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The Nursing Services Condition remains as cited on the substantial allegation survey on 05/05/2010 (OH00052699).

Based on observations, staff interviews and review of fire safety information, the Condition of Participation for Physical Environment is not met due to the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association in regard to maintaining one hour fire rated construction in the two electrical rooms, conducting fire drills quarterly and servicing annually and inspecting monthly two portable fire/halon extinguishers. This affected all patients, staff and visitors. The census at the time of the survey is 21.


Findings include:

During the survey on 08/11/10 and 08/12/10, the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association in the following areas:

The facility failed to ensure two electrical rooms were maintained with a one hour fire rated construction as the rooms were observed with multiple penetrations.
The facility failed to conduct fire drills for the third quarter this past year.
Two portable fire extinguishers were not inspected monthly and one portable halon extinguisher had not been maintained annually or inspected monthly.

Refer to A710 for the findings.

Based on observations made of the medical surgical floor and high observation area, review of medical records, policy and procedures review and interview and confirmation with staff it was determined that the hospital failed to ensure that all staff and visitors adhered to infection control policies regarding personal protective equipment. The hospital also failed to ensure that staff re-educated visitors regarding infection control and the necessity of personal protective equipment. The hospital census was 22. This affected four (Patients #1,12,18,22) of 22 patients.

Findings include:

During observations staff and visitors were observed not wearing personal protective equipment in the rooms of patients who had been placed on contact isolation precautions. Refer to A749 for the findings.

The Standard RN Supervison of Nursing Care remains as cited on the substantial allegation survey on 05/05/2010 (OH00052699).

Based on observations, staff interviews, review of fire/halon extinguishers inspection tags and review of fire drills, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association in regard to maintaining one hour fire rated construction in the electrical rooms, conducting fire drills quarterly and servicing annually and inspecting monthly two portable fire/halon extinguishers. This affected all patients, staff, and visitors. The census at the time of the survey is 21.

Findings include:

During the survey on 08/11/10 and 08/12/10, the facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association in the following areas:

The facility failed to ensure two electrical rooms were maintained with one hour fire rated construction. Refer to K29.

The facility failed to conduct fire drills for the third quarter. Refer to K50.

The facility failed to ensure two portable fire extinguishers and one halon extinguisher were inspected monthly and serviced annually in accordance with the NFPA 10 code. Refer to K64.

Based on observations made on the medical surgical unit, review of policies and procedures and interview and confirmation with staff it was determined that the infection control officer failed to ensure that active surveillance was effective and that all staff adhered to infection control policies. This involved Patient #1, 12, 18, 22. The hospital census is 22.

Findings include:

The medical record for Patient #1 was reviewed on 08/10/10. Patient #1 was admitted on 08/06/10 with heart failure, urinary infection and an irregular heartbeat. Patient #1 was currently to have contact isolation precautions followed.

On 08/10/10 at 10:50PM floor observations were made. The tour revealed that the visitors seated in Patient #1's room were not wearing any personal protective equipment. The review of the facility's Infection Control Policy entitled " Precautions for Isolation " number IC 115 revealed that when a patient is to have contact precautions followed a gown and gloves should be worn upon entering the patient ' s room if any contact with the patient is anticipated.
An interview conducted with Staff A on 08/10/10 at 2:45 PM revealed that when a visitor is found in a room with no personal protective equipment on they are re-educated by staff. Further review of the medical record revealed that there was no education done with family or visitors of Patient #1 regarding infection control or the use of personal protective equipment.

The medical record for Patient #12 was reviewed on 08/11/10. Patient #12 was admitted on 07/15/10 with a non healing surgical wound, kidney failure and infection of the bone. Patient #12 was to have contact precautions followed for MRSA (methicillin resistant staphylococcus aureus), a bacterium that is the cause of infections in different parts of the body. MRSA is difficult to treat since it is resistant to multiple antibiotics.
Floor observations made on 08/10/10 at 2:45 PM revealed a visitor was standing at the bedside with his/her hands resting on the edge of the patient's bed. This visitor was not wearing a gown or gloves as required per hospital policy. A review of Patient #12 ' s medical record revealed there was no documented evidence education had been completed with family and visitors of Patient #12 regarding infection control and the use of personal protective equipment.

The medical record for Patient #18 was reviewed on 08/12/10. Patient #18 was admitted on 08/11/10 with heart disease, pneumonia, diabetes, brain damage and MRSA. Patient #18 was to have contact precautions followed due to the MRSA diagnosis. At the time of admission on 08/11/10 at 3:00 PM visitors and a staff physician were observed in Patient's 18's room without the proper personal protective equipment of gloves and a gown as required by hospital policy. The staff physician was observed touching the patient during the assessment with ungloved hands.

Review of the medical record revealed there was no evidence that family had received education regarding infection control and the use of personal protective equipment.

The medical record for Patient #22 was reviewed on 08/12/10. Patient #22 was admitted on 07/23/10, with a dental abscess with cellulitis, diabetes and hypertension. Patient #22 was placed on contact isolation precautions for VRE (Vancomycin Resistant Enterococci); this is a bacterium that has become resistant to the antibiotic vancomycin.
Floor observation conducted on 08/12/10 at 11:45 AM, revealed the visitor was sitting at the bedside touching the patient without wearing a gown or gloves.

A review of Patient #22 ' s medical record revealed there was no documentation that any education had been completed with family or visitors regarding infection control or the use of personal protective equipment.

Interview conducted with Staff C on 08/13/10 at 11:00 AM, revealed as of May 2010, the hospital had started monitoring/auditing for the use of personal protective equipment. In May 2010, seven individuals were observed for the use of personal protective equipment. It was not clear if the individuals observed were staff or visitors. The compliance for May 2010, was listed at 100 % for the use of gowns. This audit was also conducted in July 2010, with 55 individuals and the use of gowns was recorded at 68%. Staff C stated at that point the staff were re-inserviced on the use of personal protective equipment.

This was confirmed with Staff A on 08/12/10 at 4:30 PM.


A tour of the second floor unit was conducted on 08/12/10 between 1:30 PM and 3:15 PM and revealed dietary trays were served to patients in contact isolation precautions. A non-disposable trays was observed on the over bed table of one patient (#16) who was to have contact isolation precaution followed. A staff member (H) was observed removing the tray from Patient #16's overbed table at 1:45 PM.

Interviews conducted with Staff F and G on 08/12/10 at 2:35 PM revealed these trays are removed from the rooms of patients in contact isolation precaution and placed on the dietary cart along with trays from patients who are not in isolation. Staff F stated these carts are transported to the kitchen in the basement via the elevator. Staff F stated nurse aides wear gloves to transport the trays.

On 08/12/10 at 1:34 PM, review of the contact precaution procedure documented the following: use patient dedicated single or disposable shared equipment or cleanse and disinfect between patients (blood pressure cuffs, thermometers, etc.).Wear gown whenever anticipated that clothing will have direct contact with the patient or potential contaminated environmental surfaces or equipment in close proximity to patient.



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