HospitalInspections.org

Based on staff interview, review of menus and the nutrient analysis of menus, it was determined that the Food and Nutrition Department did not ensure that the physician prescribed diets met the therapeutic needs of patients.

Findings include:

A review on 05/06/15 of the hospital three (3) week cycle menus noted the following diets: Regular, 2 gram sodium, 1500 calorie diet, Pediatric, Low/fat/Low Cholesterol, Renal, Modified Regular, Chopped and Pureed. Review of the Patient Menu Analysis for the three (3) cycles revealed that nutrient was calculated for an un-named 1800-2200 calorie diet and not for any of the diets listed on the three week cycle menus or listed in the diet manual available for physicians/practitioner(s) to order.

Therefore the nutrition adequacy and dietary restrictions on the menu is unknown. Due to lack of nutrient analysis calculated for these menus, there is no way to verify that the diet orders are provided as prescribed by the practitioner(s) responsible for the care of the patient.

During interview on 05/07/15, these findings were confirmed with the Clinical Nutrition Director.

Based on observations and staff interview, the facility failed to maintain the physical plant in a manner to provide a safe and sanitary environment of patients.

Findings include:

(1) During the tour of the Emergency Department (ED) on 05/04/15 at approximately 12:00 noon, the following was noted:

(a) Two ceiling tiles in the passage way outside the glass walled treatment rooms were observed to have dark brown stains . Concurrent interviews with facility staff revealed that roof of this one-storey building has been leaking for over a year and that the facility has not been able to ascertain the cause of leaks.

(b) During the tour of the ED waiting room, it was observed that the 2 duplex outlets were not of tamper-resistant type. Concurrent interviews with facility staff confirmed that the facility was providing emergency services to pediatric and adult patients.

(c) The use of power strips were observed at the security desk and in the patient registration office, connecting computer monitors to the counsel.

(d)Observations made in the isolation Room #14 revealed the the facility did not install cleanable and washable ceiling tiles in the isolation room.

(2) During the tour of the operating room (OR) suite on 05/04/15 at approximately 10:00 AM, the following was noted:

(a) The electrical closet outside the sterile corridor was being used for storing old and unused equipment, and supplies.

(b) During tour of OR #4 it was observed that the cove molding of the floor was cracked and the seamless floor had open seams.

(c) The ceiling tiles in the sterile corridor were not cleanable and washable tile. Observations revealed reddish brown stained ceiling tile in OR #3. The operating room was already cleaned and prepared to receive a patient for surgery. Concurrent interview with the Director of Facility Management revealed that the ceiling was not monolithic and the tiles were not of cleanable and washable type.

(d) During the tour of the OR #4, it was observed that the facility was using power strips to connect the anesthesia equipment and the monitor. Interview with the Director Of Facility Management revealed that the facility had power strips in all the Operating Rooms and in other various areas of the hospital.

(3) During the tour of the kitchen on 05/06/15 at approximately 12:00 noon, the following were noted:

(a) The three(3) food preparation sinks (dairy, salad prep and meat side) did not have indirect drain with an air gap of at least one inch. The plumbing design for these drain lines were such that the drain was directly plumed to the main drain or had less than one inch gap between the drain line and the main drain. The air gap is required to prevent back-flow.

(b) During the tour of the kitchen, it was noted that the ceiling of the kitchen was not monolithic and consisted of metal tiles with holes. Ceiling of a kitchen must be of a cleanable and washable type and also must be of the type that would prevent the collection of dust and the growth of microbes.

(c) During the tour of the kitchen, standing fans were observed in operation in the food preparation areas. Concurrent interviews with the kitchen staff and the Director of Facility Management revealed that HVAC system for the kitchen was inadequate, making the kitchen very hot during hours of operation.

(4) During the tour of the Post Anesthesia Care Unit (PACU) on 05/05/15 at approximately 12:00 noon, it was noted that the soiled Utility room inside the PACU did not have negative air pressure in relation to the room. The soiled utility room did not have a mechanical exhaust in the room.

(5) During tour of the facility, observations and staff interviews revealed that the facility failed to ensure that the Medical Gas System consisted of all the required components and that it was fully operational without having two OR medical gas pipelines being interconnected. Specific reference is made to the fact that the facility failed to install the Waste Anesthetic Gas Disposal (WAGD) inlet in the Operating Rooms and in the two endoscopy procedure rooms. In addition, the facility failed to monitor the abnormal alarm signal on the Medical Gas Master Alarm panel installed in the boiler room.
Refer to K0140.

Therefore, it was determined that the facility failed to ensure an environment that is free of all hazards for safe medical care of patients.

Based on observations and staff interview, the facility failed to ensure that all essential equipment in the facility were serviced by emergency power.

Findings include:

During the tour of the Hospital's Laboratory suite on 05/11/15 at approximately 10:00 AM, it was observed that the Laboratory did not have any electrical outlets that were powered from the generator. It was also noted that all essential equipment used for laboratory testing, such as, the hematology analyzer and urine analyzer, were not connected to the electrical outlets that were powered by the emergency generator.

Interview with the Director of Facility Management on 05/11/15 at approximately 11:30 AM, it was revealed that the facility was aware of the issue and was in the process of providing emergency power to the Laboratory suite.

In addition, based on observation, documentation (i.e., Panel Board Schedule) review and interview, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. This was noted throughout the facility.
Refer to K145.

Therefore, the facility failed to ensure the proper functioning of all essential systems required for safe care in the event, a loss of normal power occurs.

Based on observation and staff interview, the facility failed to comply with all provisions of Life Safety Code as recommended in NFPA 101 2000 Edition.

Findings include:

Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).
Refer to K0018.

Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.3 requires that there is no impediment to the closing of corridor doors in New Health Care Occupancies. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the Anesthesia storage room of the operating suite.
Refer to K0018.

Based on observation and interview, the facility failed to ensure that the enclosure for the staircase in the basement leading to the Central Sterile was provided with a two (2) hour fire barrier.
Refer to K0020.

Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in smoke barrier walls on the 3rd floor of Brigger, basements of Brigger and Minkin buildings. Conditions observed were unsealed penetrations around wires and conduits, cut holes, and improperly sealed and unfinished wall assemblies.
Refer to K0025.

Based on observation and interview, the facility failed to ensure that all door openings from Fire barrier were protected by self-closing, positive latching doors.
Refer to K0029.

Based on observation and interview, the facility failed to ensure that all sprinkler control valves were electronically supervised to sound an alarm at a continuously monitored location. This was evidenced by electronic supervisory devices noted not being provided on sprinkler control valves in-line of a sprinkler pipe located in the stairwell landing of Brigger basement. Refer to K0061.

Based on observation, interview and documentation review, the facility failed to ensure that the required monthly inspections of the Dry Chemical Extinguishing System installed in the trailer CAT Scan room are performed.
Refer to K0069.

Based on observation, documentation (i.e., Panel Board Schedule) review and interview, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. This was noted throughout the facility.
Refer to K147.

Therefore, the facility failed to ensure a safe environment, free of fire safety hazards for patients and staff.

Based on observation and staff interview, the facility failed to ensure that the bronchoscopy procedures were performed in clean and sterile environment.

Findings include:

During the tour of the colonoscopy/endoscopy suite on 05/05/15 at approximately 12:30 PM, it was revealed that the facility staff performed bronchoscopy procedures in Colonoscopy/ Endoscopy procedure room #2. Observations made in Room #2 revealed that this room did not have a sterile environment, in that there was a cubicle curtain installed, a work area for staff with a computer on a desk, and open storage of clean supplies and other materials. In addition the room did not have a seamless floor and the ceiling tiles were not of a cleanable and washable type.

Bronchoscopy procedures are deemed to be sterile procedures and infection control practices for droplet precautions must be adhered to in order to prevent cross-contamination.

Therefore, it was determined that the facility exposed the patients to risks of infections by failing to adhere to adequate infection control precautions, by performing sterile procedures in a non-sterile environment.