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Based on interview and record review, the hospital's governing body failed to provide oversight of the hospital's physical and fire safety compliance to ensure patient safety as evidence by:

1. The facility failed to maintain their exit signs to ensure egress paths were identified. (Cross reference A702)

2. The facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls, fire alarm system, smoke detectors and automatic sprinkler system. (Cross reference A710)

3. The facility failed to maintain corridor doors to resist the passage of smoke during fire. (Cross reference A712 and A724)

4. The facility failed to maintain their emergency back-up power supply. (Cross reference A715)

5. The facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. (Cross reference A701)

6. The facility failed to ensure staff were trained on their procedures to protect their patients from fire. (Cross reference A714)

7. The facility failed to maintain electrical safety. (Cross reference A724)

8. The facility also failed to ensure that fire safety was maintained in their oxygen cylinder storage areas. (Cross reference A724)

9. The facility failed to have a detailed plan and training to provide hospital staff with guidance related to water supply during the event of a disaster. (Cross reference A703)

The cumulative effect of these physical environment problems and lack of fire safety compliance, resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body, and failure to provide care to their patients in a safe environment.

Based on observation, interview and record review, the hospital failed to maintain an effective and on-going Quality Assessment and Performance Improvement Program (QAPI) to ensure compliance with physical environment and fire safety as evidence by:

1. The facility failed to maintain their exit signs illumination to ensure egress paths were identified. (Cross reference A702)

2. The facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls, fire alarm system, smoke detectors and automatic sprinkler system. (Cross reference A710)

3. The facility failed to maintain corridor doors to resist the passage of smoke during a fire. (Cross reference A712 and A724)

4. The facility failed to maintain their emergency back-up power supply. (Cross reference A715)

5. The facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. (Cross reference A701)

6. The facility failed to ensure staff were trained on their procedures to protect their patients from fire. (Cross reference A714)

7. The facility failed to maintain electrical safety. (Cross reference A724)

8. The facility failed to ensure that fire safety was maintained in their oxygen cylinder storage areas. (Cross reference A724)

9. The facility failed to have a detailed plan and training, to provide hospital staff with guidance related to water supply during the event of a disaster. (Cross reference A703)

The cumulative effect of these physical environment problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for QAPI (Quality Assessment and Performance Improvement), and failure to provide care to their patients in a safe environment.

Based on observation, document review and interview, the hospital failed to ensure a safe environment to protect the safety of their patients in accordance with NFPA( National Fire Protection Association) 101, Life Safety Code (2000 Edition) as evidence by:

1. The facility failed to maintain their exit signs to ensure egress paths were identified. (Cross reference A702)

2. The facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls, fire alarm system, smoke detectors and automatic sprinkler system. (Cross reference A710)

3. The facility failed to maintain corridor doors to resist the passage of smoke during fire. (Cross reference A712 and A724)

4. The facility failed to maintain their emergency back-up power supply. (Cross reference A715)

5. The facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. (Cross reference A701)

6. The facility failed to ensure staff were trained on their procedures to protect their patients from fire. (Cross reference A714)

7. The facility failed to maintain electrical safety. (Cross reference A724)

8. The facility also failed to ensure that fire safety was maintained in their oxygen cylinder storage areas. (Cross reference A724)

9. The facility failed to have a detailed plan and training to provide hospital staff with guidance related to water supply during the event of a disaster. (Cross reference A703)

The cumulative effect of these systemic problems identified during the Life Safety Code (LSC) portion of the survey resulted in the hospital's inability to ensure the provision of a safe environment, and could result in potential injury to 44 patients, staff and visitors from smoke inhalation and burns. The results of the survey are cross referenced to the CMS 2567 representing the K tags for the Life Safety Code. (Refer to K18, K47, K54, K144, and K60 of the LSC survey)

Based on interview and record review, the hospital failed to ensure the provision of 24-hour availability of nursing staff for surgical services.
The failure to comply with the staffing requirement was in violation of the regulatory requirement for nursing services as well as the hospital's policy to adequately staff the surgical department/operating room twenty-four (24) hours a day, seven (7) days a week.

Findings:

On 10/24/12, beginning at 12:40 P.M., an evaluation of surgical services and a tour of the hospital's operating room was conducted with the nurse manager (NM) for surgical services and director of quality management (DQM). The hospital had 4 operating rooms (OR), but only two ORs (OR 1 and OR 3) were in use. The NM indicated that only 2 ORs were used because of the low volume of surgical procedures provided by the hospital. The NM stated that the surgical procedures provided were limited to minor orthopedic procedures such as ostectomy (removal of a portion of bone) for graft, skin flap repairs for wounds, insertion of a permanent intravenous (vein) catheter, excision (surgical removal) of lesions, upper and lower GI (gastrointestinal) endoscopy procedures (the use of optical device to inspect hollow body organs or cavities).

The OR log records for July, August, September and October 2012, were reviewed with the NM. The log records confirmed the performance of the above OR procedures as specified by the NM. However, the log records showed the name of only one (1) OR nurse (the NM) who acted as the circulating nurse on all of the OR procedures done from July 2012 to October, 2012: July - 7 procedures, August - 6 procedures, September - 14 procedures, and October - 8 procedures.

On 10/24/12 at 2:05 P.M., an interview was conducted with the NM for surgical services regarding the OR staffing. The NM confirmed during the interview, that she was the only registered nurse currently working as a circulating nurse in the OR. She stated that there were no other trained OR nurses on call for emergencies and no one had been hired to relieve her for sick leave or vacations. When questioned if there were other RNs working in other patient care units who had the OR skills and competencies to be able to provide relief for OR coverage in the event of illness, vacation and emergencies, she stated there was no one. When asked about the OR staffing schedules available for review by the evaluator, she stated that there were none.

On 10/25/12 at 3:05 P.M., an interview was conducted with the hospital CEO (Chief Executive Officer) regarding the hospital's policy relative to nurse staffing for surgical services and the OR. The concern regarding the lack of OR nurse coverage to ensure the availability of nursing and surgical services 24 hours/day, particularly in emergency cases was discussed with her. She confirmed that there was only one registered nurse currently employed for the OR. She added that the other nurse who used to worked in the OR as a per diem employee had resigned in September 2012. The CEO stated that to date, she had not hired anyone to fill this position. She added that she was actively looking for a nurse with OR experience. The CEO then provided the evaluator a copy of the job posting for the OR nurse position.

The hospital administration policy entitled " Hours of Coverage for Surgical Services," dated Jan. 2011, was reviewed. The hospital policy clearly stated, "Surgery is staffed twenty-four (24) hours a day, seven (7) days a week. Evening, nights, holidays and weekends by the on-call staff consisting of 1 OR technician and 1 registered nurse to circulate all procedures. Adequate staff would be provided to manage the OR and endoscopy procedures."

Based on interview and record review, the hospital failed to ensure that 1 of 22 sampled patients (13) fall assessments, was completed accurately.

Findings:

Patient 13 was admitted to the hospital on 10/16/12, with diagnoses that included status post right femur fracture with open reduction and internal fixation, per the patient's History and Physical, dated 10/16/12.

A review of Patient 13's fall risk assessment, dated 10/16/12, indicated that the patient's total score was "4." Per the Fall Risk Screening Tool, a score equal or > 10 would be "At Risk" for falls. Further review of the patient's fall risk assessment indicated that on the section titled "Fall History," the registered nurse documented "0." Per the Fall Risk Screening Tool, if a patient had previous falls, the patient will be scored as a "10."

An interview with Patient 13 was conducted on 10/24/12 at 1:15 P.M. Patient 13 stated that she fell 2 months ago and broke her leg.

A joint record review and interview with registered nurse (RN) 12 was conducted on 10/24/12 at 1:30 P.M. RN 12 acknowledged that because of Patient 13's previous fall, the patient should have been scored as a "10" and not "0."

A interview with the Chief Clinical Officer (CCO) was conducted on 10/24/12 at 1:35 P.M. The CCO acknowledged that Patient 13's fall risk assessment on admission was inaccurate.

Based on observation, interview and record review, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for, 1 of 1 sampled patients with a portacath (Patient 1), and 1 of 2 sampled patients with a permanent catheter used as access site for hemodialysis treatment (Patient 2).

Findings:

1. Patient 1 was admitted to the hospital on 10/16/12, for medical care and treatment related to respiratory failure and pneumonia (inflammation of the lungs). The patient, per the physician's admission orders, required the administration of intravenous medications such as Lasix 40 mg daily to promote urination(diuretic); Hydralazine 10 mg every hour as needed for high blood pressure; and Hydromorphone 1 mg every 2 hours as needed for pain. All these 3 medication were give by injections through Patient 1's portacath implanted in the patient's chest. A portacath is a surgically implanted device used to administer fluids and medications.

On 10/24/12 at 9:30 A.M., a medication administration observation was conducted with registered nurse (RN 2). RN 2 gave two (2) injectable medications into the portacath via a special type of needle (Huber needle) attached to the portacath. RN 2 was observed to not have followed infection control measures, such as handwashing, prior to accessing the portacath. RN 2's assessment of the portacath's needle placement and the skin area surrounding the portacath prior to the drug administration, was also not observed.

A review of Patient 1's medical record and nursing care plan, was conducted with the director of quality management on 10/24/12 at 10:40 A.M. The nursing care plan dated 10/16/12, addressed the presence of a "central venous line," but did not include the presence and use of an implanted intravenous access port such as the portacath. The nursing care interventions failed to include the following:
the use and insertion only of non-coring safety needles to acces the portacath; the continuous assessment of the portacath site including the skin areas for signs of complications such as redness, swelling or induration; the disinfection of the insertion site; the need to maintain positive pressure when removing the needle from the portacath; the flushing method and solution to be used; the proper way of blood withdrawal from the portacath; dressing changes, and proper needle removal and infection control measures to be implemented.

2. Patient 2 was admitted on 10/20/12, for medical care and treatment related to kidney failure. The physician's admission orders for Patient 2 included the administration of hemodialysis (a procedure that involved the use of an artificial kidney or a dialyzer to remove wastes from the blood when the kidneys failed or were no longer working).

On 10/23/12 at 10:45 A.M., Patient 2 was observed receiving hemodialysis treatment with a nurse present at the bedside. RN 3 indicated during the interview, Patient 2 had a dialysis access catheter (permacath) on her left upper chest. RN 3 stated that the duration of the patient's hemodialysis treatment would be 3.5 hours.

On 10/23/12 at 2:20 P.M., Patient 2's medical record was reviewed with RN 4. The patient's medical record indicated that Patient 2 had a hemodialysis treatment on 10/22/12. The physician's order for the 10/22/12 hemodialysis treatment was for 3.5 hours. However, the dialysis nurse documented that Patient 2's hemodialysis was given only for approximately 1.5 hours, instead of 3.5 hours as ordered by the physician. RN 4 stated that according to the nurse's notes, the duration of the hemodialysis treatment was reduced because the patient's access catheter became partially occluded (blocked.) The physician was notified of the problem and gave an order to withhold the hemodialysis, and to give a medication (Alteplace) to help dissolve the substance causing the occlusion.

Patient 2's nursing care plan was reviewed with RN 4. A problem statement dated 10/22/12, addressed Patient 2's hemodialysis treatment. However, there was no indication that the nursing care plan was reviewed and revised to include the problem with the patient's hemodialysis access site (permacath) occlusion, and preventive measures to observe to prevent re-occurrence, medical and nursing management of the permacath, infection control measures, or monitoring of the patient for bleeding complications related to the use of anti-coagulant drug such as heparin.

Based on observation, interview and record review, the hospital failed to ensure that a registered nurse followed the hospital's policy and procedure relative to the administration of injectable drugs via a portacath (surgically implanted intravenous access port), for 1 of 1 sampled patients (Patient 1). In addition, the hospital failed to ensure that licensed vocational nurse double-checked the medication against the MAR (medication administration record), prior to administering the medications as indicated in the hospital's policy and procedure, for 1 of 1 sampled patients (Patient 12.)

Findings:

1. Patient 1 was admitted to the hospital on 10/16/12, for medical care and treatment related to respiratory failure and infection due to pneumonia (inflammation of the lungs). The treatment modalities ordered by the physician upon admission included the administration of drugs such as antibiotics, insulin, pain medication and other medications to manage the patient's medical condition.

On 10/24/12, beginning at 9:00 A.M., a medication pass observation was conducted in the ICU (Intensive Care Unit). The ICU nurse (RN 2) was observed preparing Patient 1's medications in the medication room. RN 2 was observed preparing 2 liquid medications, a laxative, an insulin injection, an injectable pain medication (Dilaudid), a diuretic (Lasix) injection and a Lovenox anti-blood clotting (coagulant) injection. After preparing the medications, the nurse proceeded to hand carry all the prepared medications, including the 2 cups containing the liquid medications. As the nurse was walking towards the door to exit the medication room, she was observed struggling as she hand carried all the prepared medications while attempting to open the door. When questioned by the evaluator as to why she was not using a medication tray to carry all the prepared medications, she stated that the ICU did not have medication trays.

RN 2 then proceeded to put all the hand carried and prepared medications, including the pre-filled syringes directly on top of a countertop at the nurses station. She returned to the medication room to get something, but left all the prepared medications on the countertop unattended. This was in violation of the hospital's policy that no medications be left unattended at any time. RN 2 returned to the nurses station counter and proceeded to hand carry the prepared medications to Patient 1's bedside. However, she left the vial of regular insulin and a syringe at the countertop for approximately 6 minutes while she gave Patient 1's medications. When questioned by the evaluator as to why she had left the insulin unattended, she stated that she was not ready to give the insulin because she had not checked the patient's blood sugar. The nurse acknowledged the hospital's policy that no medications be left unattended at any time.

RN 2 was asked to demonstrate the proper administration of injectable drugs via a portacath (a surgically implanted device inside the patient's chest for intravenous administration of drugs and fluids). RN 2 stated that she had 2 drugs to give via the portacath. She injected the first drug into the portacath via a needle (Huber needle) attached to the port, then followed this with another injectable drug. The nurse did not wash her hands before touching the portacath site or before injecting the medications into the port. RN 2 did not properly clean the port with a disinfectant before injecting the medications. The nurse failed to assess the portacath site, including the port's needle placement prior to the injection of the drugs. There was no handwashing observed throughout the drug administration process.

A review of the hospital's policy and procedure entitled Administration of Medications dated Feb, 2012, revealed the nurse's lack of compliance with the following policy requirements:
(a) All medications must be properly stored and secured at all times prior to administration. Prepared medications must never be left unattended; (b). Wash hands thoroughly before handling a portacath site and before giving intravenous medications; (c) Assess skin over and around the portacath and check for signs of complications; (d). Check the Huber needle placement and patency prior to the administration of drugs and fluids via a portacath.



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2. A medication administration observation was conducted on 10/24/12, at 9:00 A.M. Licensed vocational nurse (LVN 12) was observed administering medication for Patient 12. Prior to giving the last medication to the patient, LVN 12 closed the binder without checking the last medication against the MAR. LVN 12 was observed squirting 15 milliliter of a liquid medication that was labeled multivitamin with minerals, into a medicine cup and administered the medication via tube feeding without checking the medication against the MAR.

A review of the hospital's policy and procedure titled Administration of Medications indicated that, "Double-check the medication with the MAR for accuracy."

An interview with LVN 12 was conducted on 10/24/12 at 9:30 A.M. LVN 12 acknowledged that she should have checked the medication against the MAR prior to administering the medication to Patient 12.

Based on interview and medical record review, the facility failed to ensure that nursing staff completed an advanced directive form, for 1 of 26 patients ) charts reviewed (Patient 21.)
Findings:
A review of Patient 21's medical record was conducted on 10/23/12 ,at 9:00 A.M. The record indicated that on 10/6/12, on the advance directive form, a box was checked indicating "no copy provided." The section below contained 9 boxes listing different choices regarding whether the patient had advance directives or not or other legal papers. None of the 9 boxes were checked. At the bottom of the form a box was checked indicating that the patient did not want more information regarding advance directives. Further review of Patient 21's record indicated that she was a "full code."
An interview with the Nurse Manager was conducted on 10/23/12 at 9:00 pm. She stated that the nursing staff should have completed the advance directive form by checking one of the 9 choices.

Based on observation, interview and record review, the director of the food and nutrition department failed to ensure that dietary staff cooled down potentially hazardous foods (foods capable of supporting microbial growth), in accordance with safe food handling practices, and failed to ensure that the meal delivery carts were effectively sanitized.

Findings:

On 10/23/12, at 9:30 A.M., inside the walk-in refrigerator was a large bowl of cooked pasta salad, dated 10/22/12. On interview on 10/23/12, Cook 1 stated that she had cooked 4 pounds of the pasta the day before at 4:30 P.M., and that some of the pasta salad was served at 9:30 P.M. for "an event." Cook 1 stated that after she cooked the pasta she placed the pasta in the freezer to cool. Cook 1 said that she had not checked the temperature of the pasta at any time after it was cooked. Cook 1 stated that she usually checked the temperature of the pasta after 4 hours to make sure it was at 41 degrees F, or below, but "I didn't check the temp [temperature]."

Cook 1 stated that the foods that she cooked in advance to be served the following day, were pasta and potatoes which both were used for pasta salad, and potato salad. According to the hospital's Cooling Down Foods - Tracking Chart, the pasta and potato salad that was cooked in advance to be served the following day, had never been cooled down safely. Cook 1 verified that she had never been informed to cool down the pasta and potatoes, in accordance with the directions that were located on top of the Cooling Down Foods Tracking-Chart. The director of the food and nutrition department acknowledged that, the cooks had not been trained to cool down the potentially hazardous foods the pasta and potatoes that were to be served the following day.

According to the hospital's policy and procedure entitled Cooling Methods (Policy Number H-NS 04-017, last revised 06/2011), "The staff should monitor the cooling process and assure all potentially hazardous foods are cooled to below 70 degrees F within two hours and from 70 degrees F to below 41 degrees F in an additional four hours...,if food is not cooled from 140 degrees to 70 degrees F after two hours, discard or reheat to 165 degrees F for 15 seconds within the two-hour timeframe and repeat the cooling procedure. If food does not reach 70 degrees F within 2 hours again, it must be discarded."

According to the hospital's HACCP [hazard analysis critical control points] Monitoring form from the food and nutrition department's policy and procedure manual (Exhibit I, H-NS 06-007(A), other potentially hazardous foods that had been identified included cooked rice, beans, baked or boiled potatoes, milk, milk products, melon."

Based on interview and record review, the hospital failed to conduct a comprehensive nutrient analysis to determine if the menus for regular and therapeutic diets met the recommended daily dietary allowances, as recognized by national standards for dietary practices as established by the Food and Nutrition Board of the National Research Council, to meet the nutritional needs of patients and in accordance with the orders of the practitioner.

Findings:

On 10/23/12 at 2:00 P.M., the director of food and nutrition department (FSD) who is also a registered dietitian (RD) provided a "Menu Nutritional Analysis -Cycle Summary Report," for the hospital's consistent carbohydrate controlled diet. The FSD acknowledged that the nutrient analysis lacked nutrition assessment of the menus, including regular and therapeutic diets, for certain vitamins and trace minerals in which there were nationally recognized standards for recommended daily allowances (RDA's) and for dietary reference intakes (DRI's). The FSD verified that the nutrient analysis did not indicate whether the menus met all of the RDA's or DRI's, and did not include an analysis based on age and gender.

The national standards for the RDA's or RDI's were developed to, "Provide health professionals...references for planning for the nutrient needs of individuals and groups of people." (Institute of Medicine of the National Academies, 2006).

According to the hospital's policy and procedure entitled Menus (Policy Number H-NS-03-002, last revised 06/2011), "It is our policy to plan in advance nutritionally adequate menus, based on federal/state/local requirements. Menus are planned to meet the Recommended Dietary Allowances (RDA) of the Food and Nutrition Board of the National Research Council. Updates to the RDA's will be utilized and Dietary Reference Intakes (DRI's)-Estimated Average Requirements for Groups and Individuals are also used as guidelines. The facility will have nutrient or other food group analysis indicating adequacy of diets/menus provided to the patient."

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. This affected 1 of 8 smoke compartments and had the potential to allow the spread of smoke during a fire and cause injury to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 1 on October 24, 2012, the facility walls and ceilings were observed.

October 24, 2012

At 9:40 a.m., in the Staff Lounge near Room 116, an approximate 3 inch diameter circular unsealed penetration in the wall was noted, which could spread smoke and fire. Staff 1 confirmed the unsealed penetration.

Based on observation and interview, the facility failed to maintain their exit signs to ensure egress paths were identified. This was evidenced by 6 of 67 exit signs, that failed to illuminate with an internal emergency power supply source, exit signs that were missing in egress paths (path of escape), and 3 of 6 exit signs that failed to illuminate without an internal power source. This affected 3 of 8 smoke compartments, and could result in a delay in evacuation due to limited exit sign visibility.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012, through October 25, 2012, the exit signs were observed, maintenance records were reviewed, and a staff person was interviewed.

October 23, 2012
1. At 9:46 a.m., the Exit signs B-20 and B-23 in the Basement were not illuminating when the test button (battery test) were pressed. Staff 1 confirmed the finding.

October 24, 2012
At 9:48 a.m., Staff 3 said during an interview that "she tested the exit signs last week and the signs worked ok. She stated that if she found a problem then she would report it to her supervisor."

2. At 10:11 a.m., there was no exit sign in the south exit path from the Operating Room. Staff 1 confirmed that there was no exit sign in their egress path.

3. At 2:06 p.m., the CO6 exit sign near the Physician Lounge was not illuminating when tested. Staff 1 confirmed the exit sign was not illuminated.

October 25, 2012
4. At 9:54 a.m., Staff 2 inspected the three wall mounted exit signs near the floor (one each in the three units and without an internal power source "battery back up system") and said that the three exit signs were not working.

5. At 10:10 a.m., the east exit sign in the warehouse was not illuminating when inspected. When the test button (battery test) was pressed, the exit sign did not illuminate.

Based on observation, interview and record review, the hospital failed to have a hospital specific detailed plan and training, that provided guidance to hospital staff on how to make the planned disaster water supply from the hot water tank safe for human consumption. In addition, the hospital lacked a plan on how to transport the planned disaster water from the hot water tanks to patients for use during the event of a disaster.

Findings:

On 10/24/12 at 10:48 A.M., an employee who worked in central supply (CS 7) provided the hospital's "Emergency Water Supply" policy and procedure (Policy Code and Number EM.02.02.093) that indicated it pertained to [name of hospital] located in (a city in a different state). According to the policy, the hospital would have 55-gallon drums of water for washing water, toilet, and housekeeping use. According to CS 7, that was not part of this hospital's [name of hospital]disaster water plan.

CS 7 stated that in the event of a disaster the hospital had four 100 gallon hot water boiler tanks that could be used for consumption. When asked if the water from the hot water boiler would need to be treated before human consumption, she stated, "Yes, but we do not have a plan for that yet." When asked how the water from the boiler would be transported to patients for use, she stated, "We do not have a plan on how we would do that."

In addition to the planned disaster water supply to use the water from the boiler tanks, the hospital did have other planned sources of water. According to CS 7, the hospital planned to retain expired water that "could be used for cooking." According to the hospital's "Inventory Of Assets and Resources," the hospital planned to keep and store 659 gallons of expired water for various use.


On 10/25/12 at 10:20 A.M., the hospital's Chief Executive Officer (CEO) verified that the only plan that the hospital had in writing in regard to emergency water supply was the "Emergency Water Supply" policy and procedure (Policy Code and Number EM.02.02.093). The CEO acknowledged that the hospital "could use the water from the boiler tank for consumption," and verified that the hospital had not trained hospital staff on how to treat the water to make it safe for consumption during the event of a disaster. The CEO acknowledged that there was no guidance to hospital staff on how to transport the water from the hot water boiler to patients for use.

The hospital's policy that was provided was not hospital specific in regard to par levels of disaster water supply that the hospital planned to have on-site, which would specify source and location. There was no written detailed guidance or training, to hospital staff on how to treat non-bottled water sources to ensure it would be safe for consumption, and no plan on how to transport the water to patients from the hot water tanks. There was no documented evidence that the hospital used nationally accepted references when developing the hospital's emergency water supply as it indicated, "Drinking water for staff: 0.25 gallons per staff member." When CS 7 was asked if that was the national or community standards of practice, she stated, "There are no nationally referenced or community standards, it's just what our hospital says is okay."

Based on observation, interview and record review, the facility failed to ensure fire safety compliance as evidenced by the following:

1. The facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls, in accordance with NFPA (National Fire Protection Association) 101. This was evidenced by unsealed penetrations in the smoke barrier walls. The penetrations could result in the reduction in the facility's ability to protect in place and increase the risk of injury to the the patients due to smoke and fire. This affected 3 of 8 smoke compartments.

2. The facility failed to maintain the fire alarm system in accordance with the NFPA 72, as evidenced by failing to keep impediments from obstructing manual fire alarm pull station devices from view and access. This would delay activating the fire alarm system and cause harm to patients in the event of a fire emergency. This affected 2 of 8 smoke compartments.

3. The facility also failed to ensure that smoke detectors were maintained in accordance with NFPA 72, 1999 edition. This was evidenced by 4 of 167 smoke detectors that failed to activate the fire alarm when tested with canned smoke. This could result in delayed notification of fire in the facility to the fire department, patients, staff and visitors causing potential injury from smoke inhalation and burns. This affected 3 of 8 smoke compartments.

4. The facility failed to maintain their automatic sprinkler system. This was evidenced by 1 of 2 inspector test valves that failed to activate the fire alarm system when tested and the fire department connectors were impeded from view and access with ply wood on top of them. This could result in delayed notification of fire to the patients, staff, visitors and the Fire Department in the event of a fire and could result in injury to 44 patients, staff and visitors from smoke inhalation and burns. The blocked fire department connections could result in failure of the Fire Department to use the fire department connectors during fire.

5. The facility failed to maintain their automatic sprinkler system as evidenced by a sprinkler head that was covered with foreign materials and sprinklers that were not flush to the ceiling. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. The sprinkler heads could malfunction and cause potential harm to patients in the event of a fire emergency. This affected 2 of 8 smoke compartments.

Findings:

1. During a tour of the facility with Staff 1 on October 24, 2012, the smoke barrier walls were observed.

October 24, 2012

a. At 1:53 p.m., in the smoke barrier wall near the ICU (Intensive Care Unit) entrance, there was an approximate 3/4 inch unsealed conduit pipe. Staff 1 confirmed the finding.

b. At 2:14 p.m., in the smoke barrier wall near the Operating Room main entrance, there was an approximate 1/2 inch unsealed conduit pipe. Staff 1 confirmed the finding.

c. At 2:21 p.m., in the West smoke barrier wall near the Laboratory, there was an approximate 2 inch by 3 inch unsealed penetration in the wall. Staff 1 confirmed the finding.

2. During a tour of the facility with Staff 1 on October 23, 2012, the manual fire alarm devices (pull stations) were observed and a staff person was interviewed.

October 23, 2012
a. At 10:03 a.m. the manual fire alarm pull station device in the Main Lobby was impeded from view. The manual fire alarm pull station was behind a 6 1/2 foot artifical tree.

At 10:04 a.m., Staff 1 said during an interview that he has moved that tree several times in order not to obstruct the pull station.

b. At 4:30 p.m., the East Pull Station fire alarm device in the Rehabilitation Room was impeded from access with 5 wheelchairs and 4 e-cylinders (oxygen tanks) in front of the device.

3. During fire alarm testing with Staff 1 on October 24, 2012, the smoke detectors were tested with canned smoke and a staff person was interviewed.

October 24, 2012

a. At 9:07 a.m., the smoke detector near Room 409 (labeled L1D084) was not activating the fire alarm when tested with canned smoke. Four attempts were made without activating the fire alarm system.

At 9:08 a.m., Staff 1 said during an interview that "the smoke detector (L1D084) had a lot of dust in it and maybe that is why it didn't work."

b. At 9:28 a.m., the smoke detector near the Physician's lounge (labeled L1D008) was not activating the fire alarm when tested with canned smoke. Three attempts were made without activating the fire alarm system.

c. At 9:30 a.m., the smoke detector near the Nurse Manager's Office (labeled L1D018) was not activating the fire alarm when tested with canned smoke. Four attempts were made without activating the fire alarm system.

d. At 9:53 a.m., the smoke detector in the Operating Room (no label on it) and between the Recovery and Central Process Rooms, was not activating the fire alarm when tested with canned smoke. Three attempts were made without activating the fire alarm system.

4. During a tour of the facility with Staff 1 on October 24, 2012, through October 25, 2012, the sprinkler system and components were observed, maintenance documents were reviewed, and a staff person was interviewed.

October 24, 2012

At 11:00 a.m., the Inspector Test Valve (a valve that simulates water flowing from a sprinkler) in Respiratory Therapy failed to activate the fire alarm system when tested. The water valve was opened for over 2 minutes and 20 seconds and the fire alarm system did not activate. At 11:05 a.m., Staff 1 said during an interview that he is going to call the fire alarm company to get the valve replaced.

At 11:10 a.m., the information of the inspector test valve failing to activate the fire alarm system was provided to the Chief Executive Officer and she decided to initiate a fire watch until the valve is replaced.

At 11:41 a.m., A review of the last Inspector Test Valve report from (sprinkler company) dated October 18, 2012, revealed that the Inspector Test Valves (North and South) failed to activate the fire alarm system when tested. The report indicated that an adjustment was made to the inspector test valve and it worked when retested by the (sprinkler company.)

At 11:48 a.m., a Report dated October 23, 2012, from the (sprinkler company) was provided from the facility with a bid for the sprinkler test valve to be replaced to correct the problem permanently.

At 1:09 p.m., the Fire Department Connectors and sign, located outside and near the warehouse, was obstructed from view and access, by two 4 foot by 8 foot sheets of plywood in front of the sign and connectors.

October 25, 2012
At 6:48 a.m., the facility Fire Watch was abated (facility assigns a staff person to walk around the facility looking for fire and smoke).

At 8:00 a.m., a report dated October 25, 2012, from Tri-Signal Integration indicated that the inspector test valve was replaced and re-tested.

5. During a tour of the facility with Staff 1 on October 24, 2012, through October 25, 2012, the sprinkler system components were observed and a staff person was interviewed.

October 24, 2012

a. At 9:13 a.m., there was paint on the sprinkler head near smoke detector L1D095 in the Case Management Office. Staff 1 acknowledged the finding.

b. At 9:22 a.m., there was paint on the sprinkler head outside of Room 403. Staff 1 acknowledged the finding.

October 25, 2012

c. At 9:24 a.m., the escutcheon ring in the Doctor Lounge Shower Room was not flush to the ceiling. The escutcheon ring revealed an approximate 1/2 inch gap between the ceiling and ring. Staff 1 confirmed the finding.

d. At 9:32 a.m., 1 of 4 sprinklers escutcheon rings in Operating 4 was not flush to the ceiling. One sprinkler was covered with brown rusty looking mattr and the escutcheon was approximately 1/4 from the ceiling. Staff 1 acknowledged the finding.

e. At 9:50 a.m., the two sprinklers near the main entrance were covered with brown looking matter. Staff 1 confirmed the finding.

f. At 9:51 a.m., Staff 1 said during an interview that the brown material looks like rust, and he said that he will have the sprinkler company look at the sprinklers.

Based on staff interview and document review, the facility failed to ensure that staff were trained on the procedures to protect patients from fire. This was evidenced by staff members who were not familiar with their fire emergency procedures. This failure could create panic and delay and cause potential harm to patients if staff became confused and failed to follow or understand the emergency plan. This affected 1 of 8 smoke compartments.

Findings:

During fire alarm testing with Staff 1 on October 24, 2012, staff were interviewed and training documents were reviewed.

October 24, 2012

At 9:38 a.m., there were four staff members interviewed. 1 of 4 staff (6) said they would yell "fire" instead of using the code word "Code Red" during a fire emergency to request for help.

At 12:35 p.m., under the facilities Fire and Life Safety Management Plan in the section titled objectives and under line number 2 revealed the following:
Educate staff to the department specific Code Red Policies and Procedures.

Based on interview and document review, the facility failed to maintain their emergency back-up power supply in accordance with NFPA (National Fire Protection Association) 99, 1999 edition, which required an annual supplemental testing of the generator. This was evidenced by the facility's failure to conduct an annual supplemental test on their emergency generator, within the past twelve months. This could result in the failure of their back up power supply and could cause failure to power the life safety systems and emergency equipment during a power outage.

Findings:

During record review with Staff 1 on October 23, 2012, the generator test records were reviewed and a staff person was interviewed.

October 23, 2012

At 3:20 p.m., the facilities last annual supplemental test was performed on August 14, 2011.

At 3:21 p.m., Staff 1 stated during an interview that the test performed on August 14, 2011, was the last supplemental test that was done.

There was no evidence that a supplemental generator test was done 12 months after August 14, 2011.

Based on observation, interview and record review, the hospital failed to ensure that facility supplies and equipment were maintained at an acceptable level of safety as evidence by:

1. The facility failed to maintain electrical safety in accordance with NFPA (National Fire Protection Association) 70. This was evidenced by the use of multiple flexible power cords, appliances plugged to multi-outlet extension cords, and unidentified circuits in their panelboards. This affected 3 of 8 smoke compartments. This could potentially increase the risk of an electrical fire causing harm to patients.

2. The facility also failed to ensure that fire safety was maintained in their oxygen cylinder storage areas. This was evidenced by a light switch installed less than 5 feet from the floor in their oxygen cylinder storage area, the failure to provide a precautionary sign on the gate to the storage area, and failure to secure oxygen compressed cylinders. This affected 2 of 8 smoke compartments and could result in a fire and potential injury to patients, staff and visitors.

3. The facility also failed to ensure that 35 % and above humidity, was maintained in the Operating Rooms in accordance with NFPA 99, 1999 edition. This was evidenced by written documentation of humidity in the OR of below 35 %. This could increase the occurrence of fire and result in potential harm to patients. This affected 2 of 8 smoke compartments.

4. The facility failed to maintain corridor doors to resist the passage of smoke during a fire. This was evidenced by corridor doors that were impeded from closing, a double action lock, and corridor doors that failed to positive latch. This affected 6 of 8 smoke compartments which had the potential to allow the migration of smoke and fire into the corridors, their main path of egress. This could cause potential harm to the 44 patients, staff and visitors from smoke inhalation and burns.

Findings:

1. During a tour of the facility with Staff 1 on October 23, 2012, through October 25, 2012, the electrical equipment was observed.

October 23, 2012
a. At 9:40 a.m., there was a refrigerator and a microwave in the Lab Staff Lounge that was plugged into a multi-outlet power strip and not directly into a wall outlet.
October 24, 2012
b. At 10:35 a.m., there was an orange extension cord plugged into a multi-outlet power strip in the Basement Infection Control Office. Staff 1 acknowledged the finding.
c. At 1:16 p.m., there was an orange extension cord in use in the Business Office and near the Marketing Desk. Staff 1 acknowledged the finding.
d. At 3:12 p.m., in Nutrition Room near Room 109 was an Electrical Panel (C1A) with 16 of 36 circuits that were unidentified. Circuits 5, 12, 14, 20, 22, 25, and 27 through 36 were unmarked as to their purpose. At 3:13 p.m., Staff 1 said during an interview that he did not know where the circuits were connected to.

2. During the facility tour with Staff 1 on October 23, 2012, through October 25, 2012, the facility oxygen storage areas were observed.

October 23, 2012

a. At 10:14 a.m., the light switch in the Room identified as the Oxygen Cylinder Storage Room, near Admitting, was mounted 48 inches from the floor.

October 24, 2012

b. At 1:05 p.m., there was no sign on the gate or near the fence to the main Oxygen Storage area located outside, to indicate that Oxygen cylinders were stored within.

October 26, 2012
C-T SCAN Trailer

c. At 10:26 a.m., there was an oxygen tank (D Cylinder) that was laying on the floor unsecured in the C-T Scan trailer.

3. During document review with Staff 1 on October 23, 20012, the humidity logs were reviewed.

October 23, 2012

At 1:38 p.m., the humidity log revealed that the humidity was below 35 % on the following dates in the Operating Room (OR):
March 5, 2012, the humidity was 30 % in OR 1 and 24 % in OR 3, March 7, 2012, the Humidity for OR 1 was 33 % and OR 3 was 18 %, March 8, 2012, the humidity was 24 % in OR 3, March 9, 2012, the humidity was 20 % in OR 3, January 30, 2012, the humidity in OR 1 was 30 %, and OR 3 was 21 %, and November 2, 2011, the humidity was 34 %, and November 10, 2011, the humidity was 32 %.

At 1:40 p.m., the facilities humidity log titled (name of hospital), Environmental Check Log (Surgery Dept) indicated that the humidity acceptable range is 30% to 60%.

At 1:42 Staff 9 was interviewed. She stated that she will call maintenance to adjust the humidity when it is out of range.

At 1:43 p.m., there was no documentation that further tests were performed to re-check the humidity when it was out of range.

4. During a tour of the facility with Staff 1 on October 23, 2012 through October 25, 2012, the corridor doors were observed and a staff person was interviewed.

October 23, 2012

a. At 9:41 a.m., the self-closing corridor door to the Laboratory Staff Lounge was impeded from closing with a chair in front of the door. At 9:42 a.m., Staff 1 said during an interview that "he is always removing the chair from the front of the Laboratory Staff Lounge door."

b. At 9:50 a.m., the self-closing corridor door to Room 411 was impeded from closing with a trash can in front of the door. Staff 1 removed the item upon discovery.

c. At 9:52 a.m., the self-closing corridor door to Room 414 was impeded from closing with a trash can in front of the door. Staff 1 removed the item upon discovery.

d. At 9:56 a.m., the self-closing corridor door to Room 406 was impeded from closing with a chair in front of the door. Staff 1 removed the item upon discovery.

e. At 10:05 a.m., the self-closing corridor door to the Health Information Management Office was impeded from closing with a rubber wedge under the door.

October 24, 2012
f. At 8:36 a.m., the self-closing corridor door to the Admitting Office was impeded from closing with a statue in front of the door. Staff 1 removed the statue upon discovery.

g. At 9:00 a.m., the self-closing corridor door to Room 405 failed to release from the magnetic hold open device connected to the fire alarm system and close during fire alarm testing.

h. At 9:01 a.m., the self-closing corridor door to Room 412 failed to release from the magnetic hold open device connected to the fire alarm system and close during fire alarm testing.

i. At 9:09 a.m., the self-closing corridor door to Room 416 was not latching when tested. The latching mechanism was stuck in the door.

j. At 9:10 a.m., the self-closing corridor door to Room 411 was not latching when tested. The latching mechanism was stuck in the door.

k. At 9:15 a.m., the self-closing corridor door to Room 115 was not latching when tested. The latching mechanism was stuck in the door.

l. At 9:17 a.m., the self-closing corridor door to Room 109 was not latching when tested. The latching mechanism was stuck in the door.

m. At 9:18 a.m., the self-closing corridor door to Room 108 was not latching when tested. The latching mechanism was stuck in the door.

n. At 9:19 a.m., the self-closing corridor door to Room 107 was not latching when tested. The latching mechanism was stuck in the door.

o. At 9:20 a.m., the self-closing corridor door to Room 106 was not latching when tested. The latching mechanism was stuck in the door.

p. At 9:21 a.m., the self-closing corridor door to Room 424 was not latching when tested. The latching mechanism was stuck in the door.

q. At 9:24 a.m., the self-closing corridor door to Room 103 was not latching when tested. The latching mechanism was stuck in the door. At 9:25 a.m., Staff 1 said during an interview that the doors were checked on a weekly basis but the latches were not inspected.

r. At 9:32 a.m., the self-closing corridor door to Room 217 was not latching when tested. The latching mechanism was stuck in the door.

s. At 9:34 a.m., the self-closing corridor door to Room 214 was not latching when tested. The latching mechanism was stuck in the door.

t. At 9:36 a.m., the self-closing corridor door to Room 213 was not latching when tested. The latching mechanism was stuck in the door.

u. At 9:41 a.m., the self-closing corridor door to the Staff Lounge was not latching when tested. The door would not self-close completely.

v. At 9:42 a.m., the self-closing corridor door to the Traction Room/Janitor Storage was not latching when tested. The door would not self-close completely.

October 24, 2012
w. At 12:50 p.m., the self-closing corridor door to the Employee Lockers on the third floor was not latching when tested. The latching mechanism was stuck in the door.

x. At 1:42 p.m., the self-closing corridor door to the Soiled Utility Room was not latching when tested. The door was not closing completely. The room was less than 50 square feet.

y. At 3:25 p.m., the corridor door to the Center Nursing Station was not latching when tested. There was a roller latch on the door and no other latching mechanism. There was a double action lock (a lock that requires two actions to open) on the door. The lock was a key type dead bolt lock. At 3:26 p.m., Staff 1 said during an interview that he did not know that roller latches were prohibited.

October 25, 2012
z. At 9:20 a.m., the self-closing corridor door to Utility Room in the Operating Room was not latching when tested. The door was not self-closing completely. Staff 1 confirmed the door was not fully closing and latching.

aa. At 10:02 a.m., the self-closing corridor door to the South entrance of the MDS Office was not latching when tested. Staff 1 confirmed the deficiency.

Based on observation, interview and record review, the hospital failed to ensure that infection control measures to include handwashing before intravenous drug administration and administration of tube feedings, was observed by a nurse in the ICU (Intensive Care Unit). In addition, the lack of availability of equipment such as, a medication tray to carry and transport several prepared injectable medications, from the medication room to the patient care unit, caused the nurse to leave the pre-filled syringes directly on top of unclean counters and bedside stands thus presenting the risk of contamination. The hospital also failed to ensure that steps to help minimize the spread of infection were followed by licensed vocational nurse (LVN) 11 and a patient visitor, during a random observation, and LVN 12 during the medication administration observation. The hospital failed to ensure that that nursing staff implemented the policy regarding the cleaning and disinfection of the glucometer (machine used to check blood sugar). In addition, the hospital did not ensure a sanitary environment in the morgue. Finally, the hospital's infection control program failed to identify that the ice machines located in the kitchen, and in the nourishment rooms next to the nursing stationss, were cleaned and sanitized in accordance with the ice machine's manufacturer's guidelines.
Findings:
1. On 10/24/12, beginning at 9:00 A.M., a medication pass observation was conducted in the ICU (Intensive Care Unit). The ICU nurse (RN 2) was observed preparing Patient 1's medications in the medication room. The nurse was observed preparing 2 liquid medications in 2 separate cups, a laxative, an insulin injection, an injectable pain medication (Dilaudid), a diuretic (Lasix) injection and a Lovenox anti-coagulant injection. RN 2 proceeded to hand carry all the prepared medications and pre-filled syringes to the patient's room. RN 2 was observed struggling to carry all of the above prepared medications while attempting to turn the door knob to exit the medication room.

RN 2 placed all the prepared medications and 3 pre-filled syringes, directly on top of an unclean counter at the nurses station. RN 2 left and returned to the medication room to retrieve something. She returned to the nurses station, took all the prepared medications and pre-filled syringes to the patient's room and put them all directly on top of the patient's bedside table. The table was noticeably unclean, but no attempt were made to clean the table. No medication tray or any type of protective barrier was utilized to protect the pre-filled syringes from potential contamination. RN 2 then proceeded to give 2 liquid medications via the patient's nasogastric tube. She then proceeded to give the patient's injections via a needle attached to the the portacath (a surgically implanted port for intravenous infusion of drugs and fluids). This was followed by a subcutaneous injection of another drug (Lovenox). No handwashing was observed throughout the entire medication administration process. The nurse continued to use the same contaminated gloves she wore and had contact with a door knob, unclean counter, bedside table and water pitcher.

On 10/25/12 at 9:35 A.M., RN 2 was interviewed regarding her knowledge of infection control policies and procedures, particularly when performing drug administration. She acknowledged the hospital's policy relative to handwashing to prevent the spread of infection. She stated that the ICU did not have the availability of medication trays to use when they had prepared several drugs. They had to hand carry them from the medication room to the patient care units.
This practice could cause the nurses to drop the medications and pre-filled syringes, thus causing cross contamination that could potentially lead to incidence of infections.


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2. On 10/23/12 at 9:26 A.M., a family visitor was observed inside a aptient's room, sitting on a chair at the foot of the patient's bed and was leaning on the bottom footboard of the bed. Inside the room was LVN 11 who was observed wearing a gown and gloves. However, LVN 11 was not observed reminding or teaching the patient visitor to wear gloves and gown. Outside the patient's room was a sign that indicated to wear gown and gloves when entering the room. The Chief Clinical Officer (CCO), who had the same observation, reminded the visitor to wear gloves and gown. The visitor stated that he forgot.

An interview with LVN 11 was conducted on 10/23/12 at 9:28 A.M. LVN 11 stated that she had not noticed that the patient's visitor was not wearing gloves and gown. LVN 11 acknowledged that she should have noticed that the visitor was not wearing the appropriate personal protective equipment (PPE) and should have reminded the visitor to wear them.

A review of Patient 11's medical record was conducted on 10/25/12 at 9:30 A.M. Per the lab result, dated 10/12/12, the patient's left nares tested positive for methicillin resistant staphylococcus aureus (MRSA - a type of staph bacteria that is resistant to certain antibiotics).

3. A medication administration observation was conducted on 10/24/12 at 9:00 A.M. LVN 12 was going to administer Patient 12 her medication. Outside Patient 12's room was a sign that indicated to wear gloves and gown when entering the room. During the unit tour conducted on 10/23/12 at 9:40 A.M., registered nurse (RN) 11 reported that Patient 12 was on contact isolation. During the medication administration observation, LVN 12 was observed wearing gown and gloves. LVN 12 was observed placing the used dirty gloves on the edge of the nightstand. In the middle of the medication administration, one of the dirty glove fell on top of LVN 12's shoe. LVN 12 picked up the dirty glove with her clean glove. LVN 12 continued with her medication administration without changing the gloves and washing her hands.

An interview with LVN 12 was conducted on 10/24/12 at 9:30 A.M. LVN 12 acknowledged that she should not have picked up the dirty glove with her clean glove. She also indicated that after she picked up the dirty glove with her clean glove, that she should have change her gloves and washed her hands.

An interview with the Area Director of Infection Control (ADIC) was conducted on 10/26/12 at 9:00 A.M. The ADIC acknowledged that LVN 12 should have changed her gloves and washed her hands before resuming her medication administration task.





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4. On 10/24/12 at 9 A.M. during an observation of a Medication Pass, the Nurse Manager was observed cleaning the glucometer with an alcohol swab. An interview was then conducted with the Nurse Manager who initially acknowledged that alcohol swabs could be used to clean the glucometer. Later she stated that she was mistaken and that bleach wipes should be used. An interview with LVN 21 was conducted on 10/24/12 at 9:30 A.M. he stated that if a patient had C. Diff (an organism that requires bleach for disinfection) he would clean the glucometer with dispatch (bleach wipe). If the patient did not have C.Diff he would use the purple top disinfecting wipes (these wipes do not contain bleach). An interview with LVN 22 was conducted on 10/24/12 at 9:45 A.M. She stated that she cleaned the glucometer with the "purple top" disinfecting wipes (those do not contain bleach). An interview was conducted with the Nurse Manager and she acknowledged that the two LVN's were incorrect and that they should have used the bleach wipes for cleaning the glucometer.
A review of the glucometer's manufacturer's booklet indicated that "clean the outside of the meter with a cloth dampened with a 10% bleach solution."
A review of the hospital's policy titled "Point of Care Glucose Testing" was reviewed on 10/24/12 at 2 P.M. the policy indicated that "clean the outside of the meter with a cloth/disinfectant wipe dampened with a 10% bleach solution."
During an interview with the Area Director for Infection Control on 10/26/12 at 9 A.M., she stated that the hospital's policy to clean the glucometer was with a bleach solution per manufacturer's specifications. She acknowledged that using alcohol or other disinfecting wipes was not acceptable.
5. On 10/24/12 at 1:30 P.M. during a tour of the Morgue, approximately 8 plastic bags with patient names written on them were observed on a counter next to the metal autopsy table. In addition, in an alcove next to the cadaver freezer doors were approximately 8 more plastic bags piled up on the floor of what appeared to be an old unused shower. An interview with Nurse Manager was conducted on 10/24/12 at 1:35 P.M., she stated that the plastic bags contained the personal belongings of patients that have expired and that they were being stored in the morgue.
An interview with the Social Worker was conducted on 10/24/12 at 10:45 A.M. She stated that the procurement of organs or donated body parts was conducted in the morgue.
An interview with the Area Director for Infection Control was conducted on 10/26/12 at 9 A.M. She stated that the Infection Preventionist and Environmental Control was responsible for ensuring that the hospital maintained a sanitary environment. She acknowledged that storing expired patient's belongings in the morgue was not acceptable.



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6. On 10/23/12 at 1:26 P.M., an engineering department employee (E3) stated that she was responsible for cleaning the ice-machine's in the hospital. During this same interview, E3 was in the kitchen and stated that she never opened up the top panel to the ice-machine's ice-making apparatus. E3 stated that she did not know how to do that. E3 said that she cleaned the ice-machine located in the kitchen by use of a nickel-safe ice-machine cleaner in the bin portion of the ice-machine. E3 stated she would turn off the machine, remove the ice, would clean the bin with the nickel safe ice-machine cleaner, and then rinse out the chemical from the bin by use of hot water from a bucket that she would obtain from the engineering department. E3 verified that she never cleaned and sanitized the inside of the ice-making apparatus, and that only nickel-safe ice-machine cleaner was used in the ice-machine bin. E3 stated that the bucket that was used to rinse out the chemical from the ice-machine bin was designated solely for that purpose. At that time, E3 and the surveyor walked to the engineering department, and E3 stated, "The bucket is not here right now, someone else must be using it for something." E3 verified that she did not clean or sanitize the bucket. E3 stated that the above procedrue was the same steps taken with all of the ice-machine's in the hospital.

On 10/23/12 at 2:10 P.M., the engineering aid provided the ice-machine's manufacturer's guidelines. The engineering aid pointed to the manufacturer's guidelines that indicated that the ice-machine should be sanitized, and stated, "I just asked the other engineer what is the sanitizing portion and they don't know."

On 10/23/12 at 2:40 P.M., the Director of Engineering verified that the ice-machine's were only cleaned and maintained by the hospital's engineering department, and not by an outside contractor. The Director of Enginerring asked E3, "Don't we have ice-machine sanitzer?" E3 responded, "No, not that I know of." The Director of Engineering acknowledged that a bucket stored in the engineering deparment was not a sanitary method on how to rinse out a chemical from the ice-machine. The Director of Engineering acknowledged that the ice-machine's in the hospital were not being cleaned and sanitized in accordance with the ice-machine's manufacturer's guidelines.

On 10/24/12 at 9:00 A.M., located in the north nourishment room, the ice-machine chute area had white debri surrounding the inside of the chute and surfaces of the chute in which ice came in direct contact.

According to the ice-machine's manufacturer's guidelines the ice-making apparatus should be cleaned and sanitized with specific solutions in accordance with the manufacturer's guidelines. Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. The ice-machine guidelines indicated to "use 1/2 of the sanitizer/water solution to sanitize all foodzone surfaces of the ice machine and bin (or dispenser). Use a cloth or sponge to liberally apply the solution...,Do not rinse the sanitzied areas..." There was no indication that the nickel-safe ice-machine cleaner , to remove lime scale, should have been used in the ice-machine bin.

Based on observation, interview and record review, the hospital failed to ensure an effective system, linked between the medical record and the food and nutrition department, in which food allergies would be communicated thoroughly to ensure the menus would meet the needs of the patients.

Findings:

On 10/23/12 at 10:40 A.M., in the kitchen, a line of trays that held patients meal tickets that indicated the diet, allergies and menu items to be served to patients for lunch that day, were observed. There was a meal tray ticket for Patient 31 that indicated, "Lactose, Tree Nut Allergy, no corn, no celery, no oranges." The meal tray ticket indicated that peanut butter cookies were planned to be served to Patient 31 at lunch that day. The director of food and nutrition services (FSD) stated, "I will look into that."

On 10/24/12 at 9:30 A.M., Patient 31's dietary kardex system, used by the food and nutrition department to generate the meal ticket that was placed on Patient 31's meal tray, was reviewed. The dietary elctronic kardex system, did not interact with Patient 31's medical record. The electronic kardex indicated under "Special Diets/Allergies": "High Protein, Tree Nut Allergy, Lactose" (the other items such as no corn, celery or oranges was listed under the food preference area of the dietary kardex). The FSD reviewed Patient 31's dietary kardex and stated that Patient 31 was allowed to have peanut butter cookies since her allergy was to tree nuts.

On 10/24/12 at 9:40 A.M., Patient 31's medical record was reviewed with clinical registered dietitian (RD 5), and the FSD. Patient 31's medical record under nursing admission listed the following in regard to food allergies; allergic reaction: corn- rash/hives, allergic reaction: milk/milk products - nausea/vomiting, allergic reaction: celery - rash/hives, allergic reaction: nuts -rash/hives. The food allergy information was also indicated at the top of the screen in Patient 31's electronic medical record.

At that time, the FSD reviewed the medical record which indicated that Patient 31 was admitted to the facility on 10/12/12. The record indicated that Patient 31 had a food allergy to nuts. The FSD stated, "With a nut allergy, peanut butter cookies would not be okay. The recipe system should have pulled it out." The FSD verified that the dietary staff who worked on the tray line were expected to provide the items that are listed on the meal tray ticket to the patients, in which case, Patient 31's meal tray ticket had indicated to provide peanut butter cookies.

The FSD and RD 5 were asked if it were safe for Patient 31 to have received peanut butter cookies. The FSD stated, "I don't know because the RD that visited the patient is not here today to ask."

On 10/25/12, during the lunch tray line observation, Patient 31's medical record continued to indicate that Patient 31 was allergic to nuts, and patient 31's dietary kardex that generated the meal tray ticket continued to indicate that Patient 31 had a tree nut allergy. At that time, the FSD picked up the phone and spoke to Patient 31 and verified with the patient that she could tolerate peanut butter cookies.

There was a disconnect between the allergy information available in a patient's medical record versus a patient's allergy information in the food and nutrition department. According to the hospital's approved diet manual, "Peanuts and tree nuts account for most of the severe cases of food allergy and account for the majority of all severe and fatal reactions."

On 10/24/12 at 9:20 A.M., Patient 32's medical record was reviewed. According to Patient 32's medical record under "Allergies" indicated, "Latex - anaphylaxis [shock]. Drug Allergen: Penicillin - itching. Drug Allergen: Sulfa Drugs - itching. Banana - anaphylaxis. Avocado - anaphylaxis."

RD 5 reviewed Patient 32's dietary elctronic kardex system, that was not linked with Patient 32's medical record, and according to the information that the food and nutrition department had on the dietary kardex under "Special Diets/Allergies," indicated "No Restrictions." RD 5 acknoweldged that the food allergy information that was available in Patient 32's medical record was not available in the dietary kardex system, that would be utilized to develop the meal ticket that would provide direction to dietary staff on the food items to provide to the patient.

The FSD stated that the food and nutrition department's policies and procedures, did not contain a policy directly related to how the hospital's administration directed the food and nutrition department to address a latex allergy as it related to potential latex related food allergies.

The hospital's diet manual which was approved by the medical staff and governing body, which was to be used as guidance on how to process patient meals, did provide the following guidance, "Potential Problem with These Foods: Latex; High degree of association: Banana, Avocado, Chestnut, Kiwi." The diet manual included other foods under a moderate degree of association. The FSD stated, "Not everyone with a latex allergy is going to have a food allergy." There was no specific system in place on how the hospital's approved diet manual and the guidance it provided would impact how the food and nutrition department would address a patient's latex allergy.

According to the hospital's policy and procedure entitled Latex Allergy/Sensitivity Management (Policy Number H-PC 05-014, last revised 11/2010), "Purpose: To provide guidelines for a latex-safe environment for patients and staff. To prevent unnecessary latex sensitization and exposure..., Latex Risk:...Has a history of multiple allergies, especially to foods such as bananas, chestnuts, kiwis, avocados, and other tropical fruits..., Patient/Family Education; Patients and families should be provided information on the following...d. The risk of certain foods that can potentially cause latex allergic reactions."

There was a disconnect between the hospital's Latex Allergy/Sensitivity Management policy and procedure, the hospital's approved diet manual in regard to latex and potential cross-sensitivity to certain foods, food allergy information in the medical record versus the dietary electronic kardex, and knowledge base in regard to the expectations of dietary staff on how to coordinate a nutrition care plan for a patient who was admitted with a latex allergy.

The hospital's policy and procedure entitled Patient Diet Management System (Policy Number H-NS 05-005, last revised 06/2011) indicated, "It is our policy to utilize a manual or electronic system to identify patient's individual diet orders, food preferences and special needs...,Data on food preferences, food allergies, food medication interactions, ...are included. Tray tickets or menus will be individualized for each meal, as appropriate, based on information in the diet management system. Each facility will designate, by job description, the staff responsible for maintaining the diet management system accurately."

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke during a fire. This was evidenced by a roller latch (a latch that would prevent the door from fully closing) on a corridor door.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012 through October 25, 2012, the corridor doors were observed and a staff person was interviewed.

On October 24, 2012 at 3:25 p.m., the corridor door to the Center Nursing Station, was not latching when tested. There was a roller latch on the door and no other latching mechanism. There was a double action lock (a lock that requires two actions to open) on the door. The lock was a key type dead bolt lock. At 3:26 p.m., Staff 1 said during an interview, that he did not know that roller latches were prohibited.