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Based on observations, staff interviews, observations, and review of facility maintenance logs, this Condition of Participation is not met related to fire safety in regard to lack of adequate lighting outside one exit discharge, the sprinkler system wrench and corroded sprinkler heads, a medical gas inspection report, generator logs, and one exit discharge at an off-site facility. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit on 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day. Reviews were conducted of the facility's maintenance logs on 01/27/12.

Based on the tour observations, staff interviews, and review of facility maintenance logs, one exit discharge on the west wing lacked adequate lighting, the facility staff were unable to locate a wrench for the sprinkler system, a corroded sprinkler head was observed in the walk-in refrigerator and one in the freezer in the dietary department, the medical gas inspection report identified deficient areas that have not been corrected, the generator logs lacked the temperature of the water jacket to ensure the diesel fuel remained warm, and one off-site facility lacked an exit sign at the exit discharge.
Refer to A709.

Based on observation and staff interview, it was determined the hospital failed to ensure personal privacy for two of three patients during subcutaneous insulin injections (Patients #16 and 18). The sample size was 30. The hospital census was 11.

Findings include:

On 01/25/12 at 7:55 A.M. Staff R was observed to administer a Regular Insulin injection into the abdomen of Patient #16. Staff R administered the insulin without pulling the privacy curtains or closing the room door. Patient #16's abdomen and the procedure being performed were visible to any persons walking in the outside corridor or entering the patient's room. The patient's lack of privacy was verified with Staff R on 01/25/12 at 7:55 A.M.

On 01/25/12 at 9:35 A.M. Staff R was observed to administer a scheduled insulin injection into Patient #16's abdomen.
A visitor was present in the patient's room during the insulin administration. Staff R did not provide privacy for Patient #16 during the insulin injection. Staff R exposed the patient's abdomen and performed the insulin injection with a visitor present in the room without obtaining the patient's consent.

Interview with Staff S on 01/25/12 at 9:35 A.M. revealed the hospital's policy to ensure patient's privacy is to pull the patient's privacy curtains and close the room door during treatments/procedures.

On 01/25/12 at 9:00 A.M. Staff R was observed to administer an insulin injection into Patient #18's abdomen. Staff R did not pull the privacy curtains or close the room door during the insulin injection. The patient's abdomen and the procedure being performed were visible to any persons in the outside corridor or entering the patient's room. The patient's lack of privacy was verified with Staff R on 01/25/12 at 9:00 A.M.

Based on observation, policy review and staff interview the facility failed to ensure newborns were in a safe environment. This affects any baby born in the maternity unit. The census was one baby (Patient #21) and, one mother,(Patient #20) in the maternity unit on 1/25/12. The hospital census was 11.

Findings include:

Observation during tour on 1/25/12 revealed an unlocked door to the maternity unit that could be entered without staff being aware if the staff were in patient rooms or in the nursery. The surveyor entered the maternity unit at 1:45 PM. It was noted there was a camera positioned at the nursing station.

Interview of maternity staff members revealed the camera shows activity in the main hall. No other areas of the maternity unit are under camera surveillance. Interview of Staff Q revealed there is no alarm system for infant security. Interview of Staff Q on 1/25/12 revealed the policy for infant security titled "Keeping Your Newborn Safety, OB 1", is to have the mother sign acknowledgement of having been educated on baby safety. During the interview Staff Q stated a man was in approximately three weeks ago to give an estimate for setting up cameras on the outside of the maternity unit door and a system to lock the door allowing no entrance without staff observation of the person for whom she/he would be unlocking the door. Staff Q revealed the door would still not be locked for exiting the unit, and anyone would be able to leave at will.

Based on facility guidelines for food temperature review, staff interview and observations of the food service department, the facility failed to ensure opened and used dry goods were dated, stored refrigerated foods were dated, and chilled foods and drinks were maintained at a proper temperature. Six of seven inpatients in the hospital were served at the lunch meal. The facility census was seven on 1/25/12.

Findings include:

A tour of the food service department was conducted on 01/25/12 in the 12:00 PM with Staff N. Tour of the department revealed two 25 to 40 gallon bins sitting on the floor, one bin contained flour and the other contained sugar. No dates were observed on the bins to indicate when the flour or sugar had been placed in the bins. Staff N, during interview at 12:00 PM, revealed it was unknown how long the sugar and the flour had been in the bins.

Observation in the walk-in refrigerator revealed two opened gallon sized containers of salad dressing on the shelf. No dates were observed on either container to indicate when they were opened. Staff N confirmed the two opened gallon containers were not dated.

Tour of the dry goods storage area revealed two dented cans of food were stored with the undamaged cans on the shelf, one dented can contained beets and the other contained a liquid dietary supplement. Staff N confirmed the two dented cans were stored with the undamaged can.

The toaster on the tray line area was found to have a heavy buildup of crumbs. Staff N confirmed the heavy crumb buildup in the toaster.

A test tray was prepared by the food service staff at 12:00 PM along with the patient's food. The cart with the test tray, taken to the inpatient units by Staff N and the two facility food service employees, arrived on the unit at 12:10 PM.

Measuring the temperature of the food and beverages on the test tray revealed the pasta salad temperature,measured by a food service employee,was 62 degrees. The temperature of the chilled peaches was 60 degrees,

Review of the facility guidelines printed on the temperature log records revealed chilled foods temperature should be maintained between 40 degrees and 50 degrees. Staff N verified the temperatures of the chilled foods on the test tray were higher than required for food safety at 12:10 PM. on 01/25/12.

Based on observations, staff interviews, and review of facility maintenance logs, medical gas inspection report, the facility failed to meet the provisions of the Life Safety Code related to fire safety in regard to lack of lighting outside one exit discharge, lack of the sprinkler system wrench, corroded sprinkler heads, a medical gas inspection report, generator logs, and one exit discharge without an exit sign at one off-site facility. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day. Reviews were conducted of the facility's maintenance logs on 01/27/12.

Based on the tour observations, staff interviews, and review of facility maintenance logs, a medical gas inspection report, one exit discharge on the west wing lacked adequate lighting, the facility staff were unable to locate the wrench for the sprinkler system, two corroded sprinkler heads were observed one in the walk-in refrigerator and one in the freezer in the dietary department, the medical gas inspection report identified deficient areas that have not been corrected, the generator logs lacked documentation of the monitoring of the temperature of the water jacket to ensure the diesel fuel remained warm, and one off-site facility lacked an exit sign at the exit discharge. Refer to A710.

Based on observations, staff interviews, review of facility maintenance logs, review of a medical inspection report, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association related to discharge lighting outside one exit, lack of the sprinkler system wrench and corroded sprinkler heads, a medical gas inspection report, documentation of the monitoring of the temperature of the generator's water jacket in the generator logs, and one exit discharge at an off-site facility. This could affect all patients in the facility. The total census during this visit was 11 patients.

Findings include:

During this visit from 01/23/12 through 01/26/12, a tour was conducted in the facility with Staff T and M. The tour times were as follows: On 01/24/12, between 1:30 PM and 4:30 PM, and on 01/25/12 and 01/26/12, between 8:30 AM and 4:30 PM each day. Reviews were conducted of the facility's maintenance logs on 01/27/12.

During this tour, the following areas were observed:

a) An exit discharge located between the West Maternity Wing and the 1993 building was observed without a light outside the exit discharge. An interview with Staff T, during tour, verified the light was missing from the wall outside the exit discharge. Refer to K45.

b) During tour, facility staff were unable to locate the wrench for the sprinkler heads. Staff T verified the sprinkler head wrench was missing from the sprinkler head box. A corroded sprinkler head was observed in the walk-in cooler, and one in the walk-in freezer in the dietary department. Refer to K62.

c) The medical gas inspection report, dated 11/22/10, revealed deficient areas that needed to be corrected. As of the survey exit date, 01/27/12, these areas have not been corrected, based on interview with Staff T. Refer to K77.

d) A review of the generator logs for two generators lacked documentation of the monitoring of the temperature of the generators' water jackets. It was verified the facility's fuel supply for both generators was diesel. Refer to K144.

e) The urgent care facility lacked an exit sign at the exit discharge, for one of two exits. Refer to K47.