HospitalInspections.org

Based on policy review, observation during tours, interviews with staff, and review of personnel record, the facility failed to provide a system for environmental cleaning to prevent and control infections, provide job description and training for Infection Control nurse.

Findings included:

1. Review of hospital policy, review date of 10/1/2014 revealed Policy and Procedure for Clean Up of Blood Spills. Step 2: Spill Kit Equipment: The following items may be needed in cleaning a blood spill. Biohazard Spill Kit (For cleaning small spills) 10% Bleach solution, Gloves, clear plastic bags, Leak proof sharps container, brush and dustpan or tongs, forceps for picking up sharps, disinfectant wipes.

Interview with housekeeper #1 on 05/13/2015 at 1030 revealed blood spills are mopped with mop. The mop head is washed in regular wash with other laundry.

2. Observation of housekeeper #1 on 05/13/2015 at 1030 revealed bottles on housekeeper cart without labels.

Interview with housekeeper #1 while on tour 05/13/2015 at 1030 revealed no policy and procedure for labeling cleaning supplies.

Interview with administrative staff #1 on 05/13/2015 at 1105 revealed "I don't look at carts to make sure they have the right cleaning supplies."

3. Observation of housekeeper #1 on 05/13/2015 at 1030 revealed cleaning of each patient room (Room 210 and physician office) using same dry cloth.

Interview with administrative staff #1 on 05/13/2015 at 1105 revealed there is not a list of housekeeping cleaning agents used for each cart.

4. Observation of cleaning carts on 05/13/2015 at 1100 revealed housekeeper #2 cart had two cleaning bottles on cart, "orange cleaner and NABC cleaner." Observation of cleaning cart with housekeeper #1 on 05/13/2015 at 1105 revealed seven bottles on cart, "orange cleaner, NABC cleaner, toilet brush sitting in water, steel cleaner, ant spray, second bottle of orange cleaner, Clorox bottle."

Interview with administrative staff #1 on 05/13/2015 at 1105 revealed there is not a list of housekeeping cleaning agents used for each cart. "I don't look at the carts." The Clorox bottle "needs to be labeled and dated."

5. Observation of housekeeper #1 on 05/13/2015 at 1105 revealed no handwashing between cleaning of rooms (Room 210 and physician office).

Interview with Nurse #2 on 05/13/2015 at 1500 revealed no logs of observation of handwashing of staff.

6. Review of personnel record of Infection control nurse on 05/13/2015 at 1500 revealed no job description. Review revealed no documentation of training/education for the Infection Control Nurse.

Interview on 05/14/2015 at 1000 of CNO revealed no written job description for infection control nurse. Interview further revealed the nurse had no training/education related to infection control.

Based on observation during tour, and staff interview, the facility failed to provide and maintain equipment that would be necessary for life saving procedures.

Findings include:

Observation during unit tour on 05/12/2015 at 1446, revealed 1 of 2 cardiac monitor / defibrillator units was found to have a biomedical equipment inspection due sticker dated 01/2014; 1 of 2 cardiac monitor / defibrillator units and a portable 12 lead EKG (Electrocardiogram) unit was found to have no biomedical inspection sticker. Further observation revealed 1 of 1 IV (Intravenous) pump biomedical equipment inspection due sticker dated 07/2014. Further observation revealed no pediatric sized bag valve mask (a hand held device commonly used to provide positive pressure ventilation to a patient that is not breathing, or not breathing adequately) on 2 of 2 crash carts.

Staff interview was conducted on 05/12/2015 at 1500 with Nurse #14, who stated he did not know who performed preventative maintenance on the hospital's equipment. Staff interview was conducted on 05/13/2015 at 1400, with Radiology Manager, who stated the portable 12 lead EKG machine has no yearly preventative maintenance, and is only serviced by a biomedical equipment professional if it is not functioning. Staff interview was conducted on 05/14/2015 at 1045, with the named hospital's Chief Executive Officer, who revealed the named facility has no preventative maintenance program on biomedical equipment in the hospital, with the exception of equipment used to perform mammography.

Based on observations as referenced in the Life Safety Report of Survey completed May 12, 2015 and observations and staff interview, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The facility failed to ensure all preventive maintenance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

~cross refer to 485.623(b)(1) - Maintenance Standard Tag C0222

2. The facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

~cross refer to 485.623(b)(5) - Maintenance Standard Tag C0226

3. The hospital failed ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 485.623(d)(1) & (3) - Life Safety from Fire Standard Tag C0231

Based on observations as referenced in the Life Safety Report of Survey completed May 12, 2015 and observations and staff interview, the facility failed to ensure all preventive maintenance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

The findings include:

1. Based on observations, on May 12, 2015 at approximately 10.00 AM onward, the following deficiencies were noted:
A) The Life Safety transfer switch and life safety panel were not connected to the main electrical system. The Life Safety transfer switch and life safety panel were found to be wired in as sub panel through Electrical Panel P-1.
B) On the corridor wall outside the staff breakroom there is one receptacle that is cracked at the ground plug area and one receptacle on the same wall that is scorched at the blade plug in location.
C) The wall light switch located in the kitchen next to the soiled drainboard is broken and not maintained in good condition.
NFPA 70
This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K147.

2. Observation during tour of the dietary department on 05/12/2015 at 1155 revealed a black substance between the ceiling tiles in the dry storage area. Interview with the dietary manager revealed "it looks like mold. I have been trying to get them to fix that". Observation further revealed a hole in the wall under the dish sink which was covered with cardboard.







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3. Review of hospital policy titled: "POLICY: OUTDATED OR UNUSABLE SUPPLIES" dated 08/2011 revealed Procedure: 1. "All supplies that are out dated/expired or contaminated are to be removed from the supply room or the pharmacy immediately. Outdated supplies will be removed from storage rooms, trauma rooms, or patient rooms and placed in utility room. Notify DON or ADON for disposal."

A) Observation on 05/12/2015 at 1130 of clean supply room revealed two (2) 18 gauge angiocaths (device to administer intravenous fluids) past expiration dates of September 2014 (8 months ago).

Interview with Nurse #14 on 05/12/2015 at 1130 revealed angiocaths were out of date and were available for patient care.

B) Observation on 05/12/2015 at 1130 of clean supply room revealed 1000 ml (milliliters) Normal Saline (mixture of water and salt) bottle with expiration date of February 2015 (3 months ago).

Interview with Nurse #14 on 05/12/2015 at 1130 revealed the bottle of Normal Saline was expired and was available for patient care use.

Based on observations and staff interview, the facility failed to ensure maintenance and inspection of the laminar hood used for mixing intravenous medications in the pharmacy.

The findings include:

Observation of the pharmacy on 05/13/2015 at 1400 revealed a laminar hood for mixing intravenous medications. Observation revealed no documentation that the hood had been inspected, certified or maintained to ensure the hood was working properly to maintain sterile preparation of intravenous medication.

Interview on 05/13/2015 at 1400 with the pharmacy consultant revealed the laminar hood is utilized for mixing intravenous medications. Interview revealed, "the hood should be replaced".

Based on observations as referenced in the Life Safety Report of Survey completed May 12, 2015 and observations and staff interview, the hospital failed ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

1. Based on observations, on May 12, 2015 at approximately 10.00 AM onward, the following deficiencies were noted:

2. Resident room 211 is utilized as a teleconference room and has sound proofing material on the walls and exceeds 10 percent of the aggregate wall area. The facility at the time of the survey could not provide information on the flame spread rating for the material.
NFPA 101: 10.2.5
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K15.

2. The corridor door to the x-ray room did not close, latch and seal when checked
NFPA101: 19.3.6.3
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K18.

3. Resident room 202 was used for storage and was not equipped with a self closing device. The vent for the film developer that penetrates the ceiling was not equipped with a fire damper. NFPA 101:19.3.2.1
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K29.


4. The tamper alarm on the sprinkler backflow preventor, (the one located on the incoming side of the device) in the sprinkler pit did not provide a visual and/or audible alarm at the fire alarm panel. NFPA 101, 4.6.12.1.
This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K62.

5. The oxygen storage was non-compliant, specific findings include the outside main oxygen storage was not covered to protect against inclement weather. Ref: 2000 NFPA 99, 4-3.5.2.2 Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter, cylinders stored in the open shall be protected against accumulations of ice or snow. In summer, cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. The type E oxygen cylinders stored at the oxygen storage area were gang chained together and not individual supported. [NFPA 99 4-3.5.2.1b(27)]. This deficiency affected the outside oxygen storage area.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K72.

6. The generator annunciator panel located at the nurse station did not show generator running when power was transferred from normal to emergency connected load.
The indicator lights on both the critical and life safety transfer switch were not operational.
NFPA 99. 3-4.1.1.15 This deficiency affected the entire facility.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross-refer to Life Safety Code Standard-NFPA 101, Tag K144.

Based on hospital policy review, personnel files review, observation, and interviews, hospital staff failed to have policies and procedures in place to ensure that periodic inspections are performed for 4 of 5 radiology equipment and to ensure ongoing competency documentation and periodic written evaluations for 2 of 4 radiology personnel files reviewed (#1 and #16).
The findings include:
1. Hospital policy and procedure review 05/12/2015 revealed no evidence of an active, ongoing process for conducting periodic performance maintenance (PM) on the hospital ' s stationary x-ray, portable x-ray (used to produce a digital image), stationary x-ray control panel, and bone density (used to measure amount of bone tissue) equipment.
Observation on 05/12/2015 at 1215 of the radiology room revealed no evidence of biomedical PM label/sticker on the stationary x-ray, control panel, and portable x-ray equipment. Observation of the bone density equipment also revealed no evidence of a biomedical PM label/sticker.
Interview on 05/12/2015 at 1215 with the radiology manager revealed the last service provided for the portable x-ray equipment was to "replace a battery because it went bad". Interview revealed (contracted x-ray services company) was called and replaced the stationary x-ray "collimator (light whose rays are parallel) light "4-5 years ago" with no services since that time. Interview revealed the control panel for the stationary x-ray equipment performs "auto-testing" and if the test fails, "that's when you call" for inspection.
Interview on 05/12/2015 at 1500 with the radiology manager revealed the hospital does not conduct periodic biomedical PM on the stationary x-ray, control panel, portable x-ray, or bone density equipment. Interview revealed (contracted x-ray services company) come as requested for repairs. Interview revealed stationary and portable x-ray, the control panel, and bone equipment is looked at when or if problems arise. Interview revealed, "They only come if we call them and we only call them if the machine needs something fixed or looked at. We do have our mammogram equipment inspected every year for certification. It's a payment thing".
Interview revealed measures currently in place to monitor for radiation leakage is the staff's use of "the badges that measure radiation levels" and "if images start showing poor quality, then we know something's going on and we call (contracted x-ray services company). Interview revealed radiation monitoring badges are monitored quarterly and a report of cumulative radiation levels is generated "in a couple of weeks". Interview confirmed hospital staff were not aware of the need for periodic biomedical inspections for radiology equipment.
Interview on 05/14/2015 at 1045, with the named hospital's Chief Executive Officer revealed the named facility has no preventative maintenance program on biomedical equipment in the hospital, with the exception of equipment used to perform mammography.

2. Review of the personnel file for radiology manager revealed a hire date of 8/12/2010. Personnel file review on 05/14/2015 revealed no competency validation and no ongoing evaluation.
Review of the personnel file for radiology technician (#16) revealed a hire date of 02/25/2012. Personnel file review on 05/14/2015 revealed no competency validation and no ongoing evaluation.
Interview on 05/12/2015 at 1500 with radiology manager revealed no competency validation or on-going education is conducted for radiology technicians.
Interview on 05/14/2015 at 1030 with administrative staff revealed, "We don't do annual evaluations and we don't validate competencies".

Based on review of personnel files and staff interviews, the facility failed to ensure the evaluation of on-going competencies of the nursing staff for 4 of 4 nursing staff files reviewed (#2, 4, 14 and 21).

The findings include:

1. Review of the personnel file for Registered Nurse (RN) #2 revealed the RN was hired on 10/18/2013 and was currently the infection control nurse. Personnel file review on 05/14/2015 revealed no documentation of a current job description, no competency validation and no on-going evaluation. Further review revealed no training/education related to infection control responsibilities.

Interview on 05/14/2015 at 1030 with administrative nursing staff revealed RN #2 was the infection control nurse. Interview revealed a job description was not available for RN #2. Interview further revealed, "we don't do annual evaluations and we don't validate competencies". Interview confirmed RN #2 was the hospital's infection control nurse and had not received formal training/education related to her job responsibilities in infection control.

2. Review of the personnel file for RN #4 revealed the RN was hired on 03/15/1993 and was the Chief Nursing Officer (CNO) for the facility. Personnel file review on 05/14/2015 revealed no documented on-going evaluation.

Interview on 05/14/2015 at 1045 with the Chief Executive Officer revealed he did not have a documented evaluation for the CNO.

3. Review of the personnel file for RN #14 revealed the RN was hired on 02/25/2004. Personnel file review on 05/14/2015 revealed no documentation of a current job description, no competency validation and no on-going evaluation.

Interview on 05/14/2015 at 1030 with administrative nursing staff revealed RN #14 was a staff nurse in the emergency department. Interview revealed a job description was not available for RN #14. Interview further revealed, "we don't do annual evaluations and we don't validate competencies".

4. Review of the personnel file for Certified Nursing Assistant (CNA) #21 revealed the CNA was hired on 11/18/2011. Personnel file review on 05/14/2015 revealed no documentation of a current job description, no competency validation and no on-going evaluation.

Interview on 05/14/2015 at 1030 with administrative nursing staff revealed CNA #21 was a nursing assistant. Interview revealed a job description was not available for CNA #21. Interview further revealed, "we don't do annual evaluations and we don't validate competencies".

Based on hospital policy review, and review of medical records, the hospital failed to ensure complete orders were written for two blood transfusions (patients # 9 and 10), and failed to ensure a registered nurse followed hospital policy for monitoring a patient receiving a blood transfusion for 1 of 2 patients (patient # 10).

Findings include:

Review of hospital policy titled Standard of Care - Administration of Blood, dated 02/2003, revealed, "...II. Procedure 1. Blood or blood products are administered under the following guidelines: a. Blood and blood product transfusion requires the order of a physician... j. Obtain and document vital signs per transfusion sheet."

1. Closed medical record of PT (Patient) #9 revealed a physician order dated 05/22/2014, not timed, "Admit to outpt (outpatient) for blood transfusion. Give 4 units PRBCs (Packed Red Blood Cells) when available. Acetaminophen (anti-inflammatory) 650 mg (milligrams) PO (by mouth) prior to 1st (first) unit and 3rd (third) unit. Benadryl (anti-histamine) 25 mg PO prior to 1st unit. Lasix (diuretic) 20 mg PO between each unit. CBC (Complete Blood Count) 05/23/2014 at 0900." Further review of the Blood Transfusion Administration Record revealed vital signs are to be obtained prior to blood transfusion, 15 minutes after the blood transfusion is started, every thirty minutes for 1 hour, then hourly until the blood tranfusion is complete, at which time a final set of vital signs is to be obtained. For the fourth unit of PRBCs, administered and documented by RN #22, vital signs were documented on the Blood Transfusion Administration Record for Pt #9 as follows, "...Initial Set of Vital Signs Prior to Infusion. Time 2015, Temp (temperature) 96.8, Pulse 91, Resp (respirations 22, BP (blood pressure) 113/61. Date and Time Blood Started: 05/22/2014 2035 Vital Signs 15 Min (minutes) after Blood Started. Time 2050, Temp 96.9, Pulse 94, Resp 22, BP 102/61. Assessment: Patient alert and oriented to person only. No dyspnea (difficulty breathing) or c/o (complaint of) pain voiced. Vital signs q (every) 30 min. Time 2105, Temp (blank), Pulse (blank), Resp (blank), BP (blank). Vital Signs q 30 min. Time 2135, Temp 97.1, Pulse 99, Resp 22, BP 105/64. Vital Signs Hourly (until completed): (Blank). Vital Signs Upon Completion of Blood Time 2305, Temp 96.9, Pulse 102, Resp 22, BP 107/69. Date and Time of Completion: 05/22/2014 2305."

Interview on 05/14/2015 at 0915 with administrative nursing staff confirmed the vital signs were not obtained per policy by RN #22 when administering blood to Patient #9.

2. Closed medical record of Patient # 10 revealed a physician order written by a physician, dated 03/08/2015, which reads, "Add Type and Cross 2 units PRBCs to lab, scheduled tomorrow." There is no written time on the order for the blood transfusion.

Interview on 05/14/2015 at 0915 with administrative nursing staff confirmed the order for the blood transfusion for Patient #10 was not timed when written on 03/08/2015. Interview confirmed the policy was not followed for ordering a blood transfusion.

NC00103952