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Based on observation, interview, and record review, the facility failed to ensure exit signs were present when the path of travel was not readily apparent, smoke detectors were located at least 36 inches from air supply/returns, inspection was performed of the kitchen hood system, the medical gas system was in compliance with the code, and generators logs were intact for weekly inspections and automatic transfer switch initiation times. This had the potential to affect all patients, visitors, and staff to the facility. The census on the first day of survey was 49 patients.
Findings:
See A710

Based on review of the facility's admission folders at two of four locations (Location #1 and Location #5) and staff interview, the facility failed to inform patients that they may lodge a grievance with the State agency directly, regardless of whether the patients have first used the facility's grievance process. This has the potential to affect all of the facility's 49 active patients.

Findings include:

The facility's admission folders were reviewed on 3/19/14 at 11:14 AM and 3:20 PM. The folder contained two forms which instructed patients on how to file a complaint. The first form titled "Important Telephone Numbers" stated resource nurses are on duty to answer questions or resolve issues that may arise during your hospital stay. The nurse manager is available to discuss issues that remain unresolved after speaking with the resource nurse. For further unresolved issues or complaints, the Chief Nursing Officer/ Chief Clinical Officer may be reached. If issues remain unresolved, ODH can be reached at the following numbers and address.

The second form titled "Report a complaint about a Heath Care Organization to the Ohio Department of Health" stated "If you feel the facility's Administration is unable to resolve your complaint, we are providing the following information for the Ohio Department of Health."

On 3/19/14 at 11:40 AM, the findings were shared with Staff N and confirmed.

Based on medical record review, interview and policy review, the facility failed to ensure dressing changes to central line catheter were completed every seven days for two (Patient #9 and #17) of 30 medical records reviewed. The facility failed to ensure pressure ulcers were measured weekly for two patients (#15 and #20) and failed to follow physician orders for wound care for one patient (#18) of 30 medical records reviewed. This had the potential to affect the facility's 49 active patients.

Findings include:

1. The medical record review for Patient #9 was completed on 3/20/14. Patient #9 was admitted to the facility on 10/17/13 with a diagnosis of obesity and chronic respiratory failure. The medical record contained evidence Patient #9's central line dressing was changed on 10/18/13 at 2:00 PM and on 10/28/13 at 1:30 PM. The medical record did not contain evidence Patient #9's central line dressing was changed at any other time during the patient's admission.

On 3/18/14 at 11:07 AM, the facility's Intravenous Therapy Care and Maintenance policy was reviewed. The policy stated the Hohn catheter dressings should be changed every seven days and as needed if wet, loose or soiled.

On 3/19/14 at 9:35 AM, the findings were shared with Staff N and confirmed.

2. Review of the medical record for Patient # 17 revealed the patient was re-admitted to the facility on 03/18/14 following surgical repair of a right hip fracture at a different hospital. Patient #17's diagnoses included history of a fall with right hip fracture, dementia, cardiac vascular accident, dysphagia, chronic obstructive pulmonary disease. The medical record revealed the patient was originally admitted to the facility while awaiting medical clearance prior to surgery for repair of the fractured hip. The medical record documented the patient received a peripherally inserted central catheter (PICC) line (used for intravenous or vein access for extended time periods for the delivery of fluids and medications) on 03/10/14 during the patient's hospitalization at another hospital.

On 03/20/14 at 10:10 A.M. observation of Patient #17's left upper arm revealed the presence of a PICC line. The transparent occlusive dressing protecting the insertion site indicated the occlusive dressing was placed on the same day the PICC was inserted on 03/10/14. This dressing was initialed and dated as 03/10/14.

Review of the facility policy and procedure titled "Central Venous Catheter" had a revision date of 05/12. This policy directed central catheters (included PICC line) dressings to be changed within the first 24 hours after insertion, and every seven days thereafter and as necessary. The policy and procedure further directed nurses to change the dressing on new admits.

Interview with Staff B on 03/20/14 at 10:10 A.M. verified the PICC line dressing had not been changed per facility policy. Staff B further verbalized a 10 day lapsed time since the initial dressing was performed. Staff B verbalized the dressing should have been changed on 03/18/14 at the time of the patient's admission from another facility.

3. Review of the clinical record for Patient #15 revealed the patient was admitted to the facility on 3/11/14 for shortness of breath and respiratory failure. The wound assessment forms indicate Patient #15 was assessed as having three pressure ulcers on 3/12/14. A pressure ulcer on the coccyx measured 5.0 centimeters (cm.) by 7.2 cm by 0.1 cm and was described as Stage II. A pressure ulcer was on the right heel measured 3.0 cm. by 3.0 cm by 0.1 cm and was described as unstageable due to eschar (dead tissue). The third pressure ulcer was on the left iliac crest and measured 4.0 cm by 2.5 cm and was described as unstageable due to slough (a layer of dead skin).

The wound assessment forms lacked evidence the wounds were re-measured during the patient's admission on 3/20/14.

The facility's policy on Pressure Ulcer: Risk, Assessment, Prevention and Wound Management indicates pressure ulcers are to be measured weekly to determine wound progress and effectiveness of treatment plan.

4. Review of the clinical record for Patient #20 revealed the patient was admitted to the facility on 02/26/14 for respiratory failure. The wound assessment forms indicate Patient #20 was admitted with two pressure ulcers. One pressure ulcer of the left plantar foot measured 4.2 centimeters (cm.) by 3.0 cm. and was described as unstageable deep tissue injury. The second pressure ulcer was of the right plantar area of the foot and measured 3.8 cm. by 3.3 cm. and was described as unstageable deep tissue injury. The wound assessment forms indicate Patient #20 developed a third pressure ulcer of the right buttock on 03/17/14. This pressure ulcer was described as a Stage II (partial thickness skin loss) pressure ulcer and measured 2.0 cm. by 2.0 cm. by 0.1 cm.

Further review of the wound assessment forms revealed the right plantar area of the foot was measured on 03/05/14 and 03/17/14, twelve days later. The left plantar area of the foot was measured on 03/03/14 and 03/17/14, fourteen days later.

The care plan for Patient #20 revealed skin integrity was not checked as a problem. There were no interventions planned to promote skin integrity.

Review of the Medical Nutrition Therapy Assessment for Patient #20, dated 02/27/14 and 03/14/14, revealed the registered dietitian (RD) indicated Patient #20 had no skin issues.

The facility's policy on Pressure Ulcer: Risk, Assessment, Prevention and Wound Management indicates pressure ulcers are to be measured weekly to determine wound progress and effectiveness of treatment plan. The nutritional needs of patients with pressure ulcers are to be assessed to ensure nutrition is adequate to support healing.

On 03/19/14 at 4:00 PM, Staff B indicated wound measurements should be done every week but the wound nurse may have been on vacation. Also Staff B indicated the RD had access to patient information by reviewing the clinical record for the wound documentation.

5. Patient #18 was admitted to the facility on 03/12/14 with diagnoses of sepsis and paraplegia. Review of the wound assessment forms revealed Patient #18 had three pressure ulcers on admission. The pressure ulcer of the coccyx was described as Stage III (full thickness skin loss) and measured 4.0 cm. by 2.0 cm. by 0.1 cm. on 03/12/14. The pressure ulcer of the right ischium was Stage III and measured 5.0. by 3.0 cm. by 0.1 cm and the stage III pressure ulcer of the left ischium measured 4.9 cm. by 3.0 cm. by 0.1 cm.

The physician's orders for wound care dated 03/12/14, was to apply Santyl Collagenase (prescription ointment to clean wound of unhealthy tissue) to coccyx, left ischium and right ischium pressure ulcers, and apply allevyn (foam) dressing daily. Review of the documentation for the pressure ulcer treatments revealed on 03/12/14 Santyl Collagenase was applied, followed by calcium alginate (used to absorb drainage) and allevyn dressing daily for treatment of the coccyx , right ischium and left ischium pressure ulcers.

On 03/20/14 at 8:45 AM, Staff B confirmed the physician had not ordered the calcium alginate for Patient #18's pressure ulcers.

The facility's policy on Pressure Ulcer: Risk, Assessment, Prevention and Wound Management indicated the treatment for Stage III pressure ulcers was to be prescribed by the physician.





31597

Based on clinical record review and staff interview, the facility failed to ensure nurses administered medication as prescribed by the physician. This affected one (#4) of 30 sampled patients. This has the potential to affect all patients in the facility. The active census was 49.

Findings include:

Review of the clinical record for Patient #4 revealed the patient was on supplemental insulin coverage four times per day. The medication administration record revealed on 03/16/14 at 11:30 AM, Patient #4's blood sugar was 422. The Diabetes Management Physician Order form indicates performing venous blood glucose immediately and douse a glucose strip with venous blood, administer insulin as specified below, notify physician for further orders and repeat glucometer blood sugar in one hour for a blood sugars over 400 mg/dl . On the form, the amount of insulin to administer for a blood sugar over 400 was not specified. The medication administration record revealed the nurse administered 14 units of Novolog Insulin. There were no physician's orders and no documentation in the clinical record the physician was notified of the blood sugar of 422 for Patient #4. The clinical record lacked evidence of immediate testing of venous blood glucose levels or glucometer readings. The next blood sugar reading was 68 at 4:30 PM.

On 03/19/14 at 10:00 AM, Staff C indicated he/she was the nurse taking care of Patient #4. Staff C revealed the physician's orders indicated the nurse was to notify the physician when Patient #4's blood sugar was over 400 for insulin orders. The nurse stated the physician was on the unit and he/she told the physician about the blood sugar of 422. The nurse stated the physician gave him/her a verbal order to administer 14 units of Novolog Insulin. The nurse confirmed there was no physician's order in the clinical record, no physician's note indicating the blood sugar and no nurse's note documenting the physician was notified.

Based on observation and staff interview, the facility failed to ensure medical records are protected from potential water or fire damage. This affected two (building #3 and #6) of six locations where medical records are stored. This has the potential to affect all patients admitted to the hospital. The facility's active census was 49.

Findings include:

1. On 03/19/14 at 11:45 AM, medical records were observed stored in the basement of the facility's corporate office, building #3, with Staff A. The medical records were stored on open shelves in cardboard boxes with three sprinklers on the ceiling. Staff A indicated the medical records are patient records which have been stored at this location for the past year. Staff A confirmed the sprinkler system is a wet system and still active.

On 03/20/14 at 11:45 AM, Staff Y was notified of the potential for water damage of the medical records stored at the corporate office.

2. On 3/20/14 at 12:00 PM, medical records were observed stored in the facility's offices at location #6. The medical records were stored on open shelves with no sprinklers. There were approximately 1772 folders stored on the shelves.

On 3/20/14 at 12:00 PM, the findings were shared with Staff P and confirmed. Staff O indicates the medical records were records of patients who were previously admitted to the facility during the past 10 months.

Based on medical record review, policy review and interview, the facility failed to ensure physicians completed a history and physical for one patient (#9) of 30 medical records reviewed. This had the potential to affect all of the facility's active 49 patients.

The medical record review for Patient #9 was completed on 3/20/14. Patient #9 was admitted to the facility on 10/17/13 with a diagnosis of obesity and chronic respiratory failure. The medical record contained one history and physical which was completed on 10/20/13.

On 3/19/14 at 10:19 AM, the facility's medical staff bylaws were reviewed. The bylaws stated a history and physical examination is to be completed and written within 24 hours after the admission of the patient.

On 3/18/14 at approximately 10:42 AM, the findings were shared with Staff N and confirmed.

Based on observation, staff interview, review of host hospital policy and procedures and hospital contract, the agency failed to adhere to policy and procedures related to the management and maintenance of equipment and storage of medication and other biologicals as well as consumable food products for one (#5) of four buildings. These deficient practices had the potential to negatively affect the facility's entire census of those who occupied the radiological services department. The capacity of building #5 was 32 and the census was 15.

Findings included:

Environmental tour of building #5's radiological department on 03/20/14 from 2:20 P.M. until 3:12 P.M. revealed outdated blood drawing specimen tubes within the computerized tomography (CT) room. Findings include five, five milliliter red topped blood collection tubes which with a manufacturers expiration date of 02/2009. Additionally, the drawer contained two purple topped 2 milliliter blood draw vials which expired on 5/2004. These findings were verified at the time with Staff D. The supply cupboard which lacked any sort of locking device was observed to contain 23 twenty milliliter bottles of 1% Lidocaine. There was one opened 20 milliliter vial 1% Lidocaine which was not dated, timed or initialed. Interview with Staff E verbalized this product expired 30 days after opening. Staff E further verbalized the department had requested a locking device on this medication supply cabinet but had been denied by the facility. Staff E verbalized the department staff had examined the cabinets and cupboards for expired medications and biological on 12/19/2013.

Inspectional tour of the radiological department's ultrasound room revealed the supply drawer was found to have three, five milliliter blood collection tubes which expired on 02/2012, 2 which expired on 10/2013 and two which expired on 02/2014. During inspection, the flat writing surface of the room directly adjacent to the examination table was observed to have an opened 16 ounce bottle of ice tea. When asked by the surveyor what the ice tea was utilized for staff responded that it wasn't for patient examination use but it belonged to another ultrasound technician. Interview with department supervisory Staff F on 03/20/14 03/20/14 at 2:49 P.M. verbalized that food and beverages should not be in examination rooms and acknowledged the blood collection tubes were expired.

Inspection of the facility's bone density room on 003/20/14 at 3:11 P.M. revealed the examination table was covered with a clear plastic overlay which was observed to be torn or ripped in several areas and had been repaired with adhesive tape that was soiled and curled on the edges. When asked by the surveyor how these repaired surfaces were cleaned and sanitized between patients, staff was unable to answer. These findings were verified with supervisory Staff F at the time of finding on 03/20/14 at 3:11 P.M.

Review of host building #5's hospital policy and procedure entitled Dating Open Multi-dose vials of Injectable, revised on October 2013, directed at item 3 that multi-dose vials of injectables expired 28 days after opening. Item six of the policy and procedure directed that opened multi-dose vials of injectable found without an expiration date are discarded. The host facility was unable to provide a policy and procedure that addressed the maintenance of equipment and expired biological products when requested by the surveyor.

Review of the lease agreement between the host hospital and the hospital lessee hereafter landlord and tenant respectively and dated 02/08/11 directed at item 7.3 (c) of the agreement that the landlord warrants it shall provide adequate, appropriately qualified personnel to perform the duties necessary to provide the Support Services and Clinical Services to the tenant. Landlord warrants that all services and clinical services will be provided in a manner in compliance with and that personnel providing support and clinical services to the tenant shall be licensed and or certified as required by the conditions of participation of Medicare and Medicaid programs and the standards, rulings, and regulations of the United States Department of Health and Human Services.

Based on observation, staff interview, and review of facility's policies and procedures three (building #1, #4 and #5) of the four host facilities failed to maintain food labels or discard outdated food items from the facility's refrigerator and maintain the building. Additionally, one (#4) of four host dietary services failed to store hazardous cleaning products away from food or maintain food temperature logs. These deficient practices had the potential to affect any patient served from the facility's three dietary services. The facility's dietary departments served a combined daily average of 68 dietary trays. The facility's combined census was 49.

Findings included:

1) Environmental tour on 03/17/14 from 11:15 A.M. until 11:55 A.M. of the host hospital's building #1 dietary service revealed the facility's walk in refrigerators contained a large uncovered tray of prepared red gelatin. This tray of gelatin was stored on the top shelf of a cart directly under the cooler's operational fan. The fan's blade cage was observed to be coated with dust and debris and was blowing directly onto the uncovered gelatin.

A refrigerator shelf contained two boxes, each containing two 10 pound rolls of raw ground turkey pulled from the freezer to defrost on 02/28/14. Additionally, two boxes were pulled from the freezer and dated for 03/03/14. Interview with Staff G on 03/17/14 at 11:20 A.M. verbalized the facility policy allotted the product 3 days for defrosting and an additional 5 days storage before the item must be used. Staff G verbalized the turkey dated 02/28/13 should have been used or discarded on 03/08/14 and the turkey pulled from the freezer on 03/03/14 should have been used before 03/11/14. The outside of this refrigerator door contained the weekly cooler inspection log revealing the last inspection performed was on 03/16/14. The inspection for Sunday 03/16/14 and Monday 03/17/14 indicates the ground turkey had been in the refrigerator for over two weeks.

The walk in refrigerator also contained undated containers of celery sticks and chopped celery. A large pan labeled meat sauce lacked the date the product was prepared or when it was to be discarded. A large pan of prepared rice was labeled with a discard date of 03/16/14. A container of corn chowder soup was labeled with a discard date of 03/15/14. Interview with Staff G on 03/17/14 at 11:55 A.M. verified the walk in cooler contained out dated foods that had not been discarded per the facility's policy. Staff G verbalized dietary staff checked the refrigerator every day for outdated foods.

Review of the host facility's dietary policy and procedures entitled "Use By Dates for Safety and Quality" with a review date of 05/10/12, directed all prepared foods to be discarded after three days of opening, preparing, cooking or cooling.

2) Environmental tour on 03/19/14 at 2:07 P.M. of the host hospital's building #4 dietary service revealed the facility's walk in refrigerators containing the following undated or use by date on: two boxes with a manufacturer's label indicating the contents to be; turkey sausage links, a 15 pound box of raw bacon, and a 2.5 pound bag of raw chicken breasts.

The floor between the kitchen and the dry food storage hallway was observed to be a painted cement floor which was badly chipped. Review of the previous kitchen inspection report dated for 05/13/13 revealed the facility had been cited for this and recommendation was made to paint and seal the floor. Interview with Staff I on 03/20/14 at 12:10 P.M. confirms this deficient practice.

The kitchen's reach in cooler contained a tray of uncovered and unlabeled chocolate cupcakes. The same refrigerator contained several individual clear plastic containers of yogurt dated for 04/14/14. Two containers of blueberry yogurt were dated for 03/17/14. Staff H indicated the 03/17/14 was a discard date. Additionally, a plastic bag of 1.5 dozen hard boiled eggs were dated for 03/15/14 and a discard date of 03/18/14. A plastic container of Kalamata olives had a discard date of 01/06/14, a jar of picante sauce had a discard date of 01/05/14, a bottle of hot sauce had a discard date of 01/16/14 and a plastic bag of celery sticks was stamped with a the manufacturer's use date of 03/07/14.

Interview with Staff H on 03/19/14 at 2:53 P.M. verbalized the dietary department's corporate policy was to use the date labeling system on all foods. The first date was the preparation date and the second date was the discard date. The above deficient findings were verified at this time.


3) Environmental tour of the host facility's #5 building completed on 03/20/14 from 11:10 A.M. until 12:30 P.M. revealed the walk in freezer external thermometer reading minus 10 degrees, there was no internal thermometer. The freezer had evidence of condensation on the ceiling and down the freezer walls with drippings frozen on food products. The freezer shelves contained poorly wrapped foods and plastic bags of diced turkey and 12 chicken breasts which were not sealed or labeled. A package of tuna steaks located on the top freezer shelf was partially wrapped in freezer paper with the end of the steaks exposed and covered loosely with a piece of plastic wrap which poorly adhered to the product. The package was dated for 09/18/13, indicating the date it was placed in the freezer. A box of cheese cake slices with one end opened, exposed desiccated product. The freezer contained a large tray of pot pies covered with torn foil exposed the product to air. The pot pie was observed to be freezer burned and the label was deteriorated leaving the date illegible. The freezer had several additional unlabeled and unidentified food products. Interview with Staff I during these observations on 03/20/14 confirmed the above findings.

Inspection of reach in cooler #2 on 03/20/14 at 11:19 A.M. revealed a large pan with two roasted turkeys each weighing between five and seven pounds. There was no date on the turkeys. The cooler contained chili peppers having a discard date of 03/18/14, prepared beet salad with no discard date, two plastic packages of diced celery with a manufacturer's expiration date of 03/17/14 and additional multiple food products without date labels.

Inspection of the #7 reach in cooler contained lettuce without any date labels. There was a package of deli meat slices with an illegible date, a two pound package of smoked ham slices with a discard date of 03/02/14. Additionally, the refrigerator failed to contain an internal thermometer. The external thermometer read 49 degrees. Inspection of cooler #8 revealed the gaskets were heavily soiled with food and debris and the cooler floor contained a large amount of crumbs, spills, and bits of unidentifiable food products.

Inspection of the cooking area under the hood revealed a storage shelf adjacent to the grill. The shelf contained three plastic containers being a gallon jug of vinegar, a butter substitute and a gel degreaser with a manufacturer's label which read "danger, exposure can cause digestive and eye injury". The manufacturer's label further directed to keep out of reach of children, wear protective rubber gloves and long sleeves when using and directed the user to call the poison control center for accidental ingestion. Interview with Staff I on 03/20/14 at 12:10 P.M. confirmed storage of cleaning products with food products was a dietary regulation violation.

Review of the food temperature log for the months of December 2013 and March 2014 reveal the facility had failed to record required food temperatures on 17 of 31 days in December 2013 and seven of 20 days in March 2014.

Review of the facility's policy and procedures entitled "Food Safety Standards and Requirements" with a revised date of 07/30/13 gave directions to properly separate and store toxic and chemical materials away from food, food equipment and utensils. It further stated that toxic materials must not be stored above or next to food, food equipment, utensils or single service articles. The policy further directed that refrigerators and freezer must contain thermometers inside at all times. The facility's policy entitled "Food Safety Product Labeling and Dating Guide" revised on 01/27/12 directed all food to be labeled with the name of the product, date of preparation and discard date.

Interview with Staff I on 03/20/14 at 12:30 P.M. confirmed the above deficient practices and policy violations.

Interview with hospital administrative Staff N on 03/20/14 at 4:10 P.M. verbalized the hospital has contracts with the host hospital directing the host hospitals to maintain their departments in accordance with Conditions of Participation for Medicare and Medicaid.

Based on observation, review of the facility evacuation plans, facility's documentation and staff interview it was determined this facility failed to ensure it was maintained in a manner safe from fire. This had the potential to affect all patients, staff and visitors. The patient census at the beginning of the survey was 49.

Findings include:

1) The facility (building #2) failed to ensure two exits that were not readily apparent were equipped with exit signs. This involved the 9th floor dialysis unit and the ground floor by the emergency department. The facility (building #3) evacuation plans failed to ensure two exits that were not readily apparent were equipped with exit signs. This involved the one of three exits from the facility. Please see K-22

2) The facility (building # 2 and 3) failed to ensure smoke detectors were located greater than 36 inches from air supply diffusers. Please see K-52

3) The facility (building #4) failed to ensure the ansul was inspected at least every 6 months. Please see K-69

4) The facility (building #2) failed to take action to correct deficient findings in the medical gas piped-in oxygen system. Please see K-76

5) The facility (building #4) failed to ensure the generators were inspected weekly. Please see K-144

Based on medical record review and facility guideline review, the facility failed to ensure staff provided tracheostomy care according to the facility's guidelines for one patient (#9) of 30 medical records reviwed. This had the potential to affect all of the facility's 49 active patients.

The medical record review for Patient #9 was completed on 3/20/14. Patient #9 was admitted to the facility from 10/17/13 through 10/29/13 with a diagnosis of obesity, chronic respiratory failure and status post tracheostomy.

The medical record contained Respiratory Daily Data Record sheets. The sheets did not contain evidence of tracheostomy care being completed on 10/18/13 and 10/28/13 during the night shifts.

The medical record contained evidence of a sputum sample being collected from the Patient #9 on 10/19/13 and on 10/23/13. The final results of both of the samples were positive for a respiratory infection.

The facility's the Tracheostomy Care Guidelines were reviewed on 3/18/14 at 11:07 AM. The guidelines stated routine tracheostomy care will be provided each shift and as needed.

On 3/19/14 at 2:51 PM, the findings were shared with Staff M and confirmed. Staff M reported tracheostomy care is to be completed once every 12 hours and as needed. Staff M reported if the tracheostomy care box on the Respiratory Daily Data Record sheets does not contain initials, it would indicate the tracheostomy care was not completed.

This deficiency substantiates Substantial Allegation OH00073727.