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Based on observations made during the Life Safety Code tour, staff interview, review of policy, and review of inspection records, it was determined that the facility failed to meet the provisions applicable to Hospital, 2000 edition of the Life Safety Code of the National Fire Protection Association in regard to lack of sensitivity testing of smoke detectors, location of smoke detectors, dirty sprinkler heads, failure to ensure patient room corridor doors closed and positve latch shut to resist passage of smoke and failure to ensure exit signs were visibly marked to direct occupants to the exit. The cumulative effect of these systemic practices resulted in the facility's failure to ensure the facility was safe from fire.


Findings include:

Please refer to findings at A709 for life safety code violations:

Main Building-

Please refer to K18- Corridor doors have gaps greater than 1/8 inch between door leafs.

Please refer to K47- Missing directional signs and one sign with improper direction to egress.

Please refer to K62- Dusty sprinkler heads.

Please refer to K130- Smoke detectors located near air flow device.


Offsite-

Please refer to K71- Door of laundry chute lacked key access and door to room of chute lacked a fire resistant rating and self closing device.

Based on medical record review, observation, policy review, and staff interview the facility failed to provide measures to prevent pressure sores for three of four active patients in a sample of ten patients with pressure sores (Patient #'s 1, 3, 22, and 24) and failed to change soiled gloves appropriately and according to facility policy during two of two wound care observations (Patient #'s 15 and 16).
The facility census was 96.

Findings include:

The medical record for Patient #16 was reviewed on 05/16/12. The patient was re-admitted on 05/02/12 with diagnosis which included respiratory failure and status post small bowel obstruction with surgical intervention from another acute care metropolitan hospital. The patient was re-admitted with three Stage II pressure ulcers on the buttock area (open area with top layer of skin removed). On 05/16/12 at 10:30 AM observations were made by two surveyors and Staff E of the one, open, pressure ulcer (Stage II) still remaining on the patient's buttocks. Observations of wound care to the patient's buttocks were made with Staff E (Wound care nurse) and two surveyors on 05/16/12 at 10:30 AM. Staff E was seen to apply clean gloves/hand sanitize after removing the old dressing. Staff E then proceeded to clean the patient's buttock area with normal saline solution. Staff E then proceeded to apply the clean dressing to the patient's buttocks without hand washing/sanitization or changing the gloves prior to applying the medicated dressing and protective dressing cover. Staff E did not change the gloves or perform hand washing after contact with the patient's buttock wound prior to applying the clean dressing as called for in the hospital policy.


07312


Review of the medical record for patient #1 on 5/15/12 revealed this patient was admitted to the hospital on 3/21/12. The patient was admitted with dark purple discoloration to both heels, one measuring 3 centimeters by 2 centimeters and another measuring 6 centimeters by 2.5 centimeters that was also described in the documentation as deep tissue injury. The documentation for 3/22/12 revealed the patient also had a stage III pressure sore on the right elbow measuring 0.8 centimeter by 0.6 centimeter by 0.2 centimeter. The patient's medical record contained documentation of an open area on the top of the patient's right foot on 4/12/12 measuring 5 centimeters by 2.5 centimeters by 0.2 centimeter that was caused by " probable trauma". Documentation on 3/28/12, 4/05/12 and 4/12/12 for the left heel was 3 centimeters by 2 centimeters and the right heel 6 centimeters by 2.5 centimeters.
On 4/12/12 the documentation revealed a pressure sore on the right dorsal foot that measured 5 centimeters by 2.5 centimeters by 0.2 centimeter. Documentation of the right dorsal foot on 4/26/12 measured 5 centimeters by 5 centimeters by .2 centimeter.

Further documentation dated 5/03/12 revealed a skin tear on the patient's left elbow measuring 4 centimeters by 2.5 centimeters that listed this wound as a "skin tear" The right elbow was measured as 0.5 centimeter by 0.5 centimeter on 4/05/12. Documentation dated 5/10/12 revealed a right anterior hand wound that was identified as a possible skin tear. Further documentation of the patient's open areas on the right foot were not measured and noted as being secondary to trauma. A physician's order dated 4/25/12 called for the patient's side rails to be padded. Observation on 5/15/12 at 2:00 PM with Staff F revealed the patient's bed side rails were not padded. This was confirmed by Staff F on 5/15/12 at 2:00 PM.

Review of the medical record for patient #3 on 5/15/12 revealed this patient was admitted to the hospital on 4/17/12. There were physician's orders on 4/18/12 for off loading the patient's heels at all times. A physician's order dated 4/25/12 called for the placement of a pressure relieving boot on the patient's left foot. Review of the patient's wound measurement documentation for the date of 4/25/12 revealed a purple discolored area on left heel that measured 2 centimeters by 1.5 centimeter. On the date of 5/2/11 a notation was made of the patient's right heel that was described as dark purple that listed no measurement. The last wound notation dated 5/02/12 described the patient's right and left heels as dark purple with no measurements.

Observation on 5/15/12 at 2:25 PM with Staff F revealed the patient #3' heels were resting on the bed mattress and there was no pressure relieving boot on the patient as ordered by the patient's physician. Staff F confirmed this finding and was unable to find the ordered boot in the patient's room.

Observation on 5/17/12 at 2:55 PM revealed patient #22 was lying in bed on his/her back. The patient had a MAP (Monitor Alert Protect) system attached to the patient's mattress that identified patient's skin pressure areas on a computer screen. Interview of the MAP system representative (D) revealed blue on the screen meant no pressure, green meant some pressure, yellow meant moderate pressure and red meant an excessive pressure area. The screen was red in the patient's sacral area according to the representative at this time. This system could be set at specific times for the audible alarm to sound. The representative revealed at this time the system would alarm again in one hours and 41 minutes. Review of the medical record of patient #22 revealed a physician's order to turn the patient every two hours. Interview of the representative D confirmed the alarm was set for the alarm to go off at three hours.




07973

Review of the medical record for patient #24, completed on 05/17/12, revealed the patient was admitted to the hospital on 05/14/12 with a diagnosis of status post complex bowel surgeries with peritonitis. Skin assessment using the Braden Scale, completed on 05/14/12 revealed a high risk score of ten. Physician orders of 05/14/12 included an order to turn patient every two hours, off load heels at all times, and LAL mattress with MAPPING (low air loss mattress with mapping - Monitor Alert Protect a pressure sensing mattress system).
Observations made on the second floor on 05/17/12 at approximately 1:50 PM revealed patient # 24 in bed with a low air loss mattress and the MAPPING system in place. The alarm announcing need to turn patient was sounding. Two staff members repositioned the patient, however, three areas of red indicating continued high pressure remained. The surveyor pointed out to the nurse techs that the patient's heels were resting on the pillows and the techs then repositioned the heels off the pillow before leaving the room. The surveyor pointed out to nurse (I) and the MAPPING representative that the patient's MAPPING monitor continued to show red areas of "high pressure," after the nurse techs had repositioned the patient and reset the two hour turning monitor. Nurse I and the MAPPING representative then repositioned the patient until green indicator lights showed on the monitor and no red remained. Interview of a nurse tech (J) on 05/17/12 at 1:30 PM revealed that the MAPPING system seems like a good thing, but there are three on the floor today that don't work. Interview of the MAPPING representative revealed that although the hospital began using the system in late January 2012, bugs are still being worked out.


31007

Review of medical record for patient #15 completed on 05/16/12 at 4:00 PM with an admit date of 04/24/12 and a diagnosis of Respiratory Failure revealed an order for daily dressing changes of upper right quadrant surgical wound.
Per observation of Staff E completing the dressing change for Pt. #15 completed on 05/16/12 between 10:20 AM and 10:35 AM, Staff E cleansed hands with alcohol based sanitizer, donned gloves and placed supplies on bedside table. Staff E then removed old soiled dressing from upper right quadrant of the abdomen and disposed of it properly. Staff E then removed gloves, cleansed hands, and donned new gloves. Staff E then cleansed the wound with normal saline, wiped dry with gauze and disposed of gauze properly. The nurse then proceeded to applied Matrix to wound bed, covered with ABD and secured with paper adhesive tape without cleansing hands again and darning new gloves.
Review of Policy: IC III-2 hand hygiene given to surveyor on 05/17/12 at 9:05 AM revealed staff is to wash their hands after any contact with body fluids, dressings, and patient linens. This was verified by staff B on 05/17/12 at 9:05 AM.

Based on observations made during the Life Safety Code tour, staff interview, review of policy, and review of inspection records, it was determined that the facility failed to meet the provisions applicable to Hospital, 2000 edition of the Life Safety Code of the National Fire Protection Association.

Findings include:

Main Building-

Please refer to K18- Corridor doors have gaps greater than 1/8 inch between door leafs.

Please refer to K47- Missing directional signs and one sign with improper direction to egress.

Please refer to K62- Dusty sprinkler heads.

Please refer to K130- Smoke detectors located near air flow device.


Offsite-

Please refer to K71- Door of laundry chute lacked key access and door to room of chute lacked a fire resistant rating and self closing device.