HospitalInspections.org

CONDITION IS NOT MET

Based on the life safety code inspection conducted on 07/18/11 thru 07/20/11, it was determined that the facility failed to meet all of the Life Safety Code requirements. This has the potential to affect all patients, visitors, and staff members. This facility census was 57.

Findings include:

Please refer to the following Life safety code violations for more information.

K-25 This facility failed to ensure the smoke barrier was constructed with at least a one hour fire rating according to the National Fire Protection Association (NFPA) 101, Chapters 19 and 8.3.
K-38 This facility failed to ensure the exit access was readily available in regards to the exit access door equipped with two latching mechanisms.

K-54 This facility failed to ensure all smoke detectors were sensitivity tested according to the National Fire Protection Association (NFPA) 72, Chapter 7-3.2.1.
K-72 This facility failed to ensure the exit access was readily available in the event of an emergency in regards to keeping the exit access free from obstructions.



This information was shared at the time of finding and again at exit interview on Wednesday, 07/20/11.

Based on review of the Medical Staff By-laws, review of medical records and staff interview, the facility failed to ensure that the by-laws were enforced to ensure that medical staff carry out their responsibilities in regard to documenting date and time of all medical record entries. This affected 27 out of 31 current and discharged records reviewed. Patients number 1, 2, 3, 5, 7, 9, 10 and 12 thru 31.
The facility census of both locations was 57.

Findings include:

On Wednesday, 07/20/11, the Medical Staff By-laws and Rules and Regulations were reviewed. In section 6.3 for physician orders it stated " must be countersigned the next time the physician sees the patient." Further in the same section 6.3 it stated " include date, time and full signature"; under section 6.7 it stated "written clearly, legibly and completely".
In section 7.9 in regard to progress notes, the By-laws stated "progress notes must be written at least daily".
Review of the medical records revealed that when telephone orders were signed by the physicians, there were no dates or times written; orders written for restraint use were not dated or timed; physician hand written orders were not timed when written. Please see A 457 for more in-depth information.
This was confirmed by the Director of Care Services on Thursday, 07/21/11 at approximately 12:45 PM.

During review of the closed patient medical records it was noted that several of the progress notes were dictated, typed and then signed by the physician or Nurse Practitioner. The date of the visit was noted on the top of the typed page and the dictation date and time and the typed date and time were noted at the bottom of the the last page. Although there may have been a progress note dated for each day, the visit date and the dictation date were not always the same. Record reviews also revealed that consultants that may have dictated their consults were also not dictating their visit notes timely.
Review of the medical record for Patient 23 revealed that there was a dictated progress note for 05/19/11. The typed note showed that the visit had taken place on 05/19/11 but was not dictated until 05/24/11 when it was then typed. There was a progress note for a visit made on 05/21/11 that was not dictated until 05/24/11 when it was then typed. A third visit made on 05/26/11 was not dictated until 05/30/11 when it was then typed.
Review of the medical record for Patient 24 revealed that for the visits of 06/27/11, 06/28/11 and 06/29/11, dictation did not take place until 07/06/11 for all 3 days. A visit made on 06/30/11 was not dictated until 07/07/11 when it was typed and a 07/01/11 visit was dictated at that time as well.
Review of the medical record for Patient 25 revealed that a consult done on 04/14/11 was not dictated until 04/25/11 and typed that same day.
Review of the medical record for Patient 27 revealed a progress note for a visit made on 07/01/11 was not dictated until 07/06/11 when it was typed.
Review of the medical record for Patient 28 revealed that a progress note for a visit made on 04/24/11 was not dictated until 04/27/11 and typed that same day.
Review of the medical record for Patient 29 revealed that visits made on 06/08/11 and 06/09/11 were not dictated until 06/21/11. Visits made on 06/10/11, 06/13/11, 06/14/11, 06/15/11 were not dictated until 06/22/11 when they were then typed. Visits made on 06/17/11 and 06/20/11 were not dictated until 06/29/11 and a visit made on 06/21/11 was not dictated until 07/01/11.

Part of the Medical Staff Rules and Responsibilities calls for History and Physicals (H&P) to be done in 24 hours of the patient's admission.
Review of the medical record of Patient 22 revealed that the patient was admitted on 06/10/11 but did not have a H&P done until 06/13/11.
Review of the medical record of Patient 25 revealed that the patient was admitted on 03/24/11 and had their H&P done on that same day. The H&P was not dictated until 03/30/11 and typed that same day.
Review of the medical record of Patient 26 revealed that they were admitted on 06/25/11 and seen that same day for the H&P, however the H&P was not dictated until 06/29/11 when it was then typed.
Review of the medical record for Patient 28 revealed that the patient was admitted on 04/22/11 and had a H&P done on 04/23/11 that was not dictated until 04/27/11 when it was then typed.

All of the above information was shared with the facility on Thursday, 07/21/11.

Based on medical record review and staff interview, the facility failed to ensure that all orders, including verbal orders were dated and timed promptly for out of 31 records reviewed. This affected Patients 20, 23, 25, 27, 28, 29, 30 and 31. The facility census was 57.


Findings include:

Review of the medical record for Patient 20 revealed that the patient had been in restraints. The restraint orders written on 03/04/11, 05/18/11 and 05/20/11 had no time documented as to when the order was written. On 05/17/11 the physician wrote a "now" order but did not time when it was written.

Review of the medical record for Patient 22 revealed that the patient had been in restraints. The restraint orders written on 06/11/11, 06/12/11, 06/19/11, 06/22/11, 06/23/11 and 06/24/11 had no time documented as to when the orders were written.

Review of the medical record for Patient 23 revealed that the patient had orders to "hold" medications on 05/20/11 and 05/27/11 but did not have the time the orders were written. Patient 23 also had orders written on 05/18/11, one of which was for a new dressing, which were not timed when written.

Review of the medical record for Patient 25 revealed that the patient had physician orders written without a date or time. This order was found written between 2 other orders dated 03/26/11. On 04/05/11, 04/06/11, 04/09/11, 04/19/11 times 2 orders, 05/07/11 and 05/16/11 there were no times documented as to when the orders were written. Orders were noted to include medication changes, laboratory orders and a preparation order for a procedure.

Review of the medical record for Patient 26 revealed a physician order written on 07/05/11 that was not timed when written.

Review of the medical record for Patient 27 revealed physician orders that were not timed for 06/30/11, 07/01/11 and 07/07/11, one of which was an order for dialysis treatment.

Review of the medical record for Patient 28 revealed physician orders that were not timed when written for restraints on 04/22/11 thru 05/2/11 and 05/05/11. On 05/02/11 an order for a medication change was not timed when written. This patient also had orders written by a Registered Dietician for dietary recommendations on 04/25/11, 04/29/11 and 05/02/11 that were not timed when written.

Review of the medical record for Patient 29 revealed physician orders that were not timed when written on 06/06/11 (admission orders), 06/10/11 and 06/20/11.

Review of the medical record for Patient 30 revealed physician orders that were not timed when written on 06/15/11, 06/16/11 and 06/19/11.

Review of the medical record for Patient 31 revealed physician orders that were not timed when written on 04/25/11 (admission orders), 04/28/11 and 04/29/11; restraint orders on 04/26/11, 04/27/11 and 04/28/11 were not timed when written; transfer orders no date or time when written.
This information was shared with Staff B during all days of the survey. Staff B stated that they were aware of the lack of dating and timing of orders.

Based on medical record review and staff interview, the facility failed to ensure that verbal orders were authenticated within 48 hours for 15 out of 31 patients reviewed. This affected Patients 1, 2, 3, 5, 7, 9, 10, 12 thru 17 and 23 and 25. The facility census was 57 patients.

Findings include:


07973

Patients 1 and 15 had one verbal order unsigned by the physician within 48 hours of being written.

Patient 2 had 24 verbal orders unsigned by the physician within 48 hours of being written.

Patients 3 and 17 had two verbal orders unsigned by the physician within 48 hours of being written

Patient 5 had five verbal orders unsigned by the physician within 48 hours of being written.

Patients 7 and 16 had four verbal orders unsigned by the physician within 48 hours of being written.

Patients 9 and 12 had eight verbal orders unsigned by the physician within 48 hours of being written.

Patient 10 had 6 verbal orders unsigned by the physician within 48 hours of being written.

Patient 13 had 13 verbal orders unsigned by the physician within 48 hours of being written.

Patient 14 had 9 verbal orders unsigned by the physician within 48 hours of being written.

Patient 23 had a verbal order dated 05/16/11 that was not signed until 06/22/11.
Patient 25 had verbal orders that were signed however there was no date or time of when this was done.
This was confirmed by Staff B on the afternoon of 07/21/11.

Based on tour of the medical record area and staff interview, the facility failed to ensure that all medical records were complete within 30 days following discharge. The facility census was 57.


Findings include:

During the observation of the medical record area on Tuesday, 07/19/11, and staff interview at that time, it was learned that there were delinquent medical records. Staff G was asked for the actual numbers of delinquent records at that point and time and gave the numbers for both locations.
The following day, Wednesday, 07/20/11, Staff G confirmed for the surveyor that there were 13 delinquent records at the Steubenville location and 3 delinquent records at the Bellaire location.

Based on the life safety code inspection conducted on 07/18/11 thru 07/20/11, it was determined that the facility was not maintained in a manner safe from fire. This had potential to affect all patients, visitors, and staff members. This facility census was 57.

Findings include:

Please refer to the following Life safety code violations:

K-25 This facility failed to ensure the smoke barrier was constructed with at least a one hour fire rating according to the National Fire Protection Association (NFPA) 101, Chapters 19 and 8.3.
Tour of the Bellaire location took place on 07/19/11 with staff members Q, R and S. During tour of the one hour fire rated smoke barrier located at the back side of the nurses station and from within the clean utility room, observation was made above the ceiling tiles of an approximate 18 foot by two foot section of drywall missing from just above the top of the ceiling tiles to the upper deck.
This finding was observed by staff members R and S during the tour on 07/19/11.


K-38 This facility failed to ensure the exit access was readily available in regards to the exit access door equipped with two latching mechanisms.

Tour of the pharmacy department at the Steubenville location took place on 07/20/11 with staff B. Observation was made of the rear exit access door having two separate latching mechanisms. One latching mechanism was a door handle equipped with a push button lock which, when locked, would disengage by pushing down on the door handle.
The second locking mechanism was located a few inches above the door handle and was observed to be a deadbolt equipped with a thumb latch device. This door was not able to be opened with one simple effort from the egress side.
This was verified by staff B when he/she attempted to open the door and using two hands, one to grab the door handle and push down and the other to reach up to the thumb latch and twist to disengage the deadbolt.


K-54 This facility failed to ensure all smoke detectors were sensitivity tested according to the National Fire Protection Association (NFPA) 72, Chapter 7-3.2.1.
Documentation review for the Bellaire location, of the smoke detector inspection and testing took place on 07/19/11. The annual testing was performed by an outside professional company on 06/08/11. Sensitivity testing of the smoke detectors was not noted on the annual test reports. This was brought to the attention of staff S at 2:45 PM on 07/19/11. Staff S made a phone call to the company who performed the annual test and found that they have never performed sensitivity testing of the smoke detectors.

K-72 This facility failed to ensure the exit access was readily available in the event of an emergency in regards to keeping the exit access free from obstructions.

Tour of the pharmacy department at the Steubenville location took place on 07/20/11 with staff B. Observation was made of the rear exit access door from the egress side having a medication cart blocking the door and preventing it from being readily opened in the event of an emergency.
Once the medication cart was removed and the door was opened, observation was made on the opposite side of egress, of a small mobile storage unit standing about three feet tall with another type of storage device placed on top. The storage units in total were observed to be blocking the entire width of the exit access and from the floor to about four feet high.

Interview with staff O at approximately 10:20 AM revealed that the space occupying the opposite side of the exit access is a home health department.

Based on medication pass observation and staff interview on 07/21/11 it was determined that the hospital staff nurse failed to follow acceptable infection control standards of practice in administering medications to one of two patients observed (Patient 12). The hospital census was 57.

Findings include:

Observation of medication pass for Patient 12, on 07/21/11 at 10:40 AM revealed a staff nurse, employee T, pick up the patients urinal from the floor during the administration of medications. The nurse continued with the medication pass for this patient without washing or sanitizing his/her hands. This was verified by nurse T at 11:00 AM . Interview of employee B at 1:15 PM confirmed that the nurse should have sanitized his/her hands before continuing with the med pass.