Advair Diskus) one puff a day at 10:00 AM and 10:00 PM.

Per documentation review, this medication was refused by the patient on 04/2219 at 9:29 AM.

The physician ordered an anticoagulant injection medication (Heparin 50,000 units) to be given daily at 6:00 AM. Per the MAR review, the patient refused the Heparin injection on 04/20/19. The medical record lacked evidence of notification of the charge nurse and physician for this rejection of medication.

This finding was confirmed with Staff F during record review on 04/24/19 at 4:16 PM.

Based on observation, interview and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients receiving services from the facility. The facility census was 21.

Findings include:

1. Please see K324 for findings related to the facility failing to ensure a cooking facility was closed to the corridor.

2. Please see K345 for findings related to the facility failing to ensure monthly testing of signal transmission to the supervising station within 90 seconds of fire alarm actuation.

3. Please see K347 for findings related to the facility failing to ensure areas open to the corridor were equipped with smoke detectors.

4. Please see K353 for findings related to the facility failing to ensure the backflow preventer installed on the fire protection water line was tested annually and private fire hydrants were tested and maintained annually.

5. Please see K914 for findings related to the facility failing to ensure all receptacles at patient bed locations have been tested.

6. Please see K920 for findings related to the improper use of power strips and flexible power cords.

Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients receiving services from the facility. The facility census was 21.

Findings include:

Please see K354 for findings related to the facility failing to provide a policy that addressed all reporting requirements when the sprinkler system was out of service;

Based on observation, record review and staff interviews the facility failed to provide documentation the facility's negative pressure rooms used for prevention of the spread of respiratory illness were monitored and maintained in working order, failed to ensure testing protocols and acceptable ranges were developed for control measures to avoid the transmission of and exposure to Legionella in all areas identified in its policy for the water management program and failed to ensure staff followed policy and procedures for wound management for one of one patients (Patient #9) observed for wound care. These findings had the potential to affect all patients receiving services at the hospital. The facility census was 21.

Findings include:

1. Review of the facility's policy and procedure titled "Hospital Wide Infection Control Program - Healthcare Associated Infections" with a most recent review date of 2/2018 under the section titled "Implementation of the Infection Control Plan", directed that infection prevention collaborated with medical staff, nursing, infection control nurse, laboratory, environmental services, maintenance, engineering, central supply, pharmacy, food and nutrition, laundry, employee health, education departments and others to: Maintain safe air handling systems in areas of special ventilation, such as airborne infection isolation rooms.

On 04/25./19 at 3:00 PM Staff D identified the facility has three negative pressure rooms which could be used for patients who had infectious airborne illnesses. Tour of the facility on 04/24/19 between 9:00 AM and 11:00 AM revealed a monitoring device located on the outside of one of the negative pressure rooms on the first floor. Staff D stated this was a monitoring device with a built in alarm which would alert staff to issues with the negative pressure of these rooms. When asked to provide documentation of routine testing and monitoring of the ventilation system in these rooms to ensure they were working properly, Staff D stated the Plant Operations employee was responsible for this monitoring. However, at the time of the exit on 04/25/19, there was no documented evidence of testing of the negative pressure rooms.

2. A review of the Water Management Program was completed on 04/23/19. The review revealed the facility is to decide where control measures should be applied, how to monitor them, and establish ways to intervene when control limits are not met.

A review of the facility's policy, "Legionella and Other Water-Born Pathogen Management Program," effective July, 2018, was completed on 04/23/19. The review revealed hot and cold water storage were described as associated hazardous events, as well as plumbing with dead ends. The facility's water management program did not include these and did not describe what the control measures for them were, what was abnormal, how to intervene when they were abnormal, and who was responsible for all of it.

On 04/23/19 at 2:50 PM in an interview, Staff A and B could not explain what the control measures were, where they were, what is normal, how to intervene when they were abnormal, and who was responsible for doing what. Staff A explained an individual would arrive on 04/24/19 with that information.

On 04/24/19 at 4:55 PM Staff A stated the facility did not have that information.

3. Review of the facility's competency checklist for wound dressing change for clean procedures (undated) directed at item #7 that staff were to use clean gloves, followed by Item #8 which directed staff to remove soiled dressing and gloves were to be discarded, and followed with re-gloving with clean gloves.

Observation of wound care on 04/22/19 at 1:45 PM revealed Staff Z providing wound care to Patient #9's sacral area (lower portion of the spine close to buttocks). Staff Z performed hand hygiene and donned clean gloves and proceeded to remove the dressing covering Patient #9's sacral area. Staff Z disposed of the soiled dressing and without removal of the contaminated gloves and without performance of hand hygiene proceeded to clean the wound with normal sterile saline followed by pat to dry with four by four gauze. Staff completed the dressing change per policy however, Staff Z was then observed to use her contaminated gloved hands to reach into the pocket of her scrub uniform top and retrieve a pen to label the dressing, Staff Z completed labeling the dressing and again with the soiled gloves returned the pen to her uniform scrub top pocket.

Interview with Staff B on 04/22/19 at 3:58 PM confirmed that per facility skill competency list Staff Z should have changed gloves and performed hand hygiene and re-gloved with clean gloves prior to cleansing Patient #9's wound.




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Base on interview and document review, the facility failed to ensure its contract with an organ procurement organization authorized the omission of privileging and credentialing for members of the team, and agreement between it and the organ procurement organization on the definitions of dead or death and imminent death. The facility census was 21.

Findings include:

On 04/23/19 a review of the facility's contract with an organ procurement organization was completed on 04/23/19. A review of the facility's organ procurement policy was completed on 04/23/19. The reviews revealed the definitions for death and imminent death were incongruent.

The review of the contract revealed dead or death was a "patient who has been pronounced dead by cardiopulmonary criteria or due to loss of all functions of the brain, including the brain stem."

The review of the facility policy does not speak to the brain, and reads, "Death occurs upon loss of blood pressure, cessation of pulse and cessation of respiration."

The review of the contract revealed imminent death was defined as "patients, who are severely brain injured, ventilator dependent and have lost brain stem reflexes that may or may not have a plan in place to discontinue mechanical/pharmacological support."

The review of the facility policy revealed imminent death as "physician has determined that death is imminent as evidenced by unstable blood pressure, cessation of pulse and cessation of respiration."

The review of the contract did not reveal language that the hospital is not required to perform credentialing reviews for, or grant privileges to, members of organ recovery teams as long as the OPO send only "qualified, trained individuals" to perform organ recovery.

The review of the medical staff bylaws also did not include language that members of the organ recovery teams are not required to undergo credentialing and privileging reviews.

On 04/23/19 at 10:47 AM in an interview Staff A confirmed the incongruence with definitions for death and imminent death as well as having members of the organ recovery team not being required to undergo credentialing and privileging reviews.