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Based on observation, interview, record review, and policy and procedure review the facility failed to ensure the protection and promotion of patient's rights by not ensuring an appropriate process to identify a grievance from a patient complaint and follow through according to policy (A-118); ensuring that written responses to the patient regarding their grievance contained all the elements per the regulation (A-123); ensuring that patient's medical records were kept secure (A-146); and ensuring that a device that restricts the use of patient hands was defined as a restraint device (A-159).

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based on interview, record review and policy and procedure review the facility failed to ensure an appropriate process is in place to identify a grievance for patient complaints in 4 of 5 (#15, #16, #31, #33) patient complaints. Findings include:

On 8/3/2010 at approximately 1345 during the review of patient complaints the following was revealed:
Patient #15- The complaint indicated the patient alleged staff was ignoring him.
Patient #16- The complaint indicated the staff was being "mean" and "gave her a cold shoulder and yelled."
Patient #31- The complaint indicated the staff was "rude" and "did not take time to listen."
Patient #33- The complaint indicated "the nurse was short tempered and was making faces, not being nice."

Review of the facilities policy titled "Policy and Procedure Grievance" a grievance is defined as "...a patient grievance is a ' formal or informal written or verbal complaint that is made to the hospital by a patient or patient's representative, regarding the patients care, abuse or neglect, ...."

On 8/3/2010 at approximately 1415 an interview with staff #B, #C, and #L revealed that the documents referred to above should have been considered grievances.

Based on interview, record review and policy and procedure review the facility failed to ensure the written notice provided to the patient regarding the resolution to the grievance contained all the elements required for 4 of 4 (#17, #18, #34, #35) patient grievances. Findings include:

On 8/3/2010 at approximately 1345 during the review of patient grievances, 4 of 4 (#17, #18, #34, #35) written responses to the grievance did not include the steps taken on behalf of the patient to investigate the grievance, of the results of the grievance process and the date of completion.

Review of the facilities policy titled "Policy and Procedure Grievance" under the section titled "Resolution Of Grievance" it is written "... written response to the grievance, to include investigation findings, the steps taken on behalf of the patient, the results of the grievance process and its resolution, the name of the hospital contact person in the event of any further questions, and the date of completion."

On 8/3/2010 at approximately 1415 an interview with staff #B, #C, and #L revealed that the written responses were without the steps taken on behalf of the patient to investigate the grievance, of the results of the grievance process and the date of completion.

Based on observation, interview and policy review the facility failed to ensure medical records are kept secured. Findings include:

On 8/3/2010 at approximately 1005, during the tour it was observed that the medical records are stored in a wall cabinet just outside the patient's doorway, these wall cabinets were found to be unlocked.

On 8/3/2010 at approximately 1005 the staff member #A was queried regarding the unlocked wall cabinets and the accessibility to the patient's medical records and she replied "We've never done that, we haven't locked them for 16 years and we've never had a problem."

On 8/3/2010 at approximately 1630 review of the facility's policies titled "Maintenance of Protected Health Information" and a policy titled "Protected Health Information" revealed an absence of addressing securing open and current medical records. Staff #B was queried about a policy that addressed securing medical records of current patients and the above policies were presented.

Based on observation, interview, and policy review the facility failed to define a device that restricts the use of patient hands as a restraint device in 2 of 2 (#2, #3) patients. Findings include:

On 8/3/10 at approximately 1045 after the tour of the unit concluded staff #B was queried regarding if any patients were currently in restraints. Staff #B replied "no, we do not use restraints", then staff #B was queried if any patients were currently wearing mitts and staff #B replied "I am not sure, we don't consider those restraints, we remove the strap that ties them down."

On 8/3/10 at approximately 1050 staff #G was queried by a co-worker if any of her patients were wearing mitts and she stated "no".

On 8/3/10 at approximately 1055 a walk through was completed by two surveyors to look into patient rooms to see if any patients were wearing mitts. Patient #2 was wearing mitts and the use of her hands was restricted. Staff #G was queried and she stated "I didn't know she had them on, she didn't have mitts on when I went in to assess her, the aide must have put them on. Staff #F was queried about the application of the mitts on patient #2 and she replied "They're not a restraint, she has them on because she scratches herself and scratched staff when we help her." Upon review of patient #2's medical record there was no documentation that addressed applying the mitts on 8/3/10.

On 8/3/10 at approximately 1105 patient #3 was observed wearing mitts which restricted the use of her hands. Staff E was queried about a physician's order to apply mitts to patient #3 and she replied "she is wearing them so she doesn't pull at her lines, those aren't a restraint." Upon review of patient #3's medical record there was no documentation that addressed applying the mitts on 8/3/10.

On 8/4/10 at approximately 0800 upon review of the facility's policy and procedure titled "Restraints and Protective Devices" and the policy has no documentation regarding the use of mitts.

Based on documents reviewed, observation, and interview the facility failed to ensure accurate records were kept of the receipt and disposition of all scheduled drugs. Findings include:

During the course of the pharmacy observation on 8/3/10 at 1030 hrs, request was made to account for the expired controlled medications kept in the pharmacy's narcotic safe. Pharmacist H counted the narcotics against a tally sheet that was kept for each expired scheduled medication in the safe. While counting, it was noted and confirmed with Pharmacist H that Dilaudid 12mg/30ml had 14 vials identified on the count sheet, but only 13 vials were present. It was also noted that Methylin 5mg tabs and Methadone 5mg tabs (#100 ea.) had been expired since April 2010 and had not had their respective counts added to the expired narcotic count sheets.

Based upon observation during the building tour on August 6, 2010 between 11:00 AM and 1:30 PM, it was determined that the facility failed to maintain the physical plant to assure the safety and well-being of patients. The findings include:

The medication room was not being thoroughly cleaned. There was an accumulation of dust and debris under the Omnicell unit, which was identified when the unit was moved away from the wall.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on August 3-4, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 4, 2010, for Life Safety Code.

Based upon observation during the building tour on August 6, 2010, between 11:00 AM and 1:30 PM, the facility failed to maintain an acceptable level of safety and quality as evidenced by

1. The temperature readings taken at the following two sinks were above the acceptable range
for water temperature is 105 F - 120 F:
a. The hot water temperature at the handwash sink in the PT gym measured 127 F.
b. The hor water temperature at the handwash sink in the patient toilet room adjacent
to the PT gym measured 125 F.

2. The medical gas zone control valve in the corridor outside the PT gym was incorrectly labeled as to area served. On the day of the survey (Aug 6, 2010), the label read, "Zone Valve F serves Pain clinic, Fluoroscopy, and Waiting Room." The area has not been used for Pain clinic, Fluoroscopy, or waiting room for several years.

3. The labeling of the electrical circuits in the circuit panel by Room 839 was incorrect. There were seven ciruits identified to serve individual rooms 832, 833, 834, 835, 836, 837 & 838, but the circuits were turned off. There were three remaining circuit breakers that were switched off, but these were appropriately labeled "Spare."


28267

Based on observation and interview the facility failed to ensure that expired supplies were not available for patient use. Findings include:

On 8/3/2010 at approximately 1015 during the tour of the unit the crash cart that is located in the treatment room contained the following supplies that were found to be expired:
Second drawer-
Two packs of sterile 4X4 gauze pads expired in 10/09
Five 22 gauge intravenous catheter packages expired in 9/07
Four 18 gauge intravenous catheter packages expired in 8/04
Four 20 gauge intravenous catheter packages expired in 11/06
Four 24 gauge intravenous catheter packages expired in 6/07

Third drawer-
Two intravenous start packs expired in 2/08
Two packages of steristrips expired in 2/02
Four povidone prep swab packaged expired in 1/07

At the time of these findings staff #A and staff #B confirmed the findings.

Based upon observation of the facility on August 6, 2010, between 11:00 AM and 1:30 PM, it was determined that the did not maintain proper ventilation in the following two small storage rooms.
1. Storage room by the PT gym, and
2. Storage room next to Room 813.
Both storage rooms were being used to store clean medical supplies. Both rooms did not have any supply air, but only a single exhaust air grill. One room had previously been a visitor toilet room. Both rooms were under a net negative pressure rather than the net positive pressure.

Based on documents reviewed and interview the facility failed to ensure the person designated as the infection control officer had acquired specialized training in infection control. Findings include:

**The CDC definition of an "infection control professional" is; "A person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control."

During the infection control program interview conducted 8/4/10 at 0930 hrs with Pharmacist H, it was confirmed that the Director of Pharmacy had responsibility for the facilities infection control program. Review of the facility's document entitled; " Performance Improvement Plan, 2010 Infection Control / Pharmacy"(sic) (undated). The document identified; "The responsibility of the Infection Control area lies with the Director of Pharmacy. This individual is responsible for the prevention and control of HEALTHCARE ASSOCIATED INFECTIONS among employees and patients"(sic). The facility failed to appoint a qualified individual with responsibility for the hospital's infection control program.