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Based on Life Safety Code (LSC) survey, St. Vincent Seton Specialty Hospital Lafayette was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This facility occupies two smoke compartments of the northwest corners of the first and second floors of a three story building determined to be Type II (222) construction with a basement and fully sprinklered.

The facility has a fire alarm system with smoke detectors in corridors and spaces open to the corridor. The facility has the capacity for 29 patients and had a census of 7 patients.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 7 patient room doors protecting an opening to the corridor on the second floor had no impediment to closing (see K 018), failed to ensure a smoke detector connected to the fire alarm system on 1 of 2 floors smoke was properly separated from an air supply (see K 051) and failed to ensure documentation for inspection, testing and maintenance for 4 of 4 emergency generators providing Level 1 emergency power service was accurate and complete (see K 144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on policy and procedure review, observation, medical record review, and staff interview, the director of the nursing service failed to assure the "Fall Prevention" policy was followed for 2 of 2 (N10 and N11) open patient medical records reviewed that were documented as a risk for falls.

Findings:
1. Policy titled, "Fall Prevention", reviewed on 1/12/11 at 1:35 PM, indicated on pg. 3, point 4., "Large orange sticker on spine of medical chart, medium orange sticker on spine of blue chart and small orange sticker on Kardex..."

2. While on tour of the in-patient department on 1/12/11 at 12:45 PM, accompanied by P4, it was observed through review of open patient medical records and visual inspection of the patient, that patient:
A. N10, was documented as a risk for falls, but lacked the appropriate yellow fall risk arm band; orange sticker on spine of medical chart; medium orange sticker on spine of blue chart; and small orange sticker on Kardex.
B. N11, was documented as a risk for falls, but lacked the appropriate orange sticker on spine of medical chart; medium orange sticker on spine of blue chart; and small orange sticker on Kardex.

3. Personnel P4 was interviewed on 1/12/11 at 11:16 AM and indicated the above-mentioned patient medical records were indicated as risk for falls and were lacking the appropriate interventions as required per facility policy and procedure.

Based on document review, policy and procedure review, medical record review and staff interview, the facility failed to ensure telephone/verbal orders and/or authentication was documented as required per facility policy and procedure for 10 of 20 (N1, N2, N4-N8, N16, N19, and N20) closed patient medical records reviewed.

Findings:
1. Review of Rules & Regulations of the Medical Staff on 1/12/11 at 2:00 PM, indicated on pg. 6, point 2, "The person receiving a verbal or telephone order must read back and verify the order, and document such. All read back and verified orders must be authenticated no later than thirty (30) days after discharge. If an order is not read back and verified, it must be authenticated and dated by the responsible practitioner within twenty-four (24) hours."

2. Policy titled, "Telephone/Verbal Orders: Read Back and Verification of", reviewed on 1/12/11 at 10:50 AM, indicated on pg. 2, points B, G & H, "The written order must then be read back to the physician and verified for accuracy at that time...The order must be dated, timed and signed by the authorized healthcare professional receiving the order...The prescribing physician/LIP (Licensed Independent Practitioner) must authenticate read back and verified telephone/verbal orders within 30 days of discharge. If the order is not read back and verified, it must be authenticated and dated within 48 hours."

3. Review of closed patient medical records on 1/11/11 at 2:17 PM, indicated patient:
A. N1, had a telephone/verbal Physician's Order dated 10/6/10, but lacked documentation that it was read back and verified (RBAV). Patient expired 10/7/10 and the order was authenticated by the physician on 12/20/10, which is past 30 days from expiration. There was also a RBAV telephone/verbal order dated 10/6/10 at 20:00 PM that was authenticated by the physician, but lacked date and time of physician authentication.
B. N2, had a telephone/verbal Physician's Order that lacked a date and time of the order. There was also a RBAV telephone/verbal order dated 9/29/10 at 9:00 AM that was authenticated by the physician, but lacked date and time of physician authentication.
C. N4, had a telephone/verbal Physician's Order dated 10/21/10 at 3:34 AM that was authenticated by the physician, but lacked date and time of physician authentication.
D. N5, had a telephone/verbal Physician's Order dated 12/21/10 at 12:00 PM that was authenticated by the physician, but lacked date and time of physician authentication.
E. N6, had a telephone/verbal Physician's Order dated 7/22/10 at 16:15 PM that lacked authentication, date, and time by the authorized healthcare professional receiving the order.
F. N7, had a telephone/verbal Physician's Order dated 7/1/10 at 22:30 PM that was RBAV, but patient was transferred to another acute care facility on 7/2/10 and the order was authenticated by the physician on 8/21/10, which is past 30 days from transfer.
G. N8, had a telephone/verbal Physician's Order dated 5/28/10 at 9:35 AM that was authenticated by the physician, but lacked date and time of physician authentication.
H. N16, had Physician's Order dated 10/25/10 at 8:15 AM that lacked documentation that it was a telephone/verbal order that was RBAV. Patient was transferred 10/25/10 and the order was authenticated by the physician on 12/6/10, which is past 30 days from transfer.
I. N19, had a telephone/verbal Physician's Order dated 10/4/10 at 13:20 PM that was RBAV, but patient was discharged 10/5/10 and the order was authenticated by the physician on 12/20/10, which is past 30 days from discharge.
J. N20, had a Physician's Order dated 10/9/10 at 17:30 PM that lacked documentation that it was a telephone/verbal order that was RBAV and also lacked physician authentication with date and time.

4. Personnel P4 was interviewed on 1/12/11 at 11:16 AM and indicated the above mentioned patient medical records were lacking documentation of whether or not the Physician Order was a telephone/verbal order; was RBAV; was authenticated with date and time by the physician and/or authorized healthcare professional who received the order; and/or authentication within 30 days of discharge if the order was RBAV as required per facility policy and procedure.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure that informed consents for treatment were complete as required per facility policy and procedure for 7 of 20 (N2, N3, N7, N8, N11, N15 and N19) closed patient medical records reviewed.

Findings:

1. Policy titled, "Consents: Patient Consent to Health Care and Consent to Surgery/Medical Procedure(s)" was reviewed on 1/12/11 at 11:00 AM, and indicated on pgs. 1 & 2, point K, "A Properly executed informed consent shall include the following information...Signature and professional designation of the individual witnessing the consent..."

2. Review of closed patient medical records on 1/11/11 at 2:17 PM indicated patients N2, N3, N7, N8, N11, N15 and N19 lacked the signature and professional designation of the individual witnessing the consent.

3. Personnel P1 was interviewed on 1/12/11 at 11:30 AM and confirmed the Consent: Information-Records-Treatment-Financial Responsibility form requires a witness signature per policy and procedure and was lacking for the above-mentioned patient medical records.

Based on observation, interview and record review, the facility failed to ensure 1 of 7 patient room doors protecting an opening to the corridor on the second floor had no impediment to closing, failed to ensure a smoke detector connected to the fire alarm system on 1 of 2 floors smoke was properly separated from an air supply and failed to ensure documentation for inspection, testing and maintenance for 4 of 4 emergency generators providing Level 1 emergency power service was accurate and complete.

Findings:

1. Observation on 01/12/11 at 12:20 p.m. indicated the door to patient room 2317 had a linen receptacle and straight backed chair positioned in front of the open door. The impediments remained in the same position on 01/12/11 during the tour at 3:10 p.m. 19.3.6.3.6

2. SO#1 agreed at the time of observations that the equipment posed an impediment to closing the door.

3. Observation on 01/12/11 at 3:30 p.m. indicated the corridor smoke detector near patient room 2329 was located 24 inches from an air vent. 19.3.4, 9.6

4. SO#1 said at the time of observation, he/she hadn't noticed the proximity of the smoke detector to the source of air flow.

5. Review of emergency generator inspection, service, testing and maintenance records by contracted venders and building maintenance staff indicated maintenance records did not reflect conditions which were noted by outside vendors and should have been noted and addressed on weekly generator checks. An Emergency Generator Maintenance Schedule Weekly Procedure sheet was identified as the record for weekly maintenance and testing for the emergency generators. The record listed the Component (task performed), Visual Inspection, Check, Change, Clean, Test, Date, and Service Person in columns. A single sheet was used for all four emergency generators with no separation of inspection results for each generator. Aside from weekly date changes, there was no variation in the notations made for the condition of the generators during the past year. In addition, it appeared the condition entries documented since August 2010 had been made by a copier and dates and service person entries entered with pencil. Weekly maintenance reports for the past year showed no repairs or maintenance were required. A review of the semiannual outside generator contractor reports, the Generator Paralleling Control Gear Reports listed each generator, conditions for each and noted any adjustments, repairs needed, and observations requiring attention. The reports indicated conditions which should have been noted on the weekly inspection report prepared by the facility generator operator. For example, the facility report dated 03/22/10 found no problems, however, the outside contractor report dated 03/23/10 noted the oil level was low on Generator # 4 and low coolant levels for generators # 3 and # 4. Other contractor reports reflected conditions not noted on the weekly reports, such as battery cable corrosion. 3.4.4.1

6. MES#1 said at the time of record review, the record accurately reflected the condition of all four generators and they never had any trouble with them, but if they did, a contractor was called immediately to make repairs. MES#1 said nothing had been needed. When asked about oil changes and routine maintenance, he/she said the oil didn't need to be changed more frequently than every 200 hours and the generators could go for years since they were run only 50 hours per year. He/she said the fuel was checked annually for contaminants which would necessitate changing the fuel and there had been no need. MES#1 and generator operator agreed these were operating conditions which should have been checked weekly. The generator operator said at the time of record review, he/she had copied a previously prepared sheet for the generators report and used it after he/she ran out of blank sheets. He/she also said generator # 4 "blew" oil regularly and there was a drum adjacent to it for refilling. MES#1 agreed the maintenance sheets did not accurately reflect generator conditions.

Based on document review and interview, the facility failed to ensure measurement, analysis and tracking of quality indicators for hospital services of dietary, pest control and housekeeping.

Findings included:

1. Review of quality assessment/performance improvement documents and the monthly audit form utilized by infection control and safety management indicated lack of measurement, analysis and tracking of quality indicators for assessing hospital services of dietary, pest control and housekeeping.

2. Lack of measurement, analysis and tracking of quality indicators for dietary, pest control and housekeeping was confirmed by staff member A2 (10:30 AM) and A14 (11:00 AM) on 1/12/2011.