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Based on observation, staff interview and review of maintenance records between 5/11-5/15/2009, the facility failed to construct, install, and maintain the building system due to (i) lack of positive latching hardware on exit access corridor doors; (ii) one corridor not kept clear and unobstructed; (iii) lack of proper maintenance on automatic, supervised sprinkler system; (iv) two trash receptacles not stored in a room protected as a hazardous area; (v) six compressed gas oxygen cylinders not properly stored in an enclosure; and (vi) lack of required negative/positive pressure in four spaces, and lack of clean ceiling plenum in one location.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to K-tags: K-18, K-39, K-62, K-75, K-76, and A-tags A-701 and A-710

Based on review of the facility's Pt.s Rights and Responsibilities information (1 of 1 document) , policy and procedure review, and staff interview, this facility fails to inform Pt.s, families, and visitors of their right to contact the State Agency (SA) with any grievance they might have.

Findings include:

The facility's policy titled, "Patient Complaint/Grievance Process," dated 12/2008, was reviewed on 7/26/2011 at 1:40 p.m. by Surveyor #26711. The policy does not include the SA contact information (address and phone number) for grievance reporting.

In an interview with CEO A on 7/26/2011 at 2:00 p.m., A stated that the policy is a corporate policy designed for all of the corporations' facilities and an addendum is to be attached to the policy with all of the contact information for the specific hospital sites. This addendum is not attached to the policy.

The facility's document titled, "Patient's Rights and Responsibilities," dated 3/07 was reviewed on 7/26/2011 at 1:30 p.m. This document does not inform Pt.s, families, or visitors that the SA can be contacted about concerns or grievances, and does not provide contact information for the SA.

The above finding was confirmed by CEO A on 7/26/2011 at 2:04 p.m.

Based on review of the facility's Pt.s Rights and Responsibilities information (1 of 1 document) and staff interview, this facility fails to inform Pt.s of their right to have family members and their personal physician notified of their admission to this facility.

Findings include:

The facility's document titled, "Patient's Rights and Responsibilities," dated 3/07 was reviewed on 7/26/2011 at 1:30 p.m. This document does not inform Pt.s of their right to have their family members and/or personal physician notified of their admission to this facility as soon as reasonably possible after arrival.

The above finding was confirmed by CEO A on 7/26/2011 at 2:04 p.m.

Based on MR review, review of the facility's Pt.s Rights and Responsibilities information (1 of 1 document), review of facility's complaint log, and interviews with staff and Pt.s, this facility does not inform Pt.s of their right to have care in a setting that is safe and does not respond timely to Pt.s call lights in 5 of 8 Pt (Pt. # 12, 23, 27, 31, and 32) reviewed.

Findings include:

The facility's document titled, "Patient's Rights and Responsibilities," dated 3/07 was reviewed on 7/26/2011 at 1:30 p.m. This document does not inform Pt.s of their right to have care provided in a safe setting.

The above finding was confirmed by CEO A on 7/26/2011 at 2:04 p.m.

In an interview regarding the call light logging system (computerized system that logs when the call light was put on and when it was shut off) on 7/26/2011 at 8:00 a.m., CEO A stated that the system is imperfect and, "we have had glitches."

Requested data for call light wait times from the dates of 7/24/11-7/25/11 was reported as irretrievable due to a system "glitch" by CEO A and CCO F on 7/27/2011 at 7:40 a.m.

In an interview with DQM B on 7/27/2011 at 8:20 a.m., B stated that to B's knowledge the "glitch" with the call light logging system over the past weekend was the first time a problem occurred. DQM B takes data from the call light response time logs for tracking and trending for Quality Assurance purposes and stated B was not aware there was a problem with it until 7/26/2011.

In an interview with RN Mgr. E on 7/27/2011 at 9:40 a.m., E stated that the call light logging system is new (approximately 1-1 1/2 years) and it doesn't always log the way it is supposed to. Mgr. E states that the system has had to be fixed a few times and that the facility has had ongoing issues with the system since they've gotten it. Mgr. E also stated that if it does log, it is reliable however it is possible that if a call light is answered at the desk it would be shut off at the time of answering and not necessarily mean the need has been attended to.

A review of the facility's complaint log was conducted on 7/26/2011 at 3:30 p.m. Out of 59 complaints, 7 were related to lengthy call light response times. Pt. #31 submitted a complaint regarding an incident which was related to a lengthy response time for the call light and a bed pan.

Pt. #31 issued the complaint on 5/2/2011. The complaint states that an RN did not assist with the removal of the bed pan when Pt. #31 was finished, and instead went to inform a CNA to assist the Pt. The complaint states that Pt. #31 was on the bed pan for almost 3 hours before a CNA came in to assist Pt. #31.

An MR review was completed on Pt. #31's closed MR on 7/27/2011 at 8:35 a.m. in the presence of DQM B. DQM B agreed, at the time of the MR review, that it is unacceptable practice to not assist a patient with care needs, and in this case it ended with a Pt. with extensive buttock/coccyx ulcers being left on the bed pan for 3 hours, which had the potential to compromise the status of the ulcers, reverse the healing progress, and cause injury to Pt. #31.

In an interview with Mgr. E on 7/27/2011 at 9:40 a.m., E confirmed that the RN S thought S informed CNA T to assist Pt. #31 but CNA T denied being informed that Pt. #31 needed assist , and RN S forgot to go back in the room to check on the Pt.

Findings by Surveyor #29972

Per Pt. interview on 7/25/2011 at 1:40 PM, when asked by surveyor #29972 if staff are prompt in answering your call for help, pt #23 stated "no, it can take 10-15 minutes before staff answer the call light."

Per Pt. interview on 7/25/2011 at 1:30 PM, when asked by surveyor #29972 if staff are prompt in answering your call for help, visitor U of pt #27 stated, "no, sometimes 3-4 minutes, sometimes 30-45 minutes it all depends."

The above finding were confirmed in the daily conference on 7/26/2011 at 4:30 PM with CEO A, DQM B, and CCO F.

Findings by Surveyor #29963


Per Pt. interview on 7/25/2011 at 2:45 PM, Pt. #12 stated that at times it takes the staff up to 30 minutes to answer a call light. Pt. #12 stated that staff says they are assisting other people or that they are short staffed. Pt. #12 stated #12 did file a complaint with facility regarding slow response of call lights.

Per Pt. interview on 7/26/2011 at 10:45 AM, Pt. #32 stated that at times #32 waits up to 40 minutes for the staff to respond to the call light. Pt. #32 stated that on 7/25/2011 #32 turned on call light and waited 20 minutes for staff to respond. Pt. #32 could no longer wait and attempted to transfer self to go to the bathroom and fell to the floor.

These findings were discussed and acknowledged by CEO A, DQM B, and CCO F at the daily exit conference on 7/26/2011 at 4:30 p.m.

Based on MR review and staff interview, the hospital failed to ensure all verbal orders are authenticated within 48 hours for 7 of 32 records reviewed. Telephone orders for pt's #13, 14, 17, 18, 19, 26, 30 were not signed by a physician within a 48 hour time frame.

Findings by surveyor #29972

In an interview by Surveyor #26711 with MR staff V on 7/26/2011 at 11:10 a.m., in the presence of DQM B, V stated that telephone/verbal orders are to be signed within 48 hours by the physician who gave the order or a physician working with the ordering physician if the ordering physician is not available within that time frame.

Record review of Pt #26 by Surveyor #29972 on 7/26/11 at 2:10 p.m. revealed the following: 11 medication telephone orders dated 7/22/11 (Loperamide 4 mg, Diphenhydramine 25 mg, Setraline 100mg, Quetiapine Fumarate 12.5 mg, Zolpidem Tartrate 12.5 mg, Alprazolam 1 mg, Acetaminophen 650 mg, Ipratropium Bromide/Albuterol 3 ml inhalation solution, Oxycodone immediate release 10 mg, Oxycodone immediate release 20 mg) not authenticated by physician until 7/25/11.

This was confirmed in an interview with RN N on 7/26/11 at 2:10 p.m..


26711

Findings by Surveyor #26711:

An MR review was completed on Pt. #13's open MR on 7/25/2011 at 8:34 a.m. in the presence of Mgr. E. Pt. #13 was admitted on 7/18/2011 and had one telephone order for Magnesium Sulfate which was not co-signed by the physician within 48 hours.

This finding was confirmed by Mgr. E at the time of discovery.

An MR review was completed on Pt. #14's open MR on 7/25/2011 at 8:48 a.m. in the presence of Mgr. E. Pt. #14 was admitted on 7/8/2011 and had one telephone order for Interferon 30 micrograms taken by an RN on 7/20/2011 which was not co-signed by the physician within 48 hours.

This finding was confirmed by Mgr. E at the time of discovery.


29963


Findings by Surveyor #29963

MR review completed on Pt. # 19's open MR, by surveyor #29963 on 7/27/2011 at 8:45 AM, revealed 4 orders written and not authenticated by responsible staff physician within 48 hours per policy which included the following: Bacitracin topical ointment ordered on 7/21/11, Neomycin/polymixin/bacitracin ointment ordered on 7/21/11 and Oxycodone 15 mg and Lorazepam 0.5 mg ordered on 7/24/11.

MR review completed on Pt. # 30's open MR, by surveyor #29963 on 7/27/2011 at 8:50 AM, revealed 2 orders written and not authenticated by responsible staff physician within 48 hours per policy which included the following: Haloperidol 5 mg ordered on 6/28/11, Levofloxacin 250 mg ordered on 7/23/11.

MR review completed on Pt. # 17's open MR, by surveyor #29963 on 7/27/2011 at 8:50 AM, revealed 3 orders written and not authenticated by responsible staff physician within 48 hours per policy which included the following: Phenytoin 200 mg to be discontinued, ordered on 7/8/11, Ensure plus -Honey thick fluids to be discontinued on 7/11/11, and Doripenem 500 mg to be discontinued, ordered on 7/13/11.

MR review completed on Pt. # 18's open MR, by surveyor #29963 on 7/27/2011 at 8:30 AM, revealed 4 orders written and not authenticated by responsible staff physician within 48 hours per policy which included the following: Metocloperamide 5 mg to be discontinued, ordered on 7/15/11, Levofloxin 500 mg to be discontinued, ordered on 7/16/11, Levothyroxine 87.5 mcg to be discontinued, ordered on 7/13/11 and Fluconazole 100 mg to be discontinued, ordered on 7/22/11.

Findings from Patient # 19, 30, 17, and 18 medical records were confirmed by RN N on 7/27/2011 at 8:55 AM.

Based on observation and interview, the facility failed to (i) maintain required negative/positive pressure in 4 spaces, and (ii) maintain one ceiling plenum clean in accordance with the recommendations in CDC and the American Institute of Architects (AIA) guidelines Table 2.1-2. This has a potential to affect all patients.

Findings include

During a tour of the facility with Staff C (director of plant operations) between 7/25 - 7/27/2011, Surveyor 12316 observed spaces in the following five locations that were either not maintained clean, or did not have properly maintained positive or negative pressure to cause airflow in right direction from clean to dirty spaces.

Item 1. On 7/25/2011 at 1:39 pm, the Soiled Utility Room across the Nurse Station on the 2nd Floor was not under negative pressure relative to the adjacent corridor. The room was slightly under positive pressure causing airflow in a wrong direction toward corridor;

Item 2. On 7/25/2011 at 2:30 pm, the pressure differential across the Pharmacy corridor door opening was neutral, and was not positive relative to corridor outside of the Pharmacy on the 3rd Floor;

Item 3. On 7/25/2011 at 2:54 pm, the Soiled Utility Room across the Nurse Station on the 3rd Floor did not have adequate negative pressure to cause airflow from the corridor into the dirty space;

Item 4. On 7/25/2011 at 3:12 pm, the ceiling space above corridor adjacent to the Elevator Lobby and the 3rd Floor Nurse Station was used as a return air plenum, but the space had pieces of construction materials that appeared to be fire-proofing materials, and not maintained clean; and

Item 5. On 7/26/2011 at 1:59 pm, the Material Management Room with medical supplies on the 1st Floor did not have adequate positive pressure to cause airflow from the clean space to adjacent corridor.

The above deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The above deficiency was acknowledged by the director of plant operations at the time of discovery, and confirmed with Staff A (chief executive officer), Staff B (director of quality management), Staff V (regional senior director of operations), and Staff F (chief executive officer) at the exit conference on 7/27/2011 at 11:30 am.

AIA (2006) Guidelines 10.2.1.2
"Ventilation and space conditioning requirements. All rooms and areas used for patient care shall have provisions for ventilation.

(1) Ventilation rates. The ventilation systems shall be designed and balanced, as a minimum, according to the requirements shown in Table 2.1-2 and the applicable notes. The ventilation rates shown in Table 2.1-2 do not preclude the use of higher more appropriate rates.
(2) ........
(3) ........
(4) Air movement direction. To maintain asepsis control, airflow supply and exhaust shall generally be controlled to ensure movement of air from "clean" to "less clean" areas, especially in critical areas."



CDC Guidelines for Environmental Infection Control in Health-Care Facilities
Recommendations --- Air
" I. Air-Handling Systems in Health-Care Facilities
A. Use AIA guidelines as minimum standards where state or local regulations are not in place for design and construction of ventilation systems in new or renovated health-care facilities. Ensure that existing structures continue to meet the specifications in effect at the time of construction (1). Category IC (AIA: 1.1.A, 5.4) "

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

1. Failed to protect the life safety of patients from fire due to lack of positively latching hardware to keep exit access corridor doors closed and latched;
2. Failed to protect the life safety of patients from fire due to one corridor not kept clear and unobstructed;
3. Failed to protect the life safety of patients from fire due to (i) missing escutcheon plates, (ii) dirty sprinkler heads, and (iii) lack of sidewall sprinkler heads at the bottom of elevator pits;
4. Failed to protect the life safety of patients from fire due to two trash receptacles not stored in a room protected as a hazardous area;
5. Failed to protect the life safety of patients from fire due to compressed gas oxygen cylinders not properly stored.

Refer to K-tags: K-18, K-39, K-62, K-75, and K-76

Based on observation and staff interview, this facility does not ensure that gaseous supplies (7 E-style oxygen tanks) are stored in a safe and proper manner which affects all patients, staff and visitors.

Findings include:

During a tour of the second floor on 7/25/2011 at 10:00 a.m., accompanied by Mgr. E and Surveyor #29963, 7 E-style portable oxygen tanks were being stored, unsecured, in the hallway outside of the respiratory therapy room. Mgr. E confirmed that some of them had tags indicating they were empty, but some of them had tags indicating they were partially full as well.

Mgr. E agreed, at the time discovery, that the tanks should probably not be stored in the hallway.

Based on observation, interview, Policy & Procedure review and review of nationally recognized standards the hospital failed to provide an environment and deliver care in a manner that would prevent the spread of infections in 5 of 8 patient care observations (Pt.s #10, 23, 27, 32 and 33) and hospital tour.

Findings include:

Review of hospital Policy & Procedure H-IC 02-001 titled Standard Precautions dated 11/2010 revealed a section titled, "Procedure 1. Gloves" that stated in part, "Change gloves and wash or disinfect hands between tasks and procedures on the same patient after contact with materials that may contain blood and or other body fluids."

According to the Association for Professionals in Infection Control (APIC), in a publication dated 7/22/2004 titled, "Glove Use for Healthcare Providers," regarding double gloving APIC states:
"When double gloving, the inner glove is not a substitute for hand washing. Change both gloves and wash hands before proceeding to another task or another patient."

On 7-26-2011 at 8:30 AM an observation of RRT J with patient #27 was completed. RRT J removed the old dressing from pt. #27's tracheotomy site disposed of the old dressing and used Q-tips with cleaning solution to clean the tracheostomy site, placed a clean dressing on the tracheostomy site and performed oral care which included using gloved fingers to apply lip balm to pt. #27's lips. This was all performed with the same pair of gloves. RRT J was asked by the surveyor if J changes gloves during a treatment like the one just observed, RRT J stated "No". Surveyor #26390 explained the concern with using gloves that were contaminated from the dirty dressing and then performing clean tasks on pt. #27. RRT J stated, "that's interesting".

CCO F confirmed on 7-26-2011 at 9:40 AM that gloves should be changed after removal of the dirty dressing.


26711

Findings by Surveyor #26711:

During a tour of the second floor on 7/25/2011 at 9:30 a.m., in the presence of Mgr. E, Surveyor #26711 and #29963 made the following observations:

Two bottles of expired Nepro tube feeding solution, were found on the bottom shelf of a cart which was behind several other carts in the clean linen room.

Mgr. E, confirmed at the time of discovery, that they should not have been in there.

Later in the day on 7/25/2011 at 3:55 p.m., Surveyor #29963 found a build up of dust and dirt on the top and the side vents of the ice machine in the nurses station in an area designated for preparation of light food items for patients.

This finding was observed by RN D at the time of discovery.

The following observations were made by Surveyor #26711 between 7/25/2011 and 7/26/2011 while doing observations of cares and procedures on the second floor:

During a central line dressing change for Pt. #10 on 7/25/2011 at 2:15 p.m., with gloved hands RN G removed the dressings that covered Pt. #10's centrally implanted intravenous (IV) catheter (an IV tube that is directly placed into a large vein for delivering fluids and antibiotics) and dialysis catheter (an IV line used during dialysis treatments) which were approximately 1 1/2-2 inches apart from each other on Pt. #10's upper left chest.

Pt. #10 was admitted with Pseudomonas Sepsis (infection in the blood with the bacteria called Pseudomonas).

After the removal of the old dressings, RN G opened up clean supply packs with the same gloves, then removed these gloves, washed hands, and applied sterile gloves which were used to handle the packs touched by the contaminated gloves. RN G then used the same ChloroPrep swab to clean the insertion sites of both catheters and did not treat them as separate wounds during the cleansing process.

RN D was present during this observation and confirmed that the same swab should not be used for the two separate sites.

During an observation of medication administration on 7/26/2011 at 9:20 a.m. with RN I for Pt. #33, RN I was observed on two occasions to shut off the water faucet with paper towel and then dry hands with the same paper towel, thereby re-contaminating the clean hands.

This finding was discussed at 4:20 p.m. on 7/26/2011, where it was confirmed by CCO F that RN I did not follow policy for turning off the water faucet during handwashing.



29963


Findings by Surveyor #29963

On 7/26/11 at 2:40 PM, surveyor #29963 entered room of Pt. #32, a sign posted outside of door states, contact isolation and indicates use of gown and gloves by anyone in the room. Pt. #32 is on precautions due to a pseudomonas infection in the lower extremities. RN M was observed exiting the room, following the removal of gown and gloves. Visitor of Pt. #32 was noted to be sitting next to Pt. without gown or gloves. Surveyor #29963 informed visitor that gown and gloves are needed prior to entering room. Visitor stated that staff had never informed them of the need to gown and glove prior to entering the room.

At 2:50 PM, RN M returned to room and Surveyor #29963 interviewed RN M regarding the expectation for visitors when entering a room with contact isolation posted on the door. RN M stated that all visitors are required to gown and glove, but had not asked this visitor to gown and glove.

Findings confirmed with RN N on 7/26/11 at 2:50 PM.


Finding by surveyor #29972:

During an observation of a wound dressing change for Pt. #23 on 7/25/2011 at 1:46 p.m., RN U placed 2 sets of gloves on hands, removed old dressing, cleaned the site, then removed first pair of gloves and then continued to place clean dressing on the site with second pair of gloves still on. Handwashing was not done between glove changes per policy and APIC standards.

Interview with CCO F on 7/25/11 at 4:00 p.m. confirms that RN U did not follow hospital policy and procedure and APIC standard of care and that the hospital does not have a policy regarding double gloving.