HospitalInspections.org

Based on policy/procedure review, transfusion record review, and staff interview, the facility failed to follow approved medical staff policies and procedures for one (T#1) of six transfusions reviewed.

Findings include:
1. On 4/28/14, policy/ procedure called: "4.8 Administration of Blood" (last reviewed 02/10/14) was reviewed and it stated : "GENERAL INFORMATION/KEY POINTS 14. B/P, TPR are to be taken and recorded before the transfusion is started." (where B/P is blood pressure and TPR is temperature, pulse, respirations).
2. On 4/29/14, review of transfusion records demonstrated that on transfusion labeled T#1, the Pre vitals ( B/P and TPR) were documented as being taken at the same time the transfusion was started.
3. In interview on 4/29/14 between 1:30 p.m. and 2:30 p.m., staff person # 4 acknowledged the facility's policy/procedure had not been followed.

Based on Life Safety Code (LSC) survey, Henry County Memorial Hospital comprised of the main hospital and a free standing therapy building was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 482.41(b), 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 for the main hospital and with Chapter 39, Existing Business Occupancies for the Forest Ridge Therapy building.

The Henry County Memorial Hospital building (01) consists of a four story sprinkled building of Type I (332) construction with a ground level. The hospital building has a fire alarm system with smoke detection in the corridors, in patient rooms and in spaces open to the corridors. The facility has a capacity of 90 and had a census of 68 at the time of this survey.

The Forest Ridge Therapy building (02) is a three story fully sprinkled building of Type II (222) construction with a ground level and it has a fire alarm system with smoke detection in the corridors and in spaces open to the corridors.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 12 corridors in the Forest Ridge building was provided with interior finishes with a flame spread rating of Class A or class B (see K 014), failed to ensure 2 of 2 areas in the Henry County Memorial Hospital building were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception (see K 017), failed to ensure 1 of 1 corridor doors for the cart wash room and 1 of 12 first floor rooms in the purchasing corridor in the Henry County Memorial Hospital building closed and latched into the door frames (see K 018), failed to maintain the vertical opening protection of 1 of 9 exit stairwells in the Henry County Memorial Hospital building (see K 020), failed to ensure penetrations through 1 of 1 smoke barriers near the level 4 ER area in the Henry County Memorial Hospital building was protected to maintain the smoke resistance of the smoke barrier (see K 025), failed to ensure 1 of 1 sets of smoke barrier doors near the dietary storage area in the Henry County Memorial Hospital building would restrict the movement of smoke for at least 20 minutes (see K 027), failed to ensure the corridor door to 2 of 32 hazardous areas in the Henry County Memorial Hospital building, such as combustible storage areas over 50 square feet in size, were provided with smoke resistive doors equipped with self closing devices that would cause the doors to automatically close and latch into the door frames (see K 029), failed to ensure exit access was arranged so 1 of 9 exits in the Henry County Memorial Hospital building was readily accessible at all times and failed to ensure the exit corridor leading from Stairwell Exit # 6 to the exit in the Henry County Memorial Hospital building was cleared of hazardous storage(see K 038), failed to ensure 1 of 4 fire door sets on the first floor of the Henry County Hospital building was arranged to automatically close and latch (see K 044), failed to ensure 8 of 8 exit means of egress and 12 of 12 corridors in the Forest Ridge building were provided with emergency lighting (see K 046), failed to ensure 1 of 1 exit signs in the mammography unit of the Henry County Memorial Hospital building was continuously illuminated (see K 047), failed to ensure 1 of 1 fire alarm systems in the Henry County Memorial Hospital building was continuously in proper operating condition (see K 052), failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed to provide complete coverage for all portions of the building (see K 056), failed to ensure 2 of 2 kitchen corridors and 1 of 8 kitchen rooms in the Henry County Memorial Hospital building were provided with sprinkler system piping free of nonsystem components (see K 062), failed to ensure the means of egress for 1 of 2 exits for the swimming pool in the Forest Ridge building was free of all obstructions which could interfere with their full instant use (see K 072), failed to ensure soiled linen containers in 1 of 12 first floor corridors in the Henry County Memorial Hospital building did not exceed 32 gallons (see K 075), failed to ensure 2 of 2 emergency generators with over 100 horsepower in the Henry County Memorial Hospital building were equipped with a remote manual stop and failed to provide adequate emergency task lighting in and around the 1 of 2 generator sets in the Henry County Memorial Hospital building (see K 144), failed to provide a written policy for the protection for 68 of 68 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period at the Henry County Memorial Hospital building (see K 154), failed to provide a written policy for the protection for 68 of 68 patients in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period for the Henry County Memorial Hospital building (see K 155) and failed to ensure 1 of 10 sprinkled elevator equipment rooms in the Henry County Memorial Hospital building was provided with an automatic means for disconnecting the main line power supply (see K 160).

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 observations, document review and interview, the facility failed to ensure 1 of 12 corridors in the Forest Ridge building was provided with interior finishes with a flame spread rating of Class A or class B, failed to ensure 2 of 2 areas in the Henry County Memorial Hospital building were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception, failed to ensure 1 of 1 corridor doors for the cart wash room and 1 of 12 first floor rooms in the purchasing corridor in the Henry County Memorial Hospital building closed and latched into the door frames, failed to maintain the vertical opening protection of 1 of 9 exit stairwells in the Henry County Memorial Hospital building and failed to ensure the exit corridor leading from Stairwell Exit # 6 to the exit in the Henry County Memorial Hospital building was cleared of hazardous storage, failed to ensure penetrations through 1 of 1 smoke barriers near the level 4 ER area in the Henry County Memorial Hospital building was protected to maintain the smoke resistance of the smoke barrier, failed to ensure 1 of 1 sets of smoke barrier doors near the dietary storage area in the Henry County Memorial Hospital building would restrict the movement of smoke for at least 20 minutes, failed to ensure the corridor door to 2 of 32 hazardous areas in the Henry County Memorial Hospital building, such as combustible storage areas over 50 square feet in size, were provided with smoke resistive doors equipped with self closing devices that would cause the doors to automatically close and latch into the door frames, failed to ensure exit access was arranged so 1 of 9 exits in the Henry County Memorial Hospital building was readily accessible at all times, failed to ensure 1 of 4 fire door sets on the first floor of the Henry County Hospital building was arranged to automatically close and latch, failed to ensure 8 of 8 exit means of egress and 12 of 12 corridors in the Forest Ridge building were provided with emergency lighting, failed to ensure 1 of 1 exit signs in the mammography unit of the Henry County Memorial Hospital building was continuously illuminated, failed to ensure 1 of 1 fire alarm systems in the Henry County Memorial Hospital building was continuously in proper operating condition, failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed to provide complete coverage for all portions of the building, failed to ensure 2 of 2 kitchen corridors and 1 of 8 kitchen rooms in the Henry County Memorial Hospital building were provided with sprinkler system piping free of nonsystem components, failed to ensure the means of egress for 1 of 2 exits for the swimming pool in the Forest Ridge building was free of all obstructions which could interfere with their full instant use, failed to ensure soiled linen containers in 1 of 12 first floor corridors in the Henry County Memorial Hospital building did not exceed 32 gallons, failed to ensure 2 of 2 emergency generators with over 100 horsepower in the Henry County Memorial Hospital building were equipped with a remote manual stop and failed to provide adequate emergency task lighting in and around the 1 of 2 generator sets in the Henry County Memorial Hospital building, failed to provide a written policy for the protection for 68 of 68 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period at the Henry County Memorial Hospital building, failed to provide a written policy for the protection for 68 of 68 patients in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period for the Henry County Memorial Hospital building and failed to ensure 1 of 10 sprinkled elevator equipment rooms in the Henry County Memorial Hospital building was provided with an automatic means for disconnecting the main line power supply.

Findings:

1. It was observed on 04/30/14 at 1:40 p.m. with DM1, Director of Maintenance, that the ground level Service Hall corridor walls had wooden paneling on both sides of the corridor walls extending from the floor to four feet six inches above the floor.

2. Interview with DM1 on 04/30/14 at 1:45 p.m.verified there was no documentation to indicate the flame spread rating of the wood paneling along both sides of the Service Hall corridor.

3. It was observed with COO1, Chief Operating Officer and SSD1, Safety/Security Director, at 9:55 a.m. on 04/30/14 that the men's and women's secondary waiting areas of the Imaging Department were open to the corridor and the corridor was protected by an electrically supervised automatic detection system, but the individual spaces were not.

4. In interview at the time of observation, COO1 and SSD1 acknowledged the waiting areas were not protected by automatic smoke detectors and the areas were not arranged and located to permit direct supervision by the facility staff from a nursing station or similar space.

5. It was observed with DM1 on 04/30/14 at 10:30 a.m. that the cart wash room door would not latch positively into the door frame. Observation during the tour with E1, Electrician, on 04/30/14 at 9:45 a.m. evidenced the door from the purchasing room into the first floor corridor was controlled by an electronic device that locked the door with controlled access and prevented the door from latching into the frame.

6. The above observations were acknowledged by DM1 and E1 at the time of observations.

7. Observation on 04/30/14 with DM1 at 10:55 a.m. noted the ground floor stairwell #3 door lacked a label indicating a fire resistance rating and it did not latch into the door frame. This door also had a hole in the upper right hand corner on the corridor side of the door.

8. In interview during observation, DM1 acknowledged the stairwell door did not latch and lacked a label with fire resistance rating.

9. Observation with COO1 and SSD1 at 9:35 a.m. on 04/30/14 indicated there was a two inch in diameter, orange conduit penetrating through the smoke barrier near the level 4 ER area with a one inch gap around the conduit that was not firestopped.

10. In interview at the time of observation, COO1 and SSD1 acknowledged the conduit penetration had not been firestopped.

11. Observation with DM1 at 10:45 a.m. on 04/30/1 noted the set of cross corridor doors outside dietary storage did not close completely, leaving a one inch gap between the doors.

12. In interview at the time of observation, this observation was acknowledged by DM1.

13. Observation with E1 on 04/30/14 between 8:00 a.m. and 11:00 a.m. indicated the third floor hazardous storage room (called Waters Storage room) which was approximately 12 feet by 15 feet had a door without a self closer. The second floor hazardous storage room door had a louvered grate 24 inches by 18 inches in the bottom third of the door and the door did not have a self closer.

14. In the interview at the time of observation, E1 acknowledged the aforementioned conditions.

15. Observation with DM1 on 04/30/14 at 11:00 a.m. noted the exit from the first floor stairwell #3 to the exterior was provided with a concrete stoop outside the door, but the means of egress did not terminate at a public way.

16. The above observation was acknowledged by DM1 at the time of observation.

17. Observation with E1 on 04/30/14 between 08:00 a.m. and 11:00 a.m. indicated the exit corridor out to the public access was being used to store fourteen 96 gallon waste containers.

18. In the interview during the observation, E1 acknowledged the aforementioned conditions. The containers at this time were all empty but upon interview with DM1 at the exit conference, he/she stated that they could all be full at any given time before pickup.

19. Observation on 04/30/14 at 10:45 a.m. with E1 noted the first floor Surgical Hall set of fire doors was released from their electromechanical holding devices and the fire doors failed to latch into the door frame.

20. The observation was verified by E1 at the time of observation.

21. Observations during a tour of the facility with DM1 on 04/30/14 from 12:55 p.m. to 2:30 p.m. showed the eight exit discharge paths which led to the parking lot, and the twelve corridors lacked emergency lighting.

22. The above observation was verified by DM1 at the time of observations and acknowledged at the exit conference on 04/30/14 at 2:40 p.m.

23. Observation with SSD1 on 04/30/14 at 10:05 a.m. revealed the exit sign on the inside of the mammography unit was not illuminated.

24. In interview at the time of above observation, SSD1 acknowledged the exit sign was not illuminated.

25. During observation tour on 04/30/14 with SSD1 from 9:30 a.m. to 10:15 a.m., the following were noted:
a. A smoke detector in the corridor outside exam room # 1 was one foot from an air vent. Based on interview at the time of observation, SSD1 acknowledged the smoke detector was one foot from an air vent.
b. An auxiliary fire alarm panel located near the oxygen storage area had "System Trouble" and "Circuit Trouble" lights on the fire alarm panel illuminated.

26. In interview at the time of observation, SSD1 did not know why the lights were illuminated.

27. The canopy outside the first floor stairwell # 3 exit exceeded four feet in width and was constructed with a sheet of fiberglass attached to a wood frame. This canopy was not provided with sprinkler protection.

28. In interview at the time of observation, DM1 acknowledged the canopy was constructed of combustible material; exceeded four feet in width and lacked of sprinkler protection.

29. Observations with SSD1 at 10:00 a.m. and with DM1 from 10:35 a.m. to 11:00 a.m. on 04/30/14 indicated the ground floor mechanical room with electrical panels and electrical equipment lacked sprinkler protection. The room was provided with a door with a solid wood core with no label indicating a fire resistance rating. The room contained two cardboard boxes and a small wood table.

30. In interview at the time of observation, DM1 acknowledged the room was enclosed by two hour fire rated walls but the door lacked the required fire resistance rating and combustible storage was not permitted.

31. The third floor gift shop storage room had an enclosed mechanical bulk head extending down 16 inches from the ceiling and extending from one side wall to the other side wall which prevented the sprinkler head from providing full protection to the 12 foot by 16 foot room.

32. In interview during the observation, E1 acknowledged the aforementioned conditions.

33. Observations on 04/30/14 during a tour of the kitchen from 11:20 a.m. to 12:00 p.m. with DM1 noted the food storage room and food storage room corridor leading from the kitchen had twenty nine zip ties used to tie down a red fire alarm system electrical wire connected to a thirty six foot length of sprinkler pipe. The kitchen exit corridor leading to the dock had twenty one zip ties used to tie down a red fire alarm system electrical wire connected to the twelve foot length of sprinkler pipe. NFPA 13 6-1.1.5 requires sprinkler piping not to be used to support non system components.

34. The observations were verified by DM1 at the time of observations and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

35. Observation on 04/30/14 at 1:20 p.m. with DM1 showed the north swimming pool exit corridor had a desk, two chairs, and a table stored in the the center of the north exit corridor which obstructed the use of the north exit corridor.

36. The above observation was verified by DM1 at the time of observation and acknowledged at the exit conference on 04/30/14 at 2:45 p.m.

37. Observation during the tour with E1 on 04/30/14 at 9:45 a.m. noted there were fourteen, 96 gallon soiled waste containers stored in the corridor obstructing the exit door # 6 stairwell and corridor.

38. The observation was verified by the electrician at the time of observation.

39. Observation on 04/30/14 at 11:05 a.m. with DM1 indicated each of the two generators in their respective generator enclosures was equipped with a manual stop switch, but not at a remote location. A battery powered emergency light was not located in the generator enclosure for the 480 V Caterpillar generator.

40. In interview at the time of observation, DM1 acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations and the 480 V Caterpillar generator enclosure lacked emergency task lighting inside the enclosure.

41. Record review on 04/30/14 at 9:45 a.m. with DM1 indicated the facility lacked a written policy in the event the automatic sprinkler system has to be placed out of service for four hours or more in a twenty four hour period.

42. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by DM1 at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

43. Record review on 04/30/14 at 9:30 a.m. withDM1 indicated the facility lacked a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period.

44. The lack of a written policy in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period was verified by the director of maintenance at the time of record review and acknowledged at the exit conference on 04/30/14 at 12:45 p.m.

45. Observation of the first floor elevator equipment room #4 on 04/30/14 at 10:40 a.m. with DM1 revealed the elevator equipment room for elevator #4 was provided with sprinkler coverage. Observation of the main elevator electrical equipment on 04/30/14 at 10:55 a.m. with DM1and E1 revealed there was no indication in the elevator equipment room that a shunt trip, which shuts electrical power to elevator when sprinkler system is activated, was provided for the elevator equipment.

46. This observation was verified by DM1and E1 at the time of observations and at the exit conference on 04/30/14 at 12:45 p.m.

Based on observation, manufacturer's owner manual review, policy and procedure review and interview, the facility failed to document a regular periodical maintenance program for 2 pieces of medical equipment, failed to ensure that an acceptable level of safety and quality was maintained in two areas toured and failed to implement its policy related to the cleaning of pantry refrigerators in two areas toured.

Findings:

1. On 4-29-14 at 8:05 am, in the presence of employees #A6, Facilities Manager and #A7, Life Safety Manager, it was observed in the Traction Room of the Forest Ridge Medical Pavilion offsite, there was an overhead traction device used for patient treatment. On that date and time, employee #A6 was requested to provide documentation of regular periodic maintenance of the traction device. No documentation was provided prior to exit.

2. On 4-29-14 at 8:15 am, in the presence of employees #A5, Medical Staff Coordinator and #A6, it was observed in the Physical Therapy area of the Forest Ridge Medical Pavilion offsite, there was a parallel bar device used for patient treatment.

3. In interview, on 4-29-14 at 8:15 am, employee #A6 indicated the equipment was less than 1 year old and had not yet been subject to regular periodic maintenance. On that date and time, employee #A6 was requested to provide documentation of any testing or checking of the device to ensure it was in good working order prior to implementation of usage for patient treatment. No documentation was provided prior to exit.


19814

4. Review of the Amsco (also Steris) blanket warmer owner's manual indicated:
a. in the preventive maintenance section, it addresses cleaning the stainless steel surfaces with "Calgonite" on an "As Required" basis

5. At 12:20 PM on 4/28/14, while on tour of the WCU (women and children's unit) in the company of staff members #50, the chief nursing officer, and #52, the director of the unit, it was observed in the "clean distribution" room that the Amsco blanket warmer had:
a. no thermometer to determine the temperature of the unit
b. an accumulation of dust in the top cabinet on the lower shelf
c. a gross amount of dust on the top of the warmer
d. the accumulation of dust in the clean distribution room is not at the quality required by the facility

6. Interview with staff members #50 and #52 at 12:25 PM on 4/28/14 indicated:
a. there is currently no facility policy or procedure related to blanket warmers
b. blanket warmer temperatures are not monitored at the facility and no standard temperature has been determined by the facility
c. the blanket warmer was dusty as described in 1. above
d. it is thought that there is no specific discipline that is responsible for cleaning the blanket warmers

7. At 10:20 AM on 4/29/14, while on tour of the recovery room area in the company of staff members #50, the chief nursing officer, and #57, the surgery director, it was observed that the Amsco blanket warmer,
a. had a gross amount of dust in the top cabinet under the lower shelf (on the bottom shelf) and on the door gasket of the top cabinet

8. Interview with staff members #50 and #57 at 12:30 PM on 4/29/14 indicated:
a. the blanket warmer was grossly dusty as listed in 3. above
b. there is currently no facility policy or procedure related to blanket warmers
c. the accumulation of dust could be a fire hazard, and thus, a safety hazard for patients and staff

9. Review of the policy and procedure for "Infection Control Manual Housekeeping", policy number 11.5 "Refrigerator Care", with a 5/21/12 revised date, indicated:
a. under "Procedure", it reads: "...All employee and patient refrigerators will be thoroughly cleaned weekly or as needed due to spills (weekly cleaning to be performed by Housekeeping personnel, all other spills or cleaning will be the responsibility of the department personnel utilizing the refrigerator)...."
b. under "Patient Refrigerators", it reads: "...Housekeeping personnel are responsible for recording daily PM (preventive maintenance) refrigerator temperatures and cleaning the refrigerators..."

10. At 12:10 PM on 4/28/14 while on tour of the WCU (women and children's unit) in the company of staff members #50, the chief nursing officer, and #52, the unit director, it was observed that the pantry nutrition refrigerator:
a. had dust and debris on the freezer door shelves
b. had crumbs and debris in the gasket of the refrigerator door
c. had crumbs and debris under the vegetable drawer

11. Interview with the unit housekeeper, staff member #61, at 12:30 PM on 4/28/14 indicated:
a. this staff member cleans the refrigerator every Wednesday
b. there is no log, or documentation, that would show that cleaning was being accomplished

12. At 2:15 PM on 4/28/14, while on tour of the CCU (critical care unit) in the company of staff members #50, the chief nursing officer, and #53, the unit director, it was observed in the pantry nutrition refrigerator that:
a. the freezer door shelves had an accumulation of dust and debris present
b. the right vegetable drawer had a three spots of a dried liquid (brown) present
c. there were crumbs under the two vegetable drawers
d. the tray with snacks, on the top shelf of the refrigerator, had a spilled sticky substance present

13. Interview with staff member #56, the contracted manager/director of housekeeping staff, at 3:55 PM on 4/28/14 indicated that housekeeping staff are to clean the refrigerators "daily" when doing the temperature checks

14. Interview with staff member #50, the chief nursing officer, at 3:55 PM on 4/28/14 indicated the refrigerators and freezers do not appear to be cleaned on a daily basis, or even weekly, as observed today

Based on policy and procedure review and interview, the infection control officer failed to ensure that communicable diseases were controlled related to the disinfection of patient room floors, as per facility policy, and based on observation and interview, failed to ensure the cleanliness of the endoscopy room by housekeeping staff.

Findings:
1. Review of the policy and procedure "Hospital Wide Spill Kit Procedure", policy number 10.13, with a last revised date of 05/08/08, indicated under:
a. "Purpose": "To prevent exposure to bloodborne pathogens."
b. under "Policy": "To decontaminate any spill on any surface or item from bloodborne pathogens or body fluids where they are no longer capable of transmitting infectious particles and the surfaces or items are rendered safe..."
c. under "Procedure": "...Use hospital approved disinfectant...take mop or cleaning cloth and wipe or mop area..."

2. Review of the policy and procedure "Infection Control Manual Housekeeping", policy number 11.8 "Routine Dismissal Cleaning Procedure", last revised 10/16/12, indicated:
a. under "Procedure", it reads: "...Dust mop and wet mop the floor from the inside of the room and work toward the door...The floor should stay wet for at least five to ten minutes for maximum bacteria kill..."

3. Review of the policy and procedure "Infection Control Manual Housekeeping", policy number 11.5 "Isolation Terminal Cleaning", last revised 10/16/12, indicated,
a. under "Procedure", it reads: "...Put wet floor sign at the doorway. Proceed with wet mopping. Start in the farthest corner from the door, moving the furniture...Leave it damp to air dry to get the maximum kill..."
b. under "Key Points:", it reads: "Always use hospital approved disinfectant at the EPA (environmental protection agency) dilution ratio on the label. Clean all areas thoroughly. Let the surfaces air dry to get the maximum effectiveness of the disinfectant to act on the bacteria thoroughly..."

4. Interview with the infection preventionist, staff member #60, at 2:10 PM on 4/29/14 indicated:
a. housekeeping is using a cleaner called "damp mop", not a disinfectant, to clean patient room floors daily, and with terminal cleaning, even isolation patient terminally cleaned rooms
b. per the infection control policy regarding spill kits, staff are to disinfect any area that comes in contact with blood or body fluid
c. housekeeping staff are not aware of any time that blood or body fluid may have been on the floor surface during a patient's hospital stay, and whether it was cleaned and disinfected appropriately, so that disinfection of the floor by housekeeping is the only way to be certain that disinfection occurs

5. Interview with staff member #56, the contracted housekeeping manager, at 9:40 M on 5/1/14, indicated:
a. the product "Damp Mop", a "Film Free Neutral Detergent" is not EPA registered and is not a hospital grade product
b. Damp mop is a cleaner, not a disinfectant
c. housekeeping staff are using the Damp Mop product to clean patient rooms daily, at terminal cleaning, and with terminal cleaning of a room floor after isolation (except patients with C-Diff where a bleach solution is utilized)
d. it cannot be determined by housekeeping staff whtether there has been a blood or body fluid spill (or cantact with the floor) within the patient's room at discharge, and whether is was disinfected at the time
e. the only way to be certain that any blood or body fluid spills were disinfected with terminal clean of a patient's room would be to use a disinfectant for cleaning/mopping

6. The policies listed in 2. and 3. above indicate that the floor should remain wet after mopping to "get the maximum kill...", which would not be accomplished by using a cleaner rather than a disinfectant

7. At 10:10 on 4/29/14, while on tour of the endoscopy procedure room in the company of staff members #50, the chief nursing officer, and #57, the surgery director, it was observed that the Skytron boom, where patient care equipment connects and is supported by, was dusty on top horizontal arm of the equipment

8. Interview with staff members #50 and #57 at 10:12 AM on 4/29/14 indicated that housekeeping staff needed to be monitored better in their cleaning processes

Based on observations, document review and interview, the facility failed to ensure 1 of 12 corridors in the Forest Ridge building was provided with interior finishes with a flame spread rating of Class A or class B, failed to ensure 2 of 2 areas in the Henry County Memorial Hospital building were separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or meet an Exception, failed to ensure 1 of 1 corridor doors for the cart wash room and 1 of 12 first floor rooms in the purchasing corridor in the Henry County Memorial Hospital building closed and latched into the door frames, failed to maintain the vertical opening protection of 1 of 9 exit stairwells in the Henry County Memorial Hospital building and failed to ensure the exit corridor leading from Stairwell Exit # 6 to the exit in the Henry County Memorial Hospital building was cleared of hazardous storage, failed to ensure penetrations through 1 of 1 smoke barriers near the level 4 ER area in the Henry County Memorial Hospital building was protected to maintain the smoke resistance of the smoke barrier, failed to ensure 1 of 1 sets of smoke barrier doors near the dietary storage area in the Henry County Memorial Hospital building would restrict the movement of smoke for at least 20 minutes, failed to ensure the corridor door to 2 of 32 hazardous areas in the Henry County Memorial Hospital building, such as combustible storage areas over 50 square feet in size, were provided with smoke resistive doors equipped with self closing devices that would cause the doors to automatically close and latch into the door frames, failed to ensure exit access was arranged so 1 of 9 exits in the Henry County Memorial Hospital building was readily accessible at all times, failed to ensure 1 of 4 fire door sets on the first floor of the Henry County Hospital building was arranged to automatically close and latch, failed to ensure 8 of 8 exit means of egress and 12 of 12 corridors in the Forest Ridge building were provided with emergency lighting, failed to ensure 1 of 1 exit signs in the mammography unit of the Henry County Memorial Hospital building was continuously illuminated, failed to ensure 1 of 1 fire alarm systems in the Henry County Memorial Hospital building was continuously in proper operating condition, failed to ensure 1 of 1 automatic sprinkler systems in the Henry County Memorial Hospital building was installed to provide complete coverage for all portions of the building, failed to ensure 2 of 2 kitchen corridors and 1 of 8 kitchen rooms in the Henry County Memorial Hospital building were provided with sprinkler system piping free of nonsystem components, failed to ensure the means of egress for 1 of 2 exits for the swimming pool in the Forest Ridge building was free of all obstructions which could interfere with their full instant use, failed to ensure soiled linen containers in 1 of 12 first floor corridors in the Henry County Memorial Hospital building did not exceed 32 gallons, failed to ensure 2 of 2 emergency generators with over 100 horsepower in the Henry County Memorial Hospital building were equipped with a remote manual stop and failed to provide adequate emergency task lighting in and around the 1 of 2 generator sets in the Henry County Memorial Hospital building, failed to provide a written policy for the protection for 68 of 68 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period at the Henry County Memorial Hospital building, failed to provide a written policy for the protection for 68 of 68 patients in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period for the Henry County Memorial Hospital building and failed to ensure 1 of 10 sprinkled elevator equipment rooms in the Henry County Memorial Hospital building was provided with an automatic means for disconnecting the main line power supply.

Findings:

1. It was observed on 04/30/14 at 1:40 p.m. with DM1, Director of Maintenance, that the ground level Service Hall corridor walls had wooden paneling on both sides of the corridor walls extending from the floor to four feet six inches above the floor.

2. Interview with DM1 on 04/30/14 at 1:45 p.m.verified there was no documentation to indicate the flame spread rating of the wood paneling along both sides of the Service Hall corridor.

3. It was observed with COO1, Chief Operating Officer and SSD1, Safety/Security Director, at 9:55 a.m. on 04/30/14 that the men's and women's secondary waiting areas of the Imaging Department were open to the corridor and the corridor was protected by an electrically supervised automatic detection system, but the individual spaces were not.

4. In interview at the time of observation, COO1 and SSD1 acknowledged the waiting areas were not protected by automatic smoke detectors and the areas were not arranged and located to permit direct supervision by the facility staff from a nursing station or similar space.

5. It was observed with DM1 on 04/30/14 at 10:30 a.m. that the cart wash room door would not latch positively into the door frame. Observation during the tour with E1, Electrician, on 04/30/14 at 9:45 a.m. evidenced the door from the purchasing room into the first floor corridor was controlled by an electronic device that locked the door with controlled access and prevented the door from latching into the frame.

6. The above observations were acknowledged by DM1 and E1 at the time of observations.

7. Observation on 04/30/14 with DM1 at 10:55 a.m. noted the ground floor stairwell #3 door lacked a label indicating a fire resistance rating and it did not latch into the door frame. This door also had a hole in the upper right hand corner on the corridor side of the door.

8. In interview during observation, DM1 acknowledged the stairwell door did not latch and lacked a label with fire resistance rating.

9. Observation with COO1 and SSD1 at 9:35 a.m. on 04/30/14 indicated there was a two inch in diameter, orange conduit penetrating through the smoke barrier near the level 4 ER area with a one inch gap around the conduit that was not firestopped.

10. In interview at the time of observation, COO1 and SSD1 acknowledged the conduit penetration had not been firestopped.

11. Observation with DM1 at 10:45 a.m. on 04/30/1 noted the set of cross corridor doors outside dietary storage did not close completely, leaving a one inch gap between the doors.

12. In interview at the time of observation, this observation was acknowledged by DM1.

13. Observation with E1 on 04/30/14 between 8:00 a.m. and 11:00 a.m. indicated the third floor hazardous storage room (called Waters Storage room) which was approximately 12 feet by 15 feet had a door without a self closer. The second floor hazardous storage room door had a louvered grate 24 inches by 18 inches in the bottom third of the door and the door did not have a self closer.

14. In the interview at the time of observation, E1 acknowledged the aforementioned conditions.

15. Observation with DM1 on 04/30/14 at 11:00 a.m. noted the exit from the first floor stairwell #3 to the exterior was provided with a concrete stoop outside the door, but the means of egress did not terminate at a public way.

16. The above observation was acknowledged by DM1 at the time of observation.

17. Observation with E1 on 04/30/14 between 08:00 a.m. and 11:00 a.m. indicated the exit corridor out to the public access was being used to store fourteen 96 gallon waste containers.

18. In the interview during the observation, E1 acknowledged the aforementioned conditions. The containers at this time were all empty but upon interview with DM1 at the exit conference, he/she stated that they could all be full at any given time before pickup.

19. Observation on 04/30/14 at 10:45 a.m. with E1 noted the first floor Surgical Hall set of fire doors was released from their electromechanical holding devices and the fire doors failed to latch into the door frame.

20. The observation was verified by E1 at the time

Based on observation, manufacturer's owner manual review, policy and procedure review and interview, the facility failed to document a regular periodical maintenance program for 2 pieces of medical equipment, failed to ensure that an acceptable level of safety and quality was maintained in two areas toured and failed to implement its policy related to the cleaning of pantry refrigerators in two areas toured.

Findings:

1. On 4-29-14 at 8:05 am, in the presence of employees #A6, Facilities Manager and #A7, Life Safety Manager, it was observed in the Traction Room of the Forest Ridge Medical Pavilion offsite, there was an overhead traction device used for patient treatment. On that date and time, employee #A6 was requested to provide documentation of regular periodic maintenance of the traction device. No documentation was provided prior to exit.

2. On 4-29-14 at 8:15 am, in the presence of employees #A5, Medical Staff Coordinator and #A6, it was observed in the Physical Therapy area of the Forest Ridge Medical Pavilion offsite, there was a parallel bar device used for patient treatment.

3. In interview, on 4-29-14 at 8:15 am, employee #A6 indicated the equipment was less than 1 year old and had not yet been subject to regular periodic maintenance. On that date and time, employee #A6 was requested to provide documentation of any testing or checking of the device to ensure it was in good working order prior to implementation of usage for patient treatment. No documentation was provided prior to exit.


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4. Review of the Amsco (also Steris) blanket warmer owner's manual indicated:
a. in the preventive maintenance section, it addresses cleaning the stainless steel surfaces with "Calgonite" on an "As Required" basis

5. At 12:20 PM on 4/28/14, while on tour of the WCU (women and children's unit) in the company of staff members #50, the chief nursing officer, and #52, the director of the unit, it was observed in the "clean distribution" room that the Amsco blanket warmer had:
a. no thermometer to determine the temperature of the unit
b. an accumulation of dust in the top cabinet on the lower shelf
c. a gross amount of dust on the top of the warmer
d. the accumulation of dust in the clean distribution room is not at the quality required by the facility

6. Interview with staff members #50 and #52 at 12:25 PM on 4/28/14 indicated:
a. there is currently no facility policy or procedure related to blanket warmers
b. blanket warmer temperatures are not monitored at the facility and no standard temperature has been determined by the facility
c. the blanket warmer was dusty as described in 1. above
d. it is thought that there is no specific discipline that is responsible for cleaning the blanket warmers

7. At 10:20 AM on 4/29/14, while on tour of the recovery room area in the company of staff members #50, the chief nursing officer, and #57, the surgery director, it was observed that the Amsco blanket warmer,
a. had a gross amount of dust in the top cabinet under the lower shelf (on the bottom shelf) and on the door gasket of the top cabinet

8. Interview with staff members #50 and #57 at 12:30 PM on 4/29/14 indicated:
a. the blanket warmer was grossly dusty as listed in 3. above
b. there is currently no facility policy or procedure related to blanket warmers
c. the accumulation of dust could be a fire hazard, and thus, a safety hazard for patients and staff

9. Review of the policy and procedure for "Infection Control Manual Housekeeping", policy number 11.5 "Refrigerator Care", with a 5/21/12 revised date, indicated:
a. under "Procedure", it reads: "...All employee and patient refrigerators will be thoroughly cleaned weekly or as needed due to spills (weekly cleaning to be performed by Housekeeping personnel, all other spills or cleaning will be the responsibility of the department personnel utilizing the refrigerator)...."
b. under "Patient Refrigerators", it reads: "...Housekeeping personnel are responsible for recording daily PM (preventive maintenance) refrigerator temperatures and cleaning the refrigerators..."

10. At 12:10 PM on 4/28/14 while on tour of the WCU (women and children's unit) in the company of staff members #50, the chief nursing officer, and #52, the unit director, it was observed that the pantry nutrition refrigerator:
a. had dust and debris on the freezer door shelves
b. had crumbs and debris in the gasket of the refrigerator door
c. had crumbs and debris under the vegetable drawer

11. Interview with the unit housekeeper, staff member #61, at 12:30 PM on 4/28/14 indicated:
a. this staff member cleans the refrigerator every Wednesday
b. there is no log, or documentation, that would show that cleaning was being accomplished

12. At 2:15 PM on 4/28/14, while on tour of the CCU (critical care unit) in the company of staff members #50, the chief nursing officer, and #53, the unit director, it was observed in the pantry nutrition refrigerator that:
a. the freezer door shelves had an accumulation of dust and debris present
b. the right vegetable drawer had a three spots of a dried liquid (brown) present
c. there were crumbs under the two vegetable drawers
d. the tray with snacks, on the top shelf of the refrigerator, had a spilled sticky substance present

13. Interview with staff member #56, the contracted manager/director of housekeeping staff, at 3:55 PM on 4/28/14 indicated that housekeeping staff are to clean the refrigerators "daily" when doing the temperature checks

14. Interview with staff member #50, the chief nursing officer, at 3:55 PM on 4/28/14 indicated the refrigerators and freezers do not appear to be cleaned on a daily basis, or even weekly, as observed today