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Based on Life Safety Code (LSC) survey, Vibra Hospital of Fort Wayne was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 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.

The fully sprinklered Vibra Hospital of Fort Wayne is located on the fifth floor in the 5 East and West Halls of a 9-story hospital of Type I (332) construction with a basement. The facility has a fire alarm system with smoke detection at the corridor smoke barrier doors, in areas open to the corridor and hardwired smoke detectors in the patient rooms. The facility has a capacity of 48 and had a census of 21 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 1 Nutrition Centers was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception (see K 017), failed to ensure 2 of 15 East Hall patient room corridor doors and 1 of 1 electrical closet corridor doors closed and latched into the door frame (see K 018), failed to maintain 1 of 6 passenger elevator enclosures (see K 020), failed to ensure 1 of 4 stairwell exits was provided with an effective means of preventing travel beyond the level of exit discharge (see K 038), failed to ensure 1 of 2 fire barrier door sets was provided with the appropriate fire protection rating for the location in which they are installed (see K 044), failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was immediately visible from 1 of 4 stairwells (see K 047), failed to ensure 1 of 3 water valves for the sprinkler system was electronically supervised (see K 061), failed to ensure 2 of 6 sprinkler gauges were tested every five years, failed to ensure the spray pattern for 1 of 2 data room sprinkler heads was unobstructed (see K 062) and failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power equipment with a high current draw (see K 147).

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 document review and interview, the facility failed to follow its policy/procedure and assure that the process for submitting a grievance was clearly explained.

Findings:

1. The policy/procedure Patient Complaint and Grievance Process (approved 5-13) indicated the following: "In the event a patient or the patient's family or representative have a comment, complaint, or grievance he/she is encouraged to...File a grievance in writing or by calling any of the executives/agencies below: Vibra Hospital [c/o] Chief Executive Officer (CEO) ...260-203-2201
...ISDH [c/o] 2 North Meridian Street, Indianapolis, IN 46204 Telephone Number 1-317-233-5577
...Office of Quality Monitoring [c/o] The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181 Telephone Number (800) 994-6610. The patient/patient representative is provided with information upon admission, and upon request, of whom to contact to file a complaint/grievance."

2. The document Patient Rights and Responsibilities (03-11) requested and received on 3-26-14 at 1230 hours from staff A4 indicated the following: "You have the right to ...[page 3 of 4] file a grievance: If you want to file a grievance with this hospital, you may do so by writing or calling: Hospital CEO or Hospital CFO." The notice failed to indicate the address or telephone number of the facility and failed to inform the patient or patient's representative that he/she may lodge a grievance directly with the Indiana State Department of Health (ISDH) and failed to indicate the address and telephone number of the State agency.

3. The document Privacy Rights and Practices (09-13) requested and received on 3-26-14 at 1230 hours from staff A4 indicated the following: "This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully ...[page 3 of 5] you can complain if you feel we have violated your rights by contacting the Vibra Hospital of Fort Wayne's Compliance Officer [A1] at (260) 425-3810 or send a written complaint to 2200 Randallia Dr., 5th Floor, Fort Wayne, Indiana 46805 Attention [A1]. The telephone number was dialed to demonstrate validity and it was determined that the number was associated with another area hospital.

4. On 3-26-14 at 1310 hours, compliance officer A10 was requested to dial the telephone number indicated above and provided to patients to report a concern. Upon completion of the call, staff A10 confirmed that the telephone number for reporting a complaint or grievance was not the facility contact number and confirmed that both patient's rights notices failed to inform the patient or patient's representative that they (he/she) may lodge a grievance directly with the ISDH and failed to indicate the address and telephone number of the State agency.

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that restraints were used in accordance with the order of a physician, failed to ensure that the type of restraint was noted on the orders, and failed to ensure the orders were authenticated, per facility policy, for one patient. (pt. #2)

Findings:
1. Review of the policy and procedure " Medical Record Documentation Requirements " , last revised February 2014 (no policy number, indicated:
a. Under " Procedures " , in section 8., it reads: " ...b. Restraint orders must be authenticated within 24 hours by the prescribing physician. "

2. Review of the policy and procedure " Restraint Use " , with an effective date of 11/12, (No policy number), indicated:
a. Under " General Provisions " , on page two, it reads: " ...f) A physician ' s order is required to initiate, change, continue, and discontinue restraint. The order must include the type and number of restraints and duration ... "

3. Review of patient medical records indicated that patient #2 was admitted on 1/4/14, and had:
a. A " Restraint Order and Flow Record " form that lacked a date of initiation for the " bed function " restraint (no explanation of the type of restraint this was), lacked information as to when the attending physician was notified of restraint use, lacked a nurse signature, with date and time, who took the order, and lacked physician authentication of the restraint implementation
b. A " Restraint Order and Flow Record " form with a date of initiation for the " bed function " restraint of 1/14/14 (no explanation of the type of restraint this was), lacked information as to when the attending physician was notified of restraint use, lacked a nurse signature, with date and time, who took the complaint order, and lacked physician authentication of the restraint implementation
c. " Restraint Order and Flow Record " forms dated 1/15/14 and 1/16/14 that indicated " Siderails X 4 and bed function " , but lacked documentation as to when the attending physician was notified of the restraints and lacked physician authentication of the restraint orders.

4. At 12:20 PM on 3/26/14, interview with staff members #5, the chief clinical officer, #51, the director of quality and risk, and #55, the senior vice president of licensure and accreditation, indicated:
a. The documents in 3. Above are lacking completion as indicated
b. Restraint orders are to be authenticated within 24 hours, per facility policy (see #1. Above)
c. The physicians have been running a 67% delinquency rate in regards to medical record completion

Based on policy and procedure review, patient medical record review, and interview, the nurse executive failed to ensure policy implementation related to the follow up of pain medication for one patient. (pt. #2)

Findings:
1. review of the policy and procedure "Standards of Care", policy number 2001.3, last revised on "03/11", indicated:
a. on page one under "For all patients", it reads in section 5.: "Evaluate pain on admission: observe verbal and non-verbal indicators...using the 0 - 10 pain rating scale,..."
b. on page two under "For all patients", it reads in section 6.: "Re-evaluate pain:...d. After each pain management intervention, once a sufficient time had elapsed for the treatment to reach peak effect (maximum of one hour) e. Document patient's response to interventions."

2. review of the policy and procedure "Pain Management", policy number 2005.7, with a last revised date of "03/11", indicated:
a. on page two under "Nursing Intervention", it reads: "...9. Monitor safety and effectiveness of analgesics by utilizing the Pain Flow Sheet. the Pain flow Sheet is maintained with the patient's MAR (medication administration record) to ensure prompt assessment and documentation."

3. review of patient medical records indicated:
a. pt. #2:
A. was given pain medication at 9:15 AM on 1/11/14 for back pain that rated 8 out of 10 with no follow up documented (the next charting was at 11:30 AM and did not address pain)
B. complained of back pain (no scoring noted) at 7:30 PM on 1/11/14 and given IV (intravenous) Morphine with no follow up documented
C. was given Morphine for back pain, rated at 8 out of 10, at 8:25 AM on 1/15/14 with no follow up, related to pain or fever, documented

4. interview with staff member #50, the chief clinical officer, at 2:45 PM on 3/25/14 indicated:
a. follow up after the administration of pain medication was not noted for patient #2 as stated in 2. above
b. the chart had no "Pain Flow Sheet" in the patient's record. Follow up, when it occurred, was only found in the long hand nursing notes
c. this lack of follow up documentation has been noted as occurring "routinely" by facility nursing staff

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure the completeness of patient charts for 4 of 5 records reviewed. (pts. #1, #2, #3, and #5)

Findings:
1. review of the policy and procedure "Medical Record Documentation Requirements", last revised February 2014 (no policy number), indicated:
a. on page two under "Procedure", section 5. reads: "On admission, the physician must document the estimated patient's length of stay on the History & Physical."
b. on page 2 under "Procedure", section 8., it reads: "All entries into the medical record must be legible, signed, dated, and timed..."

2. review of patient medical records indicated:
a. pt. #1 had:
A. an "Advance Directive and Patient Self-Determination" document that was signed by the patient or responsible party, but was not filled out (no boxes checked) to indicate whether the patient had any advance directives, or not
B. a blank "Patient Plan of Care" document in the medical record
b. pt. #2 had a "Rapid Response Protocol #2" document in the record that the physician had authenticated, but the section for "Date/Time:" was left blank
c. pt. #3 had:
A. a H & P (History and Physical) that lacked the notation of the number of days expected for the admission ("The estimated time the patient requires in the hospital is_____days." was noted on the dictated H & P)
B. no date and time for the admission orders written by nursing as a TO (telephone order) at the time of admission (3 pages of orders that lacked a date and time the orders were written)
d. pt. #5 had:
A. an "Advance Directive and Patient Self-Determination" document that was signed by the patient or responsible party, but was not filled out (no boxes checked) to indicate whether the patient had any advance directives, or not
B. a H & P (History and Physical) that lacked the notation of the number of days expected for the admission ("The estimated time the patient requires in the hospital is_____days." was noted on the dictated H & P)
C. a document "Interdisciplinary Team Meeting/Care Conference" that lacked a date on the form and lacked a physician signature (with date and time) to indicate the practitioner had been part of planning the care for this patient admitted 1/20/14 and discharged on 2/7/14

3. interview with staff member #50, the chief clinical officer, at 2:45 PM on 3/25/14 indicated:
a. after review of the medical record copies, as stated in 2. above, it is agreed that areas of the medical records were blank, or left incomplete, as stated

4. at 2:45 PM on 3/25/14, interview with staff member #53, the director of HIM (health information management), indicated:
a. the current facility policy (stated in 1. above) does not address completeness and accuracy of the medical record, but this is expected

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure that practitioners authenticated telephone orders within the time frame of the facility policy for 5 of 5 records reviewed (pts.#1 through #5).

Findings:
1. review of the policy and procedure "Medical Record Documentation Requirements", last revised February 2014 (no policy number), indicated:
a. on page 2, in section 8., it reads: "All entries into the medical record must be legible, signed, dated, and timed...a. Telephone orders must be authenticated by the prescribing physician...in the absence of a state law specifying the timeframe for authentication of verbal orders, the order needs to be authenticated with [sic] 48 hours, effective January 26, 2013."

2. review of the policy and procedure "Verbal/Telephone Orders", policy number 2005.17, with a last revised date of "03/11", indicated:
a. under "Procedure", on page two, it reads: "6. All telephone or verbal orders for medications will be transcribed in the medical record and shall be countersigned by the practitioner within twenty-four (24) hours...8. Medical Records will check in 48 hours for completion. 9. If the verbal/telephone order has not been signed by the physician, the Medical Records or Nursing will notify the physician and attempt to get the order co-signed. 10. Medical Records will notify the Medical Staff office and Administration..."

3. review of patient medical records indicated:
a. pt. #1 had TO (telephone orders) written at 8:55 AM on 1/4/14 and at 11:00 AM on 1/5/14 that were authenticated by the physician on 3/8/14 at 4:00 PM (the same time the discharge summary was dictated)
b. pt. #2 had a TO written on 1/21/14 at 11:00 PM that still lacked authentication of the order by the physician
c. pt. #3 had a TO written on 1/22/14 at 8:10 AM that still lacked authentication of the order by the physician
d. pt. #4 had:
A. telephone orders written on 2/9/14 at 1:10 AM, 2:30 AM, 3:00 AM, one with no time noted, and one at 7:02 AM that still lacked authentication of the orders by the physician
B. telephone orders written on 2/22/14 at 1:00 PM, 1:30 PM, and one with no time noted, that still lacked authentication of the orders by the physician
C. a TO written at 9:10 AM on 2/26/14 that still lacked authentication of the order by the physician
D. a written order for "NO CODE BLUE" dated by nursing on 2/13/14 that the physician authenticated on 5/13/14 at 8:30 AM
e. pt. #5 had: TO written on 1/31/14 at 1:00 PM; 2/2/14 at 1:20 AM; 2/5/14 at 2:20 PM and 10:40 PM; 2/6/14 at 1:45 PM; and on 2/7/14 at 1:30 AM that still lacked authentication of the orders by the physician

4. at 12:20 PM on 3/25/14, interview with staff members #50, the Chief Clinical Officer, #51, the Director of Quality, and #52, the Chief Executive Officer, indicated:
a. the policy listed in #2. above may not be the current/correct policy (no other was provided prior to exit) as the TO/Verbal order policy is in conflict with the policy listed in #1 above as it says 48 hours are allowed for authentication
b. it has been known for some time that telephone and verbal orders have not been authenticated within the 48 hours specified by the facility policy listed in #1.
c. medical staff delinquency rates have been at 67%

Based on review of the medical staff by-laws, policy and procedure review, medical record review, and interview, the facility failed to ensure the implementation of its policy regarding the completion of the medical record within 30 days for 5 of 5 patient records (pts. #1 through #5).

Findings:
1. review of the Medical Staff Bylaws, with an approval date of 3/13/14, indicated:
a. on page 13, it reads in section 2.6 "Basic Responsibilities of Medical Staff Membership", in section 2.6-2: "Abide by the Medical Staff Bylaws and Rules and all other lawful standards, policies and Rules of the Medical Staff and the Hospital."

2. review of the policy and procedure "Medical Record Documentation Requirements", last revised February 2014 (no policy number), indicated:
a. on page 3, in section 13.: "Discharge Summary including final diagnosis,...e. Discharge summary is considered delinquent if not completed 30 days from date of discharge,..."

3. review of patient medical records indicated:
a. pt. #1 died on 1/6/14 and the discharge summary was dictated on 3/8/14 (> 30 days late)
b. pt. #2 died on 1/25/14 and lacked a discharge summary
c. pt. #3 died on 1/22/14 and lacked a discharge summary
d. pt. #4 died on 2/22/14 and lacked a discharge summary
e. pt. #5 died on 2/7/14 and lacked a discharge summary

4. at 12:20 PM on 3/25/14, interview with staff members #50, the Chief Clinical Officer, #51, the Director of Quality, and #52, the Chief Executive Officer, indicated:
a. it has been known for some time that discharge summaries have not been done timely and per facility policy
b. medical staff delinquency rates have been at 67%

Based on document review and interview, the medical staff failed to appoint a radiologist or physician qualified by education and experience to supervise its radiology services.

Findings:

1. On 3-24-14 at 1030 hours, staff A1 and A2 were requested to provide documentation indicating that a qualified physician was appointed by the medical staff to supervise its radiology services and none was received prior to exit.

2. During an interview on 3-25-14 at 1615 hours, staff A1 and A2 confirmed that the medical staff failed to appoint a medical director to supervise the radiology services provided by agreement at the facility.

Based on document review and interview, the utilization review (UR) program failed to assure that committee members did not review cases wherein the practitioner had professional involvement in the care of the patient.

Findings:

1. The policy/procedure Utilization Review Plan (approved 1-14) indicated the following: " The determination that an admission or continued stay does not meet medical necessity can be made by ...one member of the UR committee if the individual is responsible for the care of the patient [and] at least two members of the UR committee in all other cases. "

2. During an interview on 3-26-14 at 1230 hours, compliance officer A10 confirmed that the UR provision failed to prevent a conflict of interest and prohibit case review by committee members with professional involvement in the case under review.

Based on observation, record review and interview, the facility failed to ensure 1 of 1 Nutrition Centers was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception, failed to ensure 2 of 15 East Hall patient room corridor doors and 1 of 1 electrical closet corridor doors closed and latched into the door frame, failed to maintain 1 of 6 passenger elevator enclosures, failed to ensure 1 of 4 stairwell exits was provided with an effective means of preventing travel beyond the level of exit discharge, failed to ensure 1 of 2 fire barrier door sets was provided with the appropriate fire protection rating for the location in which they are installed, failed to ensure a continuously illuminated exit sign, where the exit or way to reach the exit was not apparent, was immediately visible from 1 of 4 stairwells, failed to ensure 1 of 3 water valves for the sprinkler system was electronically supervised, failed to ensure 2 of 6 sprinkler gauges were tested every five years, failed to ensure the spray pattern for 1 of 2 data room sprinkler heads was unobstructed and failed to ensure 1 of 1 flexible cords was not used as a substitute for fixed wiring to provide power equipment with a high current draw.

Findings:

1. Observation with FES1 and MMC1 on 03/25/14 at 10:50 a.m. indicated the Nutrition Center in the East Hall lacked a corridor door, could not be viewed from the nurse station and was not protected by an electrically supervised automatic smoke detection system.

2. This was acknowledged by FES1 at the time of observation.

3. Observation with FES1 and MMC1 on 03/25/14 from 10:36 a.m. to 11:13 a.m. indicated patient rooms 503, 507 and the electrical closet were designed with double
corridor doors. One door was equipped with a manual latching device that would latch into the door frame and the remaining door was designed to latch into the stationary door. Each door could not latch automatically, and independent of the other door, into the door frame.

4. This was acknowledged by FES1 and MMC1 at the time of observations.

5. Observation with FES1 and MMC1 on 03/25/14 at 10:56 a.m. indicated there was six inch by six inch penetration sealed with expandable foam and fire caulk in the elevator shaft wall of the data room.

6. This was acknowledged by FES1 and MMC1 at the time of observation.

7. Observation with FES1 and MMC1 on 03/25/14 at 11:50 a.m. indicated the center stairwell continues beyond the level of exit discharge into the lower level. There was no barrier to prevent patients from continuing past the level of exit into the lower level.

8. In an interview with FES1 at the time of observation, the facility has been made aware of this issue.

9. Observation with FES1 and MMC1 on 03/25/14 at 12:40 p.m. indicated the East hall two hour fire barrier wall had twenty minute fire rated cross corridor doors.

10. Interview with FES1 at the time of observation indicated this was a two hour fire barrier wall.

11. Observation with FES1 on 03/25/14 at 11:55 a.m. indicated there was no illuminated exit sign on the first floor after exiting the east stairwell.

12. This was acknowledged by FES1 at the time of observation.

13. Observation with FES1 on 03/25/14 at 12:20 p.m. indicated the water shut off valves on the main water inlet line lacked electronic supervision.

14. According to FES1 at the time of observation, this was the main water inlet line for the sprinkler system and the valve was not electronically supervised.

15. Observation with FES1 and MMC1 on 03/25/14 at 11:40 a.m. indicated the sprinkler gauges of the sprinkler riser on the second and third floor of the west stairwell had a date of 2008.

16. In interview with FES1 at the time of observation, he/she was unable to verify if the sprinkler gauges had been calibrated.

17. Observation with FES1 and MMC1 on 03/25/14 at 12:20 p.m. noted the spray pattern of the back sprinkler head in the data room was obstructed by an equipment rack located three inches from the sprinkler head.

18. This was acknowledged by FES1 at the time of observation.

19. Observation with FES1 and MMC1 on 03/25/14 at 11:07 a.m. noted a small refrigerator was plugged into an extension cord power strip.

20. MMC1 acknowledged and removed the power strip at the time of observation.

Based on document review and interview, the infection control practitioner failed to ensure the follow up of discussion topics from meeting to meeting of the infection control committee and failed to write a policy that was indicated as needed at the 10/14/13 meeting.

Findings:
1. Minutes of the Infection Control Committee (3/8/13, 4/18/13, 6/6/13, 8/12/13, 9/23/13, 10/14/13, 1/13/14 and 2/10/14) indicated:
a. the March 8, 2013 minutes indicate that the flu vaccine target percentage was discussed (no percentage noted) and that employees who decline the vaccine would be counseled, that it was discussed as to whether to institute mask wearing for those who decline, and that the corporate policy would be reviewed---no follow up regarding this discussion, review, and final decision was noted in any of the following months' minutes

2. the September 23, 2013 meeting minutes indicated:
a. a "Clue Spray and Black Light" was "ordered for housekeeping PI" (performance improvement), but there is no further discussion in meeting minutes (including January and February 2014 meetings) that indicates if this product was received, used, and the results or findings (related to terminal cleaning of pt rooms of those with the Acinetobacter organism)
b. a "Discussion 10/13: hand hygiene for C Diff/EVS (environmental services) to verify whether eye protection is needed with Virasept" (discussion was not found in the 10/14/13 meeting minutes--there was no follow up, as was stated would occur)
c. "Discussion for 10/13 mtg." would occur in regards to "curtains in rooms-consider switching to disposable or removing from as many rooms as possible..." (no discussion, or follow up, was noted in the October 2013 meeting minutes regarding this topic)

3. the October 14, 2013 meeting minutes indicated:
a. "...A temporary policy will be written and submitted to MEC (medical executive committee) for approval"---this was related to the lack of PPD (purified protein derivative) solution for annual TB (tuberculosis) testing

4. interview with staff member #51, the infection control practitioner, at 12:20 PM on 3/26/14, indicated:
a. Meeting minutes lack notation of follow up discussion of items when the previous minutes indicated this would occur
b. a policy was never developed, as was noted in the 10/14/13 meeting would be done, and sent to MEC for approval regarding steps to be taken with the shortage of PPD solution for annual TB testing

Based on policy and procedure review, personnel file review, and staff interview, the infection control practitioner failed to implement the infection control committee/employee health policy related to the determination of communicable disease history for 5 staff files reviewed. (files # N2, N10, N12, N13 and P2)

Findings:
1. review of the policy and procedure "Disease Preventable Vaccines", no policy number noted, with a last revised date of "12/13", indicated:
a. under "Policy", it reads: "...Proof of immunity (serological laboratory documentation of immunity or vaccine administration records) is required. For those persons without documentation of vaccine administration, serological laboratory testing will be required. If the healthcare worker is found to be non-immune, they will be advised and referred to their Healthcare Provider. The following vaccines will be required: Measles, Mumps, Rubella (MMR) Varicella"
b. under "Procedure", it reads: "1. All healthcare workers will have their immunization status assessed at the time of employment. The status will become a permanent part of the Employee Health file and will be maintained..."

2. review of personnel files indicated:
a. staff member N2 had a health department document indicating "History of Varicella Disease" that lacked confirmation by a physician/practitioner
b. staff member N10 was hired 11/14/12, and had a Rubeola titer done 10/25/12 that resulted in an "equivocal" number (0.94 with 0.91 to 1.09 being equivocal according to the lab report)
c. staff member N12 was hired 7/10/13 and lacked any documentation for Rubella, Rubeola, or Varicella in the file
d. staff member P2 was hired 9/11/13 and lacked any documentation for Rubella, Rubeola, Varicella

3. at 12:00 PM on 3/26/14, interview with staff member #51, the infection preventionist and employee health staff person, indicated:
a. staff member N2 should have had a titer drawn since there was no physician confirmation of history of disease
b. staff member N2 is an agency nurse and the health files are not reviewed for completeness by the employee health nurse--this was the first time staff member #51 had seen the documents
c. the equivocal result for staff member N10 was "missed" and had no follow up done, as required per facility policy
d. it is unknown why there is no communicable disease history in the file for N12 and P2, this should have been done at the time of hire