Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure the Quality Program was effective, hospital-wide and included monitoring of all aspects of patient safety processes. Observations made during a tour of the facility's patient care units on 8/16/21 beginning at 10:15 a.m., evidenced serious concerns related to the sanitary condition and maintenance of five (5) of ten (10) sampled ice/water dispensers used to provide ice and water for patients. The observations resulted in the finding of IMMEDIATE JEOPARDY. This demonstrated a systemic hospital wide failure of several processes to ensure the safety of patients. On 8/16/21 during a tour of the patient care areas the surveyor visually inspected 10 ice/water dispensers and discovered that 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit despite being cleaned on a quaterly basis. On 8/17/21 at 10:41 a.m., the surveyor discussed with Staff Member #1, and #2, the integration of Quality in the monitoring of patient care areas. Through interviews and document reviews, it was determined the facility Quality Program did not routinely monitor any of the ice machines for cleanliness. Interviews with Infection Control staff evidenced that there was no routine or random culturing of ice machines, nor water testing done at the facility, as it was not an standard of practice. Further interviews and document review revealed the Quality Program sub-committee designated as Environment of Care (EOC) would randomly choose an area of the hospital once per month to make the rounds. The facility recently developed new check-list documents for the EOC staff to use and the surveyor's review found that this Environment of Care rounds documents did not include checking the ice/water dispensers for cleanliness anywhere. Previous Environment of Care rounds documents examined by the surveyor revealed that patient care areas were not being reviewed either. Areas documented as being checked by the EOC team were lounge areas and information technology areas. The last documented rounds on a patient care area was May 2021. Please refer to 0286, 0700, 0724, 0747, and 0750 for further information.
Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility Quality program failed to identify, track and monitor all areas directly affecting patients. Observations of ice/water dispensers on patient care units used to provide ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate and black and reddish/pink substance adhering to two (2) of two ice machine dispenser nozzles. This affected 5 (five) of 10 (ten) ice/water dispensers observed. The affected ice/water dispensers observed during the tour were located in: CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3West- PCU, Emergency Department, 4East (Rehab), and 3East (Surgical Progressive Care). The findings included: On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member #6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer). On the CICU (Cardiac Intensive Care Unit): 8/16/21 at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a black slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. Staff Member #7 (Infection Prevention) stated, We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness... The surveyor asked to examine the environment of care rounding documents. At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East. At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate as well as drain. All the above noted observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated rounds made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets included an area for checking the ice/water dispenser for cleanliness, with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for other patient care units. Staff Member #1 stated that the EOC rounding sheets were turned into Quality for review and compilation of the information as well as notification of the appropriate department if there were any areas that needed attention. On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy for Conditions of Participation of Physical Environment and Infection Control, and a request to open the Condition of Participation for Quality for investigation due to the concerns of the failure of the Quality Program to monitor all hospital areas that would affect patient care. On 8/17/21 at 10:41 a.m., the surveyor discussed, in more detail, with Staff Member #1, and #2 the EOC (Environment of Care) Rounds and its integration into the Quality Program. Staff Member #1 stated EOC has it's own committee and the group consists of: Facilities Management, Contracted Vendor GE, Security Director, Emergency Management Coordinator, Information Technologies Director, Radiology Director, a Member of the Infection Prevention Team and Quality. They do the EOC rounding and document on the sheets. Infection Prevention is a member of the team. Everyone has a checklist and they go through and check the items. The surveyor inquired as to why there were no patient care areas, other than the MICU, contained in the documents completed recently. Staff Member #1 stated, I am not sure but they divide the areas up and go in pairs. They do one unit per month...we just redid the check off documents...they all report their findings and audits to the Quality Council... The surveyor examined the new check off document for the EOC rounds and noted that it did not contain an area to check/monitor the cleanliness of the ice/water dispensers, as had been on the previous documents. This was brought to the attention of Staff #1 who stated, That was an oversight. We need to add that... The surveyor inquired again as to who was responsible for cleaning the dispensers between maintenance scheduled cleanings. At 11:17 a.m. Staff Member #4 (CNO) and #15 (Asst CNO) stated, The expectation would be that the charge nurse and Nursing Leadership on the units would check the ice machines, since they are primarily the users. The Unit Nursing Leadership should be making daily rounds...if they see a problem they can call maintenance, or clean the machine if it is just a matter of wiping it down. They should be looking at it at least weekly and cleaning it as necessary...Infection Control do rounds on the units but I do not think this specifically is an area they check... The surveyor also inquired again to have an opportunity to examine documents related to the EOC group rounding on patient care areas. The surveyor was not provided any documents that related to patient care areas, only documents of rounds made in the PBX, IT, VP lounge, and other areas that were not patient units. Staff Member #1 stated that when the EOC rounds are done, they turn in their checklists and if there are areas identified as needing attention, I submit a work order, or send a message to whomever needs to take care of the concern. If it is nursing then it would go to the Nursing Leader on the unit identified. This is a new program and we are learning as we are going. We obviously see some areas of opportunities for improvement... The surveyor discussed with Staff Member #1 and #2 the concern regarding ineffective machine maintenance, staff not observing and reporting maintenance issues and Quality program systematically failing to actively identifying problems in patient care areas, implementing solutions and monitoring effectiveness on quality of patient care. Staff Member #1 stated, There was a breakdown in communication or understanding of responsibility at the lowest level right through the chain... Staff Member #2 stated, We are working on a revision of the policy and procedure for the cleaning processes to include the manufacturer's directions and cleaning instructions as well as including competencies and training. We will also review what needs to be done on a unit level... Staff #1 stated, We realize we have some areas we need to fully examine and that we have opportunities to improve... At 2:00 p.m. on 8/17/21, the surveyor discussed the concerns related to the complaint allegations and notified the facility that they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction which would demonstrate robust and sustainable corrections and monitoring for the deficient practice and inclusion into the hospital-wide Quality Monitoring Program. Facility members present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer). The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).
Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure the physical environment was maintained to ensure the safety of patients. Observations made during a tour of the facility patient care units on 8/16/21 beginning at 10:15 a.m., identified concerns related to the unsanitary condition and lack of maintenance in five (5) of ten (10) ice/water units providing ice and water to patients, visitors and staff. During the tour of the facility patient care units on 08/16/21, the surveyor examined ten (10) ice/water dispensers that provided ice/water to patients, staff and visitors. 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit. The two most adversely effected ice/water machines were located in patient care units with patients that were already acutely compromised (Cardiac Intensive Care Unit, all nine patients were Covid 19 positive) and consuming water/ice from these affected machines presented a serious potential health risk to these patients and could have caused serious negative health outcomes. This finding resulted in IMMEDIATE JEOPARDY and demonstrated the systemic failure of processes related to inspection and maintenance/cleaning of equipment which was determined on 8/16/21 at 2:45 p.m. after consultation with the State Agency and the Centers for Medicare and Medicaid Services (CMS). On 8/16/21 at 3:06 p.m., the facility Staff #1 (Director of Quality and Accreditation) and #2 (Risk Manager) were notified of the Immediate Jeopardy situation and a Plan of Removal was requested. On 8/17/21 at 9:14 a.m., the surveyor received the facility Plan of Removal. After review/revision of the Plan of Removal, validation of implementation, and consultation with the State Agency and CMS, the Immediate Jeopardy was abated on 8/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.41 Physical Environment. Please refer to A0724 for further information.
Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure equipment was maintained to ensure an acceptable level of safety. Observations of ice/water dispensers on patient care units used to provide ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate and black and reddish/pink substance adhering to two (2) of two ice machine dispenser nozzles. This substance affected various parts of 5 (five) of 10 (ten) ice/water dispensers incorporated in the sample, including two (2) of the observed units with the affected dispenser nozzles. The observations involved ice/water dispensers on : CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3East (Surgical Progressive Care), 3West- PCU, Emergency Department and 4East (Rehab), with the first two units housing the most unsanitary ice/water machines. The findings included: On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member 6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer). The following was observed: On the CICU (Cardiac Intensive Care Unit): 8/16/21 at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a black slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. The surveyor inquired as to the cleaning process for the machine. The facility staff stated that the cleaning was done by plant operations. The surveyor inquired as to when the machine was last cleaned and what was the schedule for cleaning and how was cleanliness assessed. Staff Member #6 stated, We have them on a list to clean quarterly. I believe this was cleaned about a month ago by us, but I will get the schedule... Staff Member #7 (Infection Preventionist) stated, We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness... The surveyor asked to examine the environment of care rounding documents. At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. Staff Member #2 stated the ice/water dispensers are primarily used for patients, although staff could obtain ice and water and that visitors could also be provided ice and water from the machines by staff. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East. At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate as well as drain. All the above noted observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated rounds made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets included an area for checking the ice/water dispenser for cleanliness, with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for other patient care units. The Maintenance log for the cleaning of the ice machines was presented and evidenced (16) sixteen ice/water machines. The dates for the cleaning/maintenance of the machines ranged from 4/30/21 to 7/6/21 with Work Completed: Ice machine clean and sanitize. The CICU was last documented as completed on 7/2/21, 3West- 5/10/21, 4East- 5/11/21, ED- 6/16/21 and 3East- Surgical Progressive care was not identified on the list. According to the provided facility policy and cleaning requirements the following was evidenced (in part): Quarterly Cleaning and Sanitizing of the Icemaker and Dispenser Hopper:...2. Empty, disassemble and clean bin. 3. Wipe Storage bin cover, agitator, drip ring and spouts with cleaning solution. 4. Chemically clean evaporator and water side components...15. Fully sanitize, flush and rinse with water. 16. Discard ice, wipe down bin. 17. Wipe stainless steel exterior....Additional Operating Inspections: 1. Remove all debris from drain pan. 2. Wash drain pan and grille. 3. Flush drain lines with bleach mix...5. Wipe all surfaces. The surveyor inquired as to who was responsible for cleaning and ensuring the ice/water dispensers were cleaned between the maintenance quarterly cleaning, and if there was a routine schedule, or who was responsible for ensuring this was done and if Infection Control participated in this process. Staff Member #1 stated, I will have to check on that. It could be EVS. The surveyor reviewed the EVS (Environmental Services) Cleaning schedule for patient care units. The nourishment room and Ice/water dispensers were not on the EVS cleaning schedule. According to Staff Member #6, the facility has ended a contract with a vendor providing cleaning service for the ice/water machines and that the new facilities director would be implementing monthly cleaning and another vendor would be contracted. On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy. After conferring with the State Agency and CMS, the surveyor notified the facility of the finding of Immediate Jeopardy at 3:06 p.m. and a immediate plan of removal was requested. The facility Staff Members #1 and 2 were notified of the Immediate Jeopardy finding and stated they would meet with the Executive Administration to also notify them of the concern. At 2:00 p.m. on 8/17/21, the facility was notified they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction demonstrating robust and sustainable corrections and monitoring for the deficient practice. Facility present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer). On 8/20/21 beginning at approximately 12:15 p.m., the surveyor toured the same patient care areas to validate the implementation of the Plan of Removal. During the tour on the patient care units the surveyor interviewed random staff regarding the ice/water dispensers. At 1:33 p.m., on 8/20/21 a Patient Care Technician (Staff Member #21- who was on duty on one of the units the surveyor toured) stated We have been provided and refrigerate the bottled water for the patients. If any patients request or require ice, we can get ice from the dietary department or have someone bring ice from another unit that has a working machine. A Registered Nurse (Staff Member #22) who worked on the 5th floor, stated at 1:45 p.m., We have refrigerated bottled water for the patients. If we need ice, we can get it from the cafeteria or the (other unit) ice machine because that one is in service now. Two Registered Nurses on the Cardiac Unit stated, We have bottled water for the patients. Frankly, they (the patients) are all very pleased with the bottled water. They really like it. If we need ice we can get it from dietary at any time... After observations, interviews, documents review and consultation with the State Agency and CMS, the Plan of Removal was validated and the Immediate Jeopardy removed on 08/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.41 Physical Environment. The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).
Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to ensure a clean and sanitary environment. Observations made during a tour of the facility patient care units on 8/16/21 beginning at 10:15 a.m., raised concerns related to the unsanitary condition of five (5) in ten (10) ice/water dispensers providing ice and water for patients that were already acutely compromised individuals/patients. On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas and visually inspected ten (10) ice/water units. Observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. 50% of inspected ice/water units had visible slime/mold present on the outside and 20% of the units inspected included slime/mold in the dispenser part of the unit. These machines provided water/ice to patients, staff and visitors and presented a serious potential health risk to these individuals. The findings of unsanitary ice/water machines, insufficient maintenance of equipment and only sporadic monitoring of sanitary conditions in the patient care areas resulted in consultation with the State Agency and the Centers for Medicare and Medicaid Services (CMS) and determination of IMMEDIATE JEOPARDY on 8/16/21 at 2:45 p.m. The findings demonstrated the systemic failure of having an active hospital-wide infection surveillance program to prevent infectious diseases and the maintenance of a sanitary environment. processes related to inspection and maintenance/cleaning of equipment. On 8/16/21 at 3:06 p.m., the facility Staff #1 (Director of Quality and Accreditation) and #2 (Risk Manager) were notified of the Immediate Jeopardy situation and a Plan of Removal was requested. On 8/17/21 at 9:14 a.m., the surveyor received the facility Plan of Removal. After consultation with the State Agency and CMS and on-site validation of Removal Plan's implementation through observations, staff interviews and documentation review, the facility was notified of the abatement of the Immediate Jeopardy at 3:31 p.m. on 8/20/21 but non-compliance with Condition of Participation remained for 482.42 Infection Control. Please refer to A0750 for further information.
Based on observation, staff interview, facility document review and encounters during the course of a complaint investigation, the facility staff failed to provide a clean and sanitary environment including equipment which would directly affect patients, particularly already medically compromised individuals. Observations of ice/water dispensers in patient care units providing ice and water to patients, staff and visitors evidenced a greenish-black slimy substance in the overflow grate in five (5) ice machines and black and reddish/pink substance adhering to two (2) of five (5) affected ice machine dispenser nozzles. The sample include ten (10) ice/water machines and the five (5) affected ice/water dispensers were located in: CICU (Cardiac Intensive Care Unit - housing COVID19 positive patients), 3East (Surgical Progressive Care), 3West- PCU, Emergency Department and 4East (Rehab), with the first two units housing the most unsanitary ice/water machines. The findings included: On 8/16/21 at 10:15 a.m. the surveyor toured the patient care areas accompanied by Staff Member #1 (Quality), Staff Member #2 (Risk Manager), Staff Member #5 (Nurse Manager CICU), Staff Member 6 (Environmental Services and Facilities Maintenance), Staff Member #7 (Infection Control) Staff Member #9 (PCU Manager), Staff Member #10 (ED Manager), Staff Member #13 (Pulmonary and Renal Manager), and Staff Member #15 (Assistant Chief Nursing Officer). The following was observed: On the CICU Unit: at 10:29 a.m.,the ice/water dispenser located in the nourishment room had a black material adhering to the dispenser nozzle. The surveyor retrieved a tissue and wiped the nozzle outside and inside which demonstrated a back slick substance adhering to it. There was a greenish black slimy material in the bottom overflow grate and adhering to the bottom of the pan and drain. The surveyor inquired as to the cleaning process for the machine. The facility staff stated that the cleaning was done by plant operations. The surveyor inquired as to when the machine was last cleaned and the schedule for cleaning. Staff Member #6 stated, We have them on a list to clean quarterly. I believe this was cleaned about a month ago by us, but I will get the schedule... Staff Member #7 Infection Preventionist) stated, We do not do environmental cultures. It is not a standard of practice. The observation of the machines are a part of the environment of care rounds, to check the cleanliness... The surveyor asked to examine the environment of care rounding documents. At 11:00 a.m., the surveyor observed a black slimy material in the bottom overflow grate of the ice/water dispenser on 3West. At 11:15 a.m., the surveyor observed a black-greenish slick material in the bottom grate and drain of the ice/water dispenser for the Emergency Department. Staff Member #2 stated the ice/water dispensers are primarily used for patients, although staff could obtain ice and water and that visitors could also be provided ice and water from the machines by staff. At 12:17 p.m., there was observed a greenish-brown slimy substance in the bottom grate and drain of the ice/water dispenser located on 4East, At 12:21 p.m., the surveyor observed a red-pink slick substance adhered to the dispenser nozzle of the ice/water dispenser on 3East and a black slimy substance underneath the overflow grate and drain. Observations were witnessed and confirmed by the facility staff who accompanied the surveyor on the tour. The surveyor requested and received the EOC (Environment of Care) rounding sheets and the Ice Machine cleaning logs on 8/16/21 at approximately 12:45 p.m. The EOC rounding sheets demonstrated rounds made in areas that were not patient care areas except for the MICU (Medical Intensive Care Unit) which was completed in May 2021. The rounding sheets identified a space for checking the ice/water dispenser for cleanliness with the MICU being clean at that time. The surveyor asked Staff Member #1 for EOC rounding sheets that were completed for patient care units. On 8/16/21 at 11:30 a.m. a discussion was held with the surveyor and State Agency regarding the identified concerns of Immediate Jeopardy. After conferring with the State Agency and CMS, the surveyor notified the facility of the finding of Immediate Jeopardy at 3:06 p.m. and a immediate plan of removal was requested. The facility Staff Members #1 and 2 were notified of the Immediate Jeopardy finding and stated they would meet with the Executive Administration to also notify them of the concern. On 8/17/21 at 9:17 a.m., the facility presented the surveyor with a Plan of Removal for the Immediate Jeopardy. On 8/17/21 at 10:41 a.m., the surveyor discussed with Staff Member #1, and 2 the EOC (Environment of Care) Rounds. Staff Member #1 stated EOC has it's own committee and the group consists of: Facilities Management, Contracted Vendor GE, Security Director, Emergency Management Coordinator, Information Technologies Director, Radiology Director, a Member of the Infection Prevention Team and Quality. They do the EOC rounding and document of the sheets. Infection Prevention is a member of the team. Everyone has a checklist and they go through and check the items. The surveyor inquired as to why there were no patient care areas, other than the MICU, contained in the documents completed recently. Staff Member #1 stated, I am not sure but they divide the areas up and go in pairs. They do one unit per month...we just redid the check off documents... The surveyor examined the new check off document for the EOC rounds and noted that it did not contain an area to check/monitor the cleanliness of the ice/water dispensers, as had been on the previous documents. This was brought to the attention of Staff #1 who stated, That was an oversight. We need to add that... The surveyor inquired again as to who was responsible for cleaning the dispensers between maintenance scheduled cleanings. At 11:17 a.m. Staff Member #4 (CNO) and #15 (Asst CNO) stated, The expectation would be that the charge nurse and Nursing Leadership on the units would check the ice machines, since they are primarily the users. The Unit Nursing Leadership should be making daily rounds...if they see a problem they can call maintenance, or clean the machine if it is just a matter of wiping it down. They should be looking at it at least weekly and cleaning it as necessary...Infection Control do rounds on the units but I do not think this specifically is an area they check... At 2:00 p.m. on 8/17/21, the facility was notified they would have to respond with a plan of correction for the Conditions of Participation identified with an acceptable plan of correction demonstrating robust and sustainable corrections and monitoring for the deficient practice. Facility present were: Staff Members #1 (Quality Manager), #2 (Risk Manager), #3 (Chief Medical Officer), #4 (Chief Nursing Officer), #15 (Assistant Chief Nursing Officer, #17 (President-Chief Executive Officer), #18 (Chief Operating Officer), and #19 (Chief Financial Officer). On 8/20/21 beginning at approximately 12:15 p.m., the surveyor toured the same patient care areas to validate the implementation of the Plan of Removal. During the tour on the patient care units the surveyor interviewed random staff regarding the ice/water dispensers. At 1:33 p.m., on 8/20/21 a Patient Care Technician (Staff Member #21- who was on duty on one of the units the surveyor toured) stated We have been provided and refrigerate the bottled water for the patients. If any patients request or require ice, we can get ice from the dietary department or have someone bring ice from another unit that has a working machine. A Registered Nurse (Staff Member #22) who worked on the 5th floor, stated at 1:45 p.m., We have refrigerated bottled water for the patients. If we need ice, we can get it from the cafeteria or the (other unit) ice machine because that one is in service now. Two Registered Nurses on the Cardiac Unit stated, We have bottled water for the patients. Frankly, they (the patients) are all very pleased with the bottled water. They really like it. If we need ice we can get it from dietary at any time... At 2:10 p.m. on 8/20/21 Staff Members #23 and #24 (Infection Control) were interviewed regarding their role in the inspection of the ice/water dispensers. The Staff Members stated, We have just started a visual inspection of the machines after the terminal cleaning. We were not doing any visual checks before.... After inspecting the sanitary conditions of actively used ice/water machines in patient care areas, staff interviews, documents review and consultation with the State Agency and CMS, the Plan of Removal was validated and the Immediate Jeopardy removed on 08/20/21 at 3:31 p.m. but non-compliance with Condition of Participation remained for 482.42 Infection Control. The concerns were again discussed at an exit conference on 8/20/21 at approximately 3:00 p.m. with the facility Administrative Staff (Staff Members #1, 2, 3, 4, 15, 17, 18, and 19).
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, staff interviews, and document review, it was determined that facility staff failed to implement a system for protecting the physical and emotional safety of behavioral health patients identified as having suicidal and or homicidal behaviors to ensure patients received care in a safe environment. This finding resulted in the identification of Immediate Jeopardy (IJ), which is cited at the Condition of Participation level, after the facility provided an acceptable Plan of Removal. See Tag A-0115. The plan of correction is listed below. The plan of removal was (MDS) dated [DATE] at 5:45 p.m., and evidenced the following Action Plan: ED Nursing Education: -How to document suicide screening and safe environment intervention _How to view physician orders for level of observation -Process for obtaining sitter/ED staff to monitor patient until sitter is available -Orientation to sitter request form -Handoff to sitter, when indicated Responsible Party: ED Director, Chief Nursing Officer Measurement: 100% of ED Nurses, as evidenced by sign-in sheet Implementation Date: 2/18/2020 COMPLETED 2.20.2020 ED Provider Education: -Level of orders/what they mean -Psych [psychiatric] order set -Communication on safety plan of care with nursing team -Provider to provider handoff for transition of care -Reevaluating level of observation Responsible Party: Chief Medical Officer Measurement: 100% of ED Providers, as evidenced by sign-in sheet Implementation Date: 2/18/2020 COMPLETED 2.20.2020 Sitter Education: -Handoff from nurse of level of care and reason for monitoring -How to document 1:1 observation, line of sight observation, q15 [every 15] minute observation Responsible Party: Director of Staffing Measurement: 100% of Patient Safety Attendants, as evidenced by sign-in sheet Implementation Date: 2/18/2020 COMPLETED 2.20.2020 *Level of precaution orders will print to ED Desk Tech Responsible Party Director of Advanced Clinical Measurement: Escalated to IT [information technology] for immediate implementation Implementation Date: 2/18/2020 at 1725 (5:25 p.m.) COMPLETED 2.20.2020 Monitoring Plan: -ED Charge Nurse to review all Behavioral Health patients -ED Charge Nurse to call Chief Operating Officer (COO) when patients with suicidal or homicidal ideation are registered -COO to ensure that: *Level of observation is ordered *Sitter has been requested and obtained, if indicated/ordered -ED Charge Nurse to review ED BH patients every four hours (Meditech report) Responsible Party: Chief Operating Officer Measurement: 100% review of patients with positive SI/HI [suicidal ideation/homicidal ideation] screening Implementation Date: 2/18/2020 COMPLETED 2.20.2020 Sitters can be responsible for no more than four patients with q15 minute observations (an order for 1:1 monitoring requires one sitter for one patient Responsible Party: Chief Nursing Officer Measurement: 100% review of appropriate sitter assignment, as evidenced by ED Charge Nurse Monitoring Log Implementation Date: 2/18/2020 COMPLETED 2.20.2020 The Plan of Removal was reviewed by the survey team and accepted at 4:45 p.m. on 2/20/2020, the IMMEDIATE JEOPARDY was abated during the survey, and findings now cited at the Condition of Participation level. Please see citation 0144 for further detailed information regarding the observations and concerns identified related to patient safety interventions.
Based on interviews, hospital document review and the course of a complaint investigation, it was determined the staff failed to follow the grievance process as determined by the facility's policy. The findings include: Review of supplemental information provided by the complainant evidenced the complainant had called the ED speaking with a nurse named (name) and requesting a formal meeting to discuss concerns related to the care received while in the ED on 8/26/21. The complainant stated the ED Director never got in touch to arrange a meeting or address their concerns. The surveyor found the nurse the complainant spoke with, who was the Administrative Assistant (Staff #17) to the Director of the ED. During an interview on 12/8/21 Staff #17 remembered taking the call while the ED Director was on vacation and stated the information was shared with the Director of ED via email. Staff #5, the ED Director was able to provide the surveyor with a copy of the email. Staff #5 confirmed during an interview they made an attempt to contact the complainant by phone but ware unable to reach the complainant. Staff #5 stated there were no additional attempts made to contact the complainant and confirmed the grievance was not forwarded to the Patient Safety Coordinator for documentation, investigation and resolution. The facility policy titled Patient Grievance and Complaint Management Policy revised 6/2018 was reviewed on 12/8/21 and contained the following information in part: A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative. A written complaint also includes those complaints received via electronic mail or facsimile. Regardless of the form in which a complaint is received, whenever a patient or patient's representative requests a response from the facility, the issue is defined as a grievance... Upon receipt of a grievance the Patient Safety Coordinator shall be notified and shall confer with the appropriate Department Director to review investigate and resolve with the patient and/or the patient representative within seven days of the receipt of the grievance... In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion... The written notice must be communicated appropriately to the patient or the patient's representative in a language and manner the patient or the patient's representative understands. When a patient communicates a grievance via email, the response may be provided via email. However, the response must contain the aforementioned elements. The failure of hospital staff to execute the grievance process as outlined in the facility policy was discussed with Staff #1 and Staff #2 at the time of discovery and with the management team prior to exit on 12/9/21.
Based on observations, staff interviews, and facility document reviews, it was determined the facility staff failed to ensure that Patient Safety policies related to patients experiencing suicidal and homicidal ideations were followed The findings include: On 02/18/2020 at 12:50 p.m., the surveyor spoke with the family member of Patient #17. During the conversation, the family member relayed concerns that Patient #17 had been in the ED for six (6) days waiting for bed placement in a psychiatric facility, and that for the first thirty-six hours (36) of the stay, the patient had been on a stretcher in the hallway when the complainant observed that there were unoccupied ED rooms. At the time of the interview, Patient #17 was in an ED room, where the complainant stated Patient #17 had been moved on 2/14/2020 at around 9:00 p.m. After speaking with the complainant, the surveyor interviewed Staff Member (SM) #14, ED Manager, and SM #15, ED Director at 1:00 p.m. on 2/18/2020. The surveyor inquired as to the number of ED beds, and SM #14 told the surveyor that there were twenty-six (26) ED rooms, and one (1) stretcher outside every room, for a total of approximately twenty (20) additional hallway beds. SM #15 added that room #13 was used as the facility's behavioral health room, but that all behavioral health (BH) patients go in the hallway on a stretcher after they are wanded, placed in paper scrubs, and personal belongings are searched for contraband. SM #15 told the surveyor that BH patients are placed in the hallway across the board so that staff will recognize which patients are BH. SM #15 went on to tell the surveyor that generally length of stay in a hallway bed could be two (2) to three (3) days, but added that pediatric patients are usually given a room, because they usually stay the longest. SM #15 told the surveyor that we usually put a sitter with patients with suicidal ideation (SI), and that the hallway beds are as safe and secure as they can be. SM #15 told the surveyor that there were three (3)rooms in which behavioral health assessments were conducted via tele-psych, and that patients were moved from the hall into one of the 3 rooms, then moved back into the hallway after the BH assessment has been conducted. The surveyor asked SM #27, an ED Registered Nurse (RN) on duty at the time of the ED visit, which patients were BH who also had suicide precautions ordered. SM #27 told the surveyor that Patient #10 was currently on suicide precautions. The surveyor observed Patient #10 walk down the hallway unaccompanied, and get onto a stretcher. SM #27 responded that suicide precautions were ordered, but a sitter was not available. The surveyor asked SM #27 to pull up Patient #10's physician orders, and noted that on 2/17/2020 at 5:54 p.m. there was a physician order for one to one (1:1) sitter, which was acknowledged by a nurse on 2/18/2020 at 2:18 a.m. When asked if Patient #10 had been monitored by a 1:1 sitter after the order was written, SM #27 said No, and that some providers don't know the difference between 1:1 and suicide precautions. we [nurses] reach out every day for sitters, we just don't have enough. We always ask for sitters. Another SM who was standing in the area of the conversation said that there was only one (1) sitter in the ED, and that person was sitting with four (4) BH patients around the corner in the red subwait area. One (1) patient (Patient #17) did not have a diagnosis of suicidal or homicidal ideations (SI/HI), and was in attendance of family members in ED room 13. At 1:15 p.m. the surveyor went to the red subwait area just outside of ED room 13 and interviewed SM #28 who was monitoring 4 patients sitting in recliner chairs at the end of the hall where a television was on the wall, just outside of ED room #13. The surveyor inquired as to the patients in the chairs and for what reason they were being monitored. SM #28 said I don't know why they are being watched, nobody told me. I am just doing every 15 minute checks. The surveyor reviewed the Patient Monitoring Record on which SM #28 was documenting every 15 minute checks for Patients #11, 12, 13, and 14. The document reviews revealed that for four (4) of four (4) of the patients being monitored, the records lacked evidence of what type of safety precautions were ordered for the patient (suicide precautions, standard (every 15 minute), line of sight, or 1:1). The surveyor inquired as to the status of Patient #18, who was wearing blue paper scrubs and lying on a stretcher in the hallway of the ED. Patient #18 had an order written 2/18/2020 for a 1:1 sitter. SM #27 told the surveyor that facility staff had contracted with the family for 1:1 sitter. An abbreviated review of the electronic health record (EHR) with SM #27 while in the ED revealed a physician order for a 1:1 sitter for Patient #18; however, a sitter was not present and conducting every 15 minute checks. On 2/18/2020 the surveyor found seven (7) behavioral health (BH) patients awaiting disposition in the ED (Patients #10, 11, 12, 13, 14, 17, and 18). Two (2) of seven (7) patients (Patients #11 and 13) were in the ED for detox (detoxification (detox) is a period of medical treatment, usually including counseling, during which a person is helped to overcome physical and psychological dependence on alcohol or drugs), and were not diagnosed as having SI/HI. Patients #11 and 13 did not have a physician order for safety monitoring; however, the surveyor was advised as a nursing measure, they were being monitored every 15 minutes by a Safety Attendant. Three (3) of seven (7) patients had been diagnosed with suicidal ideations (SI), and had a physician order for a one to one (1:1) sitter (Patients #10, 14, and 18). The surveyor observed, and Staff Member (SM) #27 confirmed, that there was no 1:1 sitter in attendance of Patients #10, 14, and 18. Patients #10 and 18 were lying in the hallway on stretchers dressed in blue paper scrubs. One patient (Patient #12) was admitted to the ED with SI/HI, and a behavioral health assessment documented on 2/18/2020 that Patient #12 was Agitated, rocking back and forth, combative, homicidal with delusions of grandeur, having auditory hallucinations, and at high risk for suicide and homicide. The nursing suicide assessment of Patient #12 evidenced that the patient was at high risk for suicide, and that the patient was also homicidal. Nursing Documented further that safety precautions and safe environment were implemented, but did not specify what safety precautions were initiated. There was no physician order for safety precautions. Patient #12 was being monitored every 15 minutes by a safety attendant in the red subwait area of the ED, along with three (3) other BH patients (Patients #11, 13, and 14). Patients # 11, 12, 13 and 14 were sitting in recliner chairs at the end of a hall watching television while SM #28, a Patient Care Attendant (PCA), who was functioning in the capacity of a Safety Attendant, was documenting every 15 minute safety checks on the four aforementioned patients. The surveyor asked for the facility's policy for monitoring patients with suicidal and/or homicidal behaviors in the ED, and was given a policy titled Suicide Screening and Prevention: Non-Behavioral Health, NPSG.11.606.00.0. The policy was last revised 7/2011, and documented an Expiration of 6/2018. A review of the policy revealed the following information, in part: ...The scope of this plan begins prior to admission to the hospital and continues through the patient's discharge...A. The Registered Nurse will screen all patients presenting for admission for risk of suicidality as outlined in this plan...C. If the patient is determined to be of suicide risk, the results of this screening will be clearly communicated to the treatment team in the treatment area immediately...B. Screening and Reassessment; 1. Suicide Risk Screening and Assessment...b. The Emergency Department (ED) Registered Nurses will screen patients admitted to the ED with a primary focus/complaint of a behavioral issue(s) and/or if the RN has any clinical concerns for any patients presenting with risk for self harm. c. Any patient cared for in the ED or inpatient care areas of the hospital that has a yes answer to any of the suicide risk screening questions will be identified as patients that are at risk for suicide. Any patient that responds yes to any of the interview questions on the suicide risk screening will be placed on suicide precautions and the RN will assign patient observation monitoring immediately and a LIP [licensed independent practitioner] order will be generated in order to gain further suicide risk assessment by a qualified mental health professional (QMHP) or assigned LIP and determine an ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be documented and implemented to ensure the environment and patient will be safe...C. Heightened observations-Patients who are screened and assessed to be at risk for suicidality will be placed on patient observation and monitoring as assigned by the RN and reassess {sic} after the QMHP or assigned LIP assessment is completed. The patient may be placed on every 15 minute monitoring (Standard observations), continuous or visual or line of sight observation or a one to one (1:1) observation status as outlined in the Level of Observation definitions below (Use monitoring Documentation form for all levels of observation) and as determined by the treatment team and LIP order. 1. Level 1: Standard Observation- Monitor and observe minimally every 15 minutes. Staff visually observes the patient at least every 15 minutes, verifies their well-being, and ensures that they are safe both physically and mentally. Staff ensures the right patient is in the right bed and if the patient is sleeping, ensuring that they are breathing and in no distress...2. Level 2: Line of Sight Observation-Line of sight at all times monitoring and observation. Continuous Visual Observations means that at no time is the patient out of the visual contact of a staff member. Staff shall ensue safety when the patient is in the restroom, shower, or changing clothes. Staff shall attempt to maintain the patient's privacy as much as possible, however the safety of the patient must be the main consideration. Staff can be outside the open door but the patient must be in site...3. Level 3- 1:1 monitoring and observation. The patient is NEVER to be out of arms reach of the assigned and dedicated staff member. The patient will be in seclusion, restraint or emergency use of medications, actively attempting to harm self or others, hallucinations which have the potential to result in harm to self or others, demonstrated dangerous and unpredictable behavior, patient failed on line of sight and is unsafe at a lower level of care...D. Suicide Precautions...2. Suicide precautions are to be clearly indicated on the assignment sheet and patient specific rounds sheets and communicated during every transition of care (change of shift, breaks, and lunches) through thorough hand-off communication.... The aforementioned policy also included instruction that 1:1 observation would be supported at the time of reassessment for patients who had attempted suicide in the past 48 hours, had displayed self injurious behaviors in the last 8/12 (shift specific) hours, verbalized SI with a plan to harm self, is having command hallucinations to harm self, verbalized hopelessness, or had experienced traumatic loss or a disrupted support system in the last 24 hours. On 2/19/2020 at 5:10 p.m. SM #2, Vice President (VP) of Quality advised surveyors that a new Suicide Screening and Prevention Policy had been in progress for about six (6) weeks, but it was not approved until 2/14/2020 at approximately 4:30 p.m. SM #2 also said that corporate put Meditech changes for the new policy through and was available for staff to use on 2/18/2020.
Based on observations, staff interview, and review of facility documents, it was determined that facility staff failed to ensure that their policy and procedure for self administration of patient's home medications was followed for one (1) patient (Patient #19). Findings included: On 2/13/2020 at 3:00 p.m. the surveyor observed two (2) bottles of eye drops on the bedside table in the room of Patient #19. One (1) bottle was over-the-counter lubricant eye drops, and the other was a prescription bottle of eye drops used to treat chronic dry eyes. The surveyor interviewed a family member present in the room with Patient #19 who told the surveyor that when Patient #19 was admitted the eye drops were not available for the patient to use, so he and another family member have been administering the eye drops since Patient #19's admission to the hospital. The surveyor asked the Unit Manager, Staff Member (SM) #29 to review Patient #19's electronic medication administration record (eMAR) in order to determine whether the medications had been ordered by the physician, and whether the record included an order for self-administration of the eye drops. SM #29 told the surveyor that Patient #19 had been an inpatient for three (3) days. The eMAR lacked evidence of an order for either of the eye drops sitting on the bedside table in Patient #19's room. SM #29 advised the surveyor that there is a procedure for patient's who use their own home medications when they are unavailable from the hospital pharmacy, and that the medications should have been sent to the pharmacy to be verified and bar coded. The surveyor reviewed the facility's policy entitled Patient's Personal Medications, last revised 3/2018, with an expiration of 3/2021. The policy review revealed the following information, in part: ...Procedure: When a Patient brings personal medications to the hospital at the time of admission, one of three scenarios: 1. The medication is identified by the nurse for medication reconciliation, and then sent home with a family member or caregiver within 24 hours after admission. 2. A physician writes an order for the patient to be administered their own home medications. If the patient is going to take medication(s) brought in from home during his/her stay, a pharmacist must identify these medications. a. A prescriber may order the patient may use his/her home medication(s) under any of the following conditions: i. The pharmacy and Therapeutics Committee classifies the medication as non-formulary and no suitable formulary option is acceptable to the prescribing licensed independent practitioner. ii. The pharmacy cannot obtain the formulary medication. iii. The medication is supplied to the patient as an investigational drug (refer to investigational study drugs portion of the Medication Administration Policy). iv. The medication is in an unopened multiple dose container such as eye drips {sic}, topical creams, inhalers, etc. v. The patient is classified as an out-patient or 23-hour hold patient... The surveyor also reviewed the facility's policy entitled Medication Administration, last revised 8/2015, expiration: 7/2021, which revealed, in part: ...E. Patient Personal Medication/Self Administration of Medications 1. Patients own medications will be handled according to the Patient Own Medication policy and procedure. 2. To allow self-administration of medications by patients, a written order must appear in the medical record. Self administration is permissible where patient participation is essential for patient teaching purposes, such as rehabilitation, the use of metered dose inhalers, teaching the patient to self-administer insulin injections or investigational agents. Patients who will be self-administering drugs (or family members who might administer drugs to inpatients) should receive training about the medication, including the nature of the medication, how to administer it, expected effects, potential adverse effects and reporting side effects. Prior to ordering the drug, the provider must deem the patient or family member competent to administer the drug. The nurse should document patient self-administration in the e-MAR. Concerns were discussed with SM's #1 and 2 at the time of the observation, and again on 2/21/2020 at 2:15 p.m. with administration and department directors at the exit conference.
Based on observations, interview and document review, it was determined the facility failed to meet this condition based on the scope and severity of infection control deficiencies. See Tag A-0749
Based on observations, interview, and document review, it was determined facility and contracted staff failed to ensure that facility policies and procedures, as well as policies and procedures of contracted vendors and their staff, were followed in order to prevent cross contamination and spread of communicable infections. Findings included: On 2/13/2020 at 9:50 a.m., while making observations of a medication pass on 5 East, the surveyor observed Staff Member #30 remove a pair of scissors and an alcohol prep pad from their uniform top, open the prep pad, wipe the blades of the scissors before cutting a pill in half through the packaging, put the scissors back in their pocket, place the medication into a pill cup and administer it to the patient. On 2/13/2020 at approximately 9:55 a.m., while walking with the surveyor to the medication room to get medications for a patient in room 511, a nurse asked SM #30 if they knew where the pill crusher was located. SM #30 responded that the pill crusher was in room 501. On the way to room 511 to observe medication administration, the surveyor observed the nurse walk from the direction of room 501 with a small clear baggie of what appeared to be crushed medication. After observation of the medication pass in room 511, at approximately 10:25 a.m., the surveyor walked to room 501 and observed a Silent Night pill crusher setting on the counter to the right of the door upon entering room 501. SM #5 advised the surveyor that typically staff take the pill crusher with them and use a wipe to clean it on the way out of the room. On 2/13/2020 between 10:00 a.m. and 10:20 a.m., the surveyor accompanied SM #30 into room 511 to observe administration of medications. The patient in room 511 was on Contact Isolation Precautions as evidenced by the green contact isolation sign at the doorway; SM #30 confirmed to the surveyor that the patient was on Contact Isolation precautions due to a Methacillin-resistant Staphylococcus aureus (MRSA) infection. Both the surveyor and SM #30 sanitized hands and donned appropriate personal protective equipment (PPE) prior to entering the room. After touching the patient with gloved hands in attempts to scan the arm band prior to the administration of medications, SM #30 pushed the PPE gown to the side and reached into their uniform pocket, retrieving a pair of scissors and some alcohol prep pads. SM #30 then cut the wrist band from the patient's arm, replaced it with one provided by staff outside the room, wiped the scissor blades with an alcohol prep pad, and put them back into the pocket of their uniform top. While administering medications to the patient, a physician, SM #31 entered room 511 without donning PPE. After seeing SM #30 and the surveyor wearing PPE, SM #31 asked if the patient was on isolation precautions, to which we both responded Yes. SM #31 did not don PPE, took a stethoscope from around their neck, and, after auscultating the patient's chest, placed the stethoscope back around his/her neck and left the room. SM #31 neither cleaned and disinfected the stethoscope nor washed or sanitized their hands prior to exiting the room and walking down the hall. The surveyor asked for and was given the facility's policy entitled Guidelines for Isolation Precautions, last revised 1/2020, expiration 1/2023. A review of the policy revealed, in part, the following information: ...C. Contact isolation Precautions (Green Door Sign)- Contact Precautions are designed to reduce the risk of transmission of epidemiologially important microorganisms by direct- or indirect-contact...Contact Precautions apply to specified patients known or suspected to be infected or colonized (presence of microorganism in nor on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct- or indirect-contact...2. Gloves and Hand Hygiene-In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate) when entering the room...Remove gloves before leaving the patient's environment perform hand hygiene immediately with an antimicrobial agent or a waterless antiseptic agent...wear a gown (a clean, non-sterile gown is adequate) when entering the room...When possible, dedicate the use of non-critical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient... The surveyor also reviewed the facility policy entitled Hand Hygiene, IC.05.1105.0.0 Last revised 7/2019, expiration 7/2022. The hand hygiene policy stated, in part to perform hand hygiene ...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...D. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. *Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another.... A tour of the facility's kitchen was conducted, and observations were made on 2/12/2020 and 2/13/2020. On 2/12/2020 at 11:15 a.m. the surveyor, accompanied by SM #10, an employee of the contracted services provider for the facility's kitchen, entered the walk in freezer, and the surveyor noted loose particles of food lying on the floor of the walk in unit, containers of french fries, diced chicken, frozen Lo mein noodles, ground turkey burgers, egg patties, biscuits, and sausage links, all of which were open and exposed, and none of which were labeled with an open date. SM #10 told the surveyor I have never dated an open container of frozen food. The surveyor also noted a box sitting on the floor of the walk in freezer which was packed with loaves of bread and french fries, and when the surveyor inquired as to why the box of food items were setting in the floor, SM #10 stated They are just odds and ends stuff that the stock guy is going to throw away. In the pot storage area the surveyor observed clean muffin pans with crumbs on the sides of them, and food debris in the floor under the storage racks. The surveyor observed an open/undated container of basil pesto (with the top off) setting on a cart which contained slices of pizza being prepped for meals. At 11:45 a.m., the surveyor asked staff to check the chemical concentration in the sanitation bucket in the cold prep area; the chemical test strip registered 0. The surveyor was told by SM #9, Operations Manager for the contracted food services vendor, that the facility used Quaternary Ammonia (QUAT) in the sanitation buckets, and that the solution is premixed when it goes into the sanitation bucket. Food sanitation buckets are used for routine cleaning and sanitizing of food contact surfaces and equipment necessary to prevent the growth of bacteria, and should be tested regularly to ensure that they maintain the proper strength of sanitizer for food contact surfaces. Buckets should register between 200-400 ppm (parts per million), and should be changed every two (2) to four (4) hours, or more often, as needed to keep the buckets clean, and the chemical sanitizer effective. In the cold prep area, the surveyor observed a staff member's personal drink in a styrofoam cup setting on the food prep area with food supplies. At 11:50 a.m. on 2/12/2020, in a refrigerator used to store items for use in Jazzman's cafe, the surveyor observed already prepared bacon which had an expiration date of 1/18/2020, open coleslaw in a pan with an expiration date of 1/15/2020, prepared Caeser salad was not labeled with an expiration date, and boiled eggs had two (2) expiration date stickers (1/18/2020 and 2/17/2020). SM #9 stated Whoever labeled these things probably forgot to change the stamp date to February, I know these things haven't been in here this long. At 12:05 p.m. on 2/12/2020 the surveyor asked to review the temperature log for the hot prep food area. The log lacked documentation for the first temperature reading of the day, during the breakfast meal. SM #11, cook stated Looks like it didn't get done. It's usually done about 10:30 a.m. when it's [food] is up on the line, whoever is on the line should be doing that. The surveyor also noted that there were no temperatures documented for the cold prep area as of 12:05 p.m. on 2/12/2020. On 2/13/2020 At 10:55 a.m., the surveyor asked staff to check the mixture in random sanitation buckets in the kitchen area to ensure that the chemical concentration was at least 200 ppm (parts per million) The sanitation bucket at the tray line measured 100 ppm, the sanitation bucket in the cold prep area showed a test strip that was orange in color, indicating the sanitizer was less than 200 ppm. At 10:55 a.m. on 2/13/2020 the surveyor observed metal food containers which had been run through the facility's dishwasher, being stored on a shelf while wet (wet nesting). Wet nesting is the practice of placing two recently washed items together in a nested fashion, which prevents proper airflow, and can lead to bacterial growth. At 11:00 a.m. on 2/13/2020, the surveyor observed a food services staff member who was working with food while wearing gloves in the catering area move from food preparation to the walk in refrigerator, enter the refrigerator, pick up shredded cheese and return to the catering area, pick up labels and a pen, wrote on the bag of cheese, and resumed preparing food, all while wearing the same gloves. The same staff member then went to the small refrigerator near the catering area, got something from the refrigerator, and started working with the food, again without washing or sanitizing hands, or changing gloves. On 2/13/2020 at 11:00 a.m., the surveyor held a discussion with SM #10, General Manager of dietary services for the contracted company, related to observations over the past two (2) days. SM #10 agreed with the surveyor that the freezers and refrigerators have not been swept out this week, and there was food on the floors. SM #10 also told the surveyor that if an employee goes from working with food to touching a direct surface, they need to wash their hands and change gloves. SM #10 told the surveyor that they perform monthly food safety audits, and provided the surveyor with a copy of the audit performed 1/15/2020. The surveyor asked SM #10 for the contracted food vendors policies and procedures related to infection control, hand hygiene and glove use, labeling of foods, testing of sanitation bucket chemicals, employee training requirements. The surveyor was given copy of a document entitled Operational Standard: SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION Food Safety (HACP), effective 10/1/14, of review 6/12/19, and included the following information, in part: ...All food items are to be properly labeled, dated, covered and stored using first-in, first-out rotation; Food Services personnel will routinely inspect all cold food storage units for food items not meeting quality standards f any standard stipulated in this policy...Food Services will maintain clean, sanitary and safe food storage areas and equipment; Food Service personnel will handle/store all food items according to related HACCP [Hazard analysis and critical control points] guidelines and infection control policies and procedures...Food Service personnel are trained in the process of handling potentially hazardous foods to include: personal hygiene, hand hygiene & glove use, thermometer calibration, proper cooking methods, proper temperature documentation, and proper sanitation...Food temperatures of potentially hazardous foods are monitored during cooking to ensure adequate minimum internal cooking temperatures per HACCP guidelines as identified in department HACCP Food Safety Program...Temperature records are maintained for each service location where potentially hazardous food is served. Foods found to be outside the acceptable range are immediately removed from service and rapidly chilled, reheated or discarded as indicated...Food Services personnel will receive skill-based HACCP training appropriate for their level of responsibility. Competency will be assessed based on observation of job performance.... The surveyor reviewed the contractors HACCP employee training information for new employee and annual training, which included the following in part: Food Safety Information: ...Clean, rinse and sanitize all food contact surfaces between each use or at regular intervals... A document When to Wash Hands, which guides employees to always wash hands thoroughly after going to the restroom, before beginning work or when returning from breaks, after handling raw meat, poultry, seafood, and produce, before working with ready-to-eat foods, before handling different types of food, after touching hair, face, nose, or other body part, after coughing, sneezing, or blowing nose, after cleaning, after handling chemicals, after handling dirty equipment, after handling trash or other contaminated objects. SM #17, Director of Infection (IP) on 2/20/2020 at approximately 10:00 a.m. in order to discuss concerns related to observations of infection control practices throughout the facility during the survey process. SM #17 shared infection control meeting minutes, infection control policies and procedures, and the facility's 2019 infection prevention annual evaluation. SM #17 also told the surveyor that quarterly rounds are conducted in the facility's kitchen, and any noted issues would be addressed. SM #17 described the facility's Secret Shopper program to monitor for proper hand hygiene throughout the facility. Unit Managers gather and provide data to IP, information is then shared with the facility's quality program. The surveyor discussed observations related to a physician entering an isolation room without donning proper PPE, and SM #17 said that leadership staff accompanying the surveyor at the time of the observation spoke with the clinician at the time of the incident, and that the incident had been referred for peer review. A discussion was also held related to clinical staff having supplies in their uniform pockets, and SM #17 said uniforms are not for storage of supplies. Concerns were discussed with the facility's Quality, Infection Prevention, Nursing, and Contracted Kitchen staff throughout the survey as described above; concerns were again discussed with administrative staff and department directors on 2/21/2020 at 2:15 p.m. at the exit conference.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and document review, it was determined facility staff failed to ensure that a signed consent was obtained prior to a procedure for one (1) out of twenty-one (21) patient (Patient #1) records reviewed. Findings included: Patient #1 was admitted on [DATE] with diagnoses which included, but were not limited to sepsis, shortness of breath, dizziness, blurred vision, headache, and chest pain. A review of the medical record for Patient #1 revealed an order for lab testing for HIV (human immunodeficiency virus). There was no consent for HIV testing signed by the patient or his/her representative. The lab test was drawn and results recorded on 11/30/18. The general consent for treatment dated 11/29/18 included documentation that the patient was admitted no family. There were telephone consents in the record witnessed by hospital staff, with permission for tests/procedures granted by the patient's son, for the following dates/procedures: 12/2/18: lumbar puncture; 12/3/18: Dialysis catheter; and 12/4/18 TEE (transesophageal echocardiography) and blood products. On 12/6/18 the case manager's note documented attempted to call family, phone disconnected. Staff Member (SM) #2 was interviewed on 12/14/18 at 11:00 a.m. and stated Case management would get involved and talk with the family. The facility's policy entitled HIV testing Consent, Explanation and Counseling, IC.05.1109.0.0 was reviewed, and evidenced the following in part: Policy: In order to comply with Virginia State Law, the physician must get the consent of the patient to perform HIV testing. If any patient refuses the HIV test, the physician should so document in the patient's chart and the test will not be performed except in the case of the Deemed Consent as stated in Virginia State Law 32.1-45.1... Procedure: A. The physician writes an order for the HIV test on the patient's chart. B. The physician must get the patients {sic} consent for the HIV test. C. If the patient refuses the test, the physician must so state in the chart and cancel the HIV order. D. Once the HIV order and patients {sic} consent are obtained, the nurse will initiate a lab slip for the test. E. Once HIV test results are charted, the physician will disclose the results to the patient. At this time, the physician, by law, must offer the patient counseling and education regarding HIV test results as outlined in Virginia State Law (32.1-37.2, Section B).... On 12/14/18 at approximately 11:30 a.m. SM #16, epidemiologist, advised the surveyors that a second HIV test was ordered/ drawn on Patient #1 due to a staff exposure, and that a separate consent was not required due to deemed consent. SM #16 stated a consent is required, except when drawn due to staff exposure/deemed consent. Concerns were discussed with SM #2, Director of Quality and Accreditation on 12/14/18 at approximately 11:00 a.m. on 12/14/18, and again at 12:00 p.m. on 12/14/18 with members of administration.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and document review, it was determined that facility staff failed to ensure that the plan of care for one (1) out of of seven (7) patients (Patient #13) was updated when restraints were placed. Findings included: A review of the medical record was conducted for Patient #13, who was admitted to the facility on [DATE] with diagnosis of altered mental status. There was documentation in the record that bilateral upper extremity (BUE) mitts were ordered on [DATE] at 8:22 p.m. for safety (non-violent) due to pulling out his/her nasogastric tube (NGT). Mitt restraints were ordered/documented on 11/30/18, 12/1/18, 12/2/18, 12/3/18, 12/4/18, 12/5/18, and 12/6/18. Restraints were added to Patient #13's plan of care on 12/3/18 at 9:51 p.m., three (3) days after mitt restraints were placed. The facility's policy entitled Patient Restraint/Seclusion, PC.13.329.00.0 was reviewed, and stated the following, in part: ...10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. b. Patients and/or families should be involved in care planning to the extent possible and made aware of changes to the plan of care.... The facility's policy entitled Documenting the Provision of Care was also reviewed, and stated the following, in part: ...A. Plan of Care:...The Plan of Care is reviewed daily and updated as needed based on changes in the patient condition and progress toward identified outcomes or goals. Progress is documented as Improved, Stabilized, or Deteriorated, as defined by the CCC taxonomy. The daily focus for the patient is identified at the beginning of the shift, usually during bedside handoff. The focus is generally written on the white board at bedside to assure that all members of the care team, including the patient's family are aware of the focus for the day.... Concerns were discussed with Staff Member (SM) #4, Outcomes Specialist and record navigator, on 12/13/18 at approximately 3:30 p.m., and with members of administration on 12/14/18 at 12:00 p.m.
Based on observation and inspection the facility failed to maintain building construction. Findings include: On 5-14-18 at approximately 9:31 am it was observed through observation and inspection that drywall mud has been used to patch holes in the spray on fire proofing on the steel beams of Mechanical Penthouse #4 on the roof. On 5-14-18 at approximately 9:32 am it was observed through observation and inspection that the fire proofing on the steel beams in Mechanical Penthouse #3 on the roof is not sprayed on, it appears to be tooled. On 5-14-18 at approximately 9:24 am it was observed through observation and inspection that the fire proofing has not been reapplied around the beam clamps in Mechanical Penthouse #3 on the roof . On 5-14-18 at approximately 9:44 am it was observed through observation and inspection that the roof for the elevator mechanical room for elevators 4 & 5 on the roof has exposed wooden beams. On 5-14-18 at approximately 9:46 am it was observed through observation and inspection that spray on fire proofing on the steel beams of Mechanical Penthouse #1 on the roof is missing or improperly applied. On 5-14-18 at approximately 10:34 am it was observed through observation and inspection that the spray on fire proofing is not complete above the ceiling outside of Room 642. On 5-14-18 at approximately 11:17 am it was observed through observation and inspection that a steel column above the 5 East Clinical Coordinators Office is not completely enclosed in drywall. On 5-14-18 at approximately 11:37 am it was observed through observation and inspection that there exposed areas to the steel beams where the spray on fire proofing is missing above the ceiling in the 5 East elevator Lobby. On 5-14-18 at approximately 1:50 pm it wa
Based on observation and inspection the facility failed to maintain means of egress. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided. On 5-14-18 at approximately 10:05 am it was observed through observation and inspection that egress is obstructed out of the Clinical leaders office on the sixth floor. On 5-14-18 at approximately 10:50 am it was observed through observation and inspection that beds are being stored in the sixth floor center stairwell alcove. On 5-14-18 at approximately 1:43 pm it was observed through observation and inspection that there is furniture being stored in the 5 East corridor obstructing egress. On 5-14-18 at approximately 3:03 pm it was observed through observation and inspection that a food tray cart is being stored in the egress corridor by Elevator #3 obstructing egress. On 5-14-18 at approximately 2:32 pm it was observed through observation and inspection that the corridor door going out of the PT Office is obstructed by a homemade desk. On 5-15-18 at approximately 9:00 am it was observed through observation and inspection that beds are being stored in the egress corridor outside of the CICU on the 3rd floor. On 5-15-18 at approximately 12:36 pm it was observed through observation and inspection that beds are being stored in the exit corridor of the Cath Lab. On 5-15-18 at approximately 1:35 pm it was observed through observation and inspection that the exit corridor outside of the bed storage area is being used to store beds and carts. On
Based on observation and inspection the facility failed to maintain Doors with Self-Closing Devices. On 5-16-18 at approximately 9:05 am it was observed through observation and inspection that the rated doors in the 2 hour fire wall going into the Cancer Center do not close and latch automatically. The Facility Maintenance Director witnessed this evidence through observation and interview.
Based on observation and inspection the facility failed to maintain smokeproof enclosures. Findings include: On 5-14-18 at approximately 11:14 am it was observed through observation and inspection that stairwell #5 at 5 East has unprotected through penetrations. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain emergency lighting. Findings include: On 5-22-18 at approximately 5:50 am it was observed through observation and inspection that documentation could not be provided to show that the battery power emergency lighting in the Endo OR's is being inspected/ tested monthly and a 90 minute activation test is done annually. The Facility Maintenance Director witnessed this evidence through observation and interview.
Based on observation and inspection the facility failed to maintain exit signs. Findings include: On 5-15-18 at approximately 10:48 am it was observed through observation and inspection that the exit sign by Nurse station A on 2 West L&D points you to a non exit area. On 5-15-18 at approximately 12:37 pm it was observed through observation and inspection that the exit sign by the Cath Lab supply room points you to a non exit area. On 5-16-18 at approximately 9:39 am it was observed through observation and inspection that the exit sign in the Discharge Lounge is not illuminated as designed. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain vertical openings. Findings include: On 5-14-18 at approximately 2:59 pm it was observed through observation and inspection that there are unprotected through penetrations the 5 West elevator shaft #3. On 5-14-18 at approximately 9:27 am it was observed through observation and inspection that there are unprotected through penetrations at the top of the elevator shaft in Mechanical Penthouse #4 on the roof. On 5-14-18 at approximately 2:59 pm it was observed through observation and inspection that there are unprotected through penetrations the 5 West elevator shaft #3. On 5-14-18 at approximately 2:43 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator 1 & 2 shafts on the 4th floor. On 5-15-18 at approximately 11:07 am it was observed through observation and inspection that there are unprotected through penetrations to the 2 Center L&D elevator shaft above the ceiling. On 5-15-18 at approximately 3:13 pm it was observed through observation and inspection that documentation could not be provided to show that the tube system is constructed within a fire rated barrier. On 5-22-18 at approximately 10:22 am it was observed through observation and inspection that Elevator shafts 6 and 7 have unprotected through penetrations. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain hazardous areas. Findings include: On 5-14-18 at approximately 2:21 pm it was observed through observation and inspection that the corridor door for the Occupational Therapy Biohazard Room will not close and latch automatically. On 5-14-18 at approximately 2:54 pm it was observed through observation and inspection that the corridor door to the 4 East combustible storage room is not self closing by Elevator #7 Lobby. On 5-14-18 at approximately 3:14 pm it was observed through observation and inspection that the 3 East soiled utility electrical room is being used as a combustible storage area. On 5-15-18 at approximately 1:38 pm it was observed through observation and inspection that there is a change of use to the bed storage room. This area used to be an office now its used as combustible storage. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview the facility failed to maintain anesthesia locations. Findings include: On 5-22-18 at approximately 5:41 am it was observed through observation and inspection that the anesthesia control valves are obstructed in Endo OR 32. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain cooking facilities. Findings include: On 5-16-18 at approximately 8:31 am it was observed through observation and inspection that there are gap between the vents in the Kitchen hood system. On 5-16-18 at approximately 8:37 am it was observed through observation and inspection that the Kitchen hood vents have an accumulation of grease. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview the facility failed to maintain Alcohol Based Hand Rubs. Findings include: On 5-15-18 at approximately 11:00 am it was observed through observation and inspection that a ABHR dispenser is installed directly above a light switch. in the 2nd floor lactation room. On 5-16-18 at approximately 9:11 am it was observed through observation and inspection that a ABHR dispenser is installed directly over a light switch in the Blue Ridge Cancer Care back office break room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the fire alarm system. Findings include: On 5-22-18 at approximately 5:54 am it was observed through observation and inspection that there is a damaged heat detector in the Central Sterile Supply Room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the sprinkler system. Findings include: On 5-14-18 at approximately 9:24 am it was observed through observation and inspection that sprinklers above the air handler in Mechanical Penthouse #4 on the roof have an accumulation of dust. On 5-14-18 at approximately 9:40 am it was observed through observation and inspection that the inspectors test valve is missing the smooth boar orifice outside of Mechanical Penthouse #3 on the roof. On 5-14-18 at approximately 10:46 am it was observed through observation and inspection that wires are strapped to sprinkler piping above the ceiling by Elevator 1 & 2 on the sixth floor. On 5-14-18 at approximately 2:58 pm it was observed through observation and inspection that there is a painted sprinkler in the corridor by Room 544. On 5-14-18 at approximately 3:01 pm it was observed through observation and inspection that there is sprinkler piping that is not properly hung and that wiring is strapped to the spinkler piping on 5 West by the elevator shaft #3. On 5-14-18 at approximately 3:00 pm it was observed through observation and inspection that ceiling tiles are missing in the 4th floor Lobby IT room. On 5-15-18 at approximately 12:11 pm it was observed through observation and inspection that a sprinkler in the 2nd floor Janitors closet appears to have signs of corrosion. On 5-15-18 at approximately 1:01 pm it was observed through observation and inspection that the concealed sprinkler head covers are painted over in the CVOR 1 area. On 5-15-18 at approximately 1:29 pm it was observed through observation and inspection that sprinklers in the 2nd floor Biohazard room appear to be painted. On 5-15-18 at approximately 1:32 pm it was
Based on observation and inspection the facility failed to maintain portable fire extinguishers. Findings include: On 5-14-18 at approximately 9:21 am it was observed through observation and inspection that the portable fire extinguisher in Mechanical Penthouse #4 on the roof is not mounted. On 5-14-18 at approximately 2:53 pm it was observed through observation and inspection that the portable fire extinguisher in the 4 East Nurse Station is obstructed by medical equipment. On 5-15-18 at approximately 1:28 pm it was observed through observation and inspection that a portable fire extinguisher is missing in the 2nd floor Biohazard room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain smoke barriers. Findings include: On 5-14-18 at approximately 11:08 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall above the ceiling above the smoke doors by the 6 East soiled utility room. On 5-14-18 at approximately 11:17 am it was observed through observation and inspection that the smoke barrier wall does not go completely to the above decking above the 5 East Clinical Coordinators Office. On 5-14-18 at approximately 2:48 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall above the 4 Center smoke doors by Room 400. On 5-15-18 at approximately 9:15 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier above the CICU entrance doors. On 5-15-18 at approximately 12:05 pm it was observed through observation and inspection that there is an unprotected through penetration to the smoke barrier above the 2nd floor double corridor doors going into the OR on 2 East. On 5-15-18 at approximately 12:13 pm it was observed through observation and inspection that there is an unprotected through penetration to the smoke barrier above the ceiling at the Director of Surgical Services Office on 2 East. On 5-15-18 at approximately 12:25 pm it was observed through observation and inspection that there are unprotected through penetrations above the ceiling to the smoke barrier wall of the SICU Mechanical room. On 5-15-18 at approximately 12:48 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke partition wall above the ce
Based on observation and inspection the facility failed to maintain smoke doors. Findings include: On 5-14-18 at approximately 10:23 am it was observed through observation and inspection that the double corridor smoke doors do not completely close at the 6 West staff lounge. On 5-14-18 at approximately 1:42 pm it was observed through observation and inspection that the door in the 1 hour rated smoke barrier is held open by a bungee cord in the 5 Center Dialysis supply Room. On 5-14-18 at approximately 2:20 pm it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier corridor door going into Physical Therapy. On 5-14-18 at approximately 2:33 pm it was observed through observation and inspection that the door sequencer device has been removed off of the double corridor smoke doors by Room 433. On 5-15-18 at approximately 10:21 am it was observed through observation and inspection that the door sequencer device has been removed off of the double corridor smoke doors by Room 334. On 5-15-18 at approximately 12:15 pm it was observed through observation and inspection that the 2 East double smoke corridor doors do not completely close. On 5-15-18 at approximately 12:49 pm it was observed through observation and inspection that the door sequencer device does not operate on the 2 East double corridor doors by the soiled utility room. On 5-16-18 at approximately 9:19 am it was observed through observation and inspection that the door sequencer device has been removed off of the smoke corridor doors by Stairwell #1. On 5-16-18 at approximately 9:36 am it was observed through observation and inspection that the smoke door on the left side of the Lobby does not close completely. T
Based on observation and inspection the facility failed to maintain rubbish chutes. Findings include: On 5-15-18 at approximately 10:34 am it was observed through observation and inspection that the Trash chute door in the 3 East Biohazard room is not self closing and latching. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to conduct fire drills. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held as required. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain combustible decorations. Findings include: On 5-15-18 at approximately 2:02 pm it was observed through observation and inspection that documentation could not be provided to show that the combustible decorations suspended from the ceiling in the 11-7 Lab Supervisors Office meet NFPA 701 requirements or are non-combustible. On 5-16-18 at approximately 10:51 am it was observed through observation and inspection that documentation could not be provided to show that the combustible curtains suspended from the wall in the Radiology Associates Office in MRI meet NFPA 701 requirements or are non-combustible. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain portable space heaters. Findings include: On 5-15-18 at approximately 10:35 am it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the 3 East Case Managers Office. On 5-15-18 at approximately 11:01 am it was observed through observation and inspection that a portable space heater is plugged into a power strip in the 2nd floor lactation room. On 5-15-18 at approximately 2:03 pm it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the Lab Managers Office. On 5-15-18 at approximately 3:09 pm it was observed through observation and inspection that a portable space heater is in use within 3 feet of combustible materials in the Admin. Office on the 1st floor. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain a risk assessment. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that a formal and documented risk assessment procedure performed by qualified personnel could not be produced. On 5-14-18 at approximately 10:19 am it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster ovens, crockpots, griddles and toasters all listed for household use in the 6 West staff lounge. On 5-14-18 at approximately 1:37 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the electric griddle in the 5 East Nurse breakroom. On 5-14-18 at approximately 1:51 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster oven, microwave, electric flat top griddle, and coffee pot in the 5 West conference room. On 5-15-18 at approximately 1:51 PM it was observed through observation and inspection that a documented risk assessment or policy could not be provided for the toaster oven in the MICU clean utility room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the roof construction of the Tank Farm outside enclosure is of combustible materials. (NFPA 99 2012 5.1.3.3.2 #3) On 5-8-18 at approximately 11:24 am it was observed through observation and inspection that the Tank Farm outside enclosure has only one means of entry/exit. (NFPA 99 2012 5.1.3.3.2 #3) The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems categories. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show what category of gas and vacuum piped systems is utilized by the facility. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the entry door to the Tank Farm outside enclosure does not have a sign containing the minimum verbiage. The Facility Maintenance Director witnessed this evidence by observation and interview.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation for the Medical gas, vacuum, WAGD, or support gas systems indicates the systems were tested on ,d+[DATE]-[DATE]. The testing documents report deficiencies, and documentation could not be produced to show that they have been corrected The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the electrical system. Findings include: On 5-14-18 at approximately 9:36 am it was observed through observation and inspection that side knock outs are missing from electrical panels H-084 & H-028 in Mechanical Penthouse #2 on the roof. On 5-14-18 at approximately 9:48 am it was observed through observation and inspection that a side knock out is missing from the air handler in the Elevator #7 control room on the roof. On 5-14-18 at approximately 9:49 am it was observed through observation and inspection that a junction box is missing the approved cover in the Elevator #7 control room on the roof. On 5-14-18 at approximately 10:12 am it was observed through observation and inspection that side knock out is missing from electrical panel H-081by Room 660. On 5-14-18 at approximately 10:26 am it was observed through observation and inspection that the electrical service panel located at the 6 West nursing station is obstructed. On 5-14-18 at approximately 2:21 pm it was observed through observation and inspection that there is a junction box that is missing the side knockouts above the ceiling by the OT smoke doors. On 5-14-18 at approximately 3:13 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling by Room 315. On 5-14-18 at approximately 3:30 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling by smoke door FD-33. On 5-15-18 at approximately 9:05 am it was observed through observation and inspection that there are power strips plugged one into another in the CICU med/supply room. On 5-15-18 at appro
Based on observation and inspection the facility failed to maintain electrical systems. On 5-22-18 at approximately 5:33 am it was observed through observation and inspection that a written record of the risk assessment is not being maintained and available for inspection. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to test receptacles. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the generator system. Findings include: On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain patient-care-related electrical equipment. Findings include: On 5-15-18 at approximately 9:05 am it was observed through observation and inspection that there is medical equipment not plugged into a medical grade power strips in the CICU med/supply room. On 5-22-18 at approximately 5:44 am it was observed through observation and inspection that there is a non medical grade power strip in use by the computer in the patient care vicinity in Endo OR #31 On 5-22-18 at approximately 6:17 am it was observed through observation and inspection that the communication equipment for the hyperbaric chamber closest to the desk, is plugged into a power strip. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas equipment. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the Tank Farm outside enclosure is within 20 feet of other combustible structures. On 5-8-18 at approximately 11:23 am it was observed through observation and inspection that the Tank Farm outside enclosure contains an accumulation of combustible dead leaves. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain hyperbaric facilities. Findings include: On 5-22-18 at approximately 6:09 am it was observed through observation and inspection that there is not appropriate required signage. ( NFPA 99 14.2.6.1) The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the building construction type. Findings include: On 05/16/2018 between approximately 12:57 pm it was observed through observation and inspection that the spray on fire proofing has come off of the steel beams in the Oncology mechanical room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain means of egress. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided. On 5/16/2018 at approximately 1:40 pm it was observed through observation and inspection that the egress corridor on the second floor of Oncology going into L&D 2 West is being used as a storage area for beds. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain exit doors. Findings include: On 5/16/2018 at approximately 1:16 pm it was observed through observation and inspection that the exit door by Accelerator #3 in Oncology requires more than 5 pounds of force to operate. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain smoke barrier doors. Findings include: On 05/16/2018 between approximately 12:57 pm it was observed through observation and inspection that the corridor door in the smoke barrier to the Oncology mechanical room is not maintained self closing. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the sprinkler system. Findings include: On 05/16/2018 between approximately 12:51 pm it was observed through observation and inspection that wire is suspended from the sprinkler piping in the Oncology IT Room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain smoke barriers. Findings include: On 5/16/2018 at approximately 1:03 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier above the double corridor doors by the soiled holding room in Oncology. On 5/16/2018 at approximately 1:03 pm it was observed through observation and inspection that the double smoke doors in the Oncology corridor by the soiled holding room has a center gap that exceeds the allowable limit. On 5/16/2018 at approximately 1:10 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier wall above the ceiling in Oncology by Accelerator #2. On 5/16/2018 at approximately 1:47 pm it was observed through observation and inspection that there are unprotected through penetrations to the one hour smoke barrier wall in the Oncology second floor shell space. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to conduct fire drills. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held as required. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the electrical system. Findings include: On 5/16/2018 at approximately 1:24 pm it was observed through observation and inspection that there is a junction box that is missing the approved cover above the ceiling in the Oncology waiting room by the elevator. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to test receptacles. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the generator system. Findings include: On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain building construction type. Findings include: On 5-17-18 at approximately 8:47 am it was observed through observation and inspection that there are unprotected through penetrations to the 1 hr fire barrier wall of the ED Mechanical Room. On 5-17-18 at approximately 8:48 am it was observed through observation and inspection that there is no spray on fire proofing to the back side of a steel beam in the ED Mechanical Room.\ On 5-17-18 at approximately 10:17 am it was observed through observation and inspection that there are unprotected through penetrations to the 1 hr fire barrier wall of the MOB- West second floor Mechanical Room. On 5-17-18 at approximately 10:27 am it was observed through observation and inspection that there are unprotected through penetrations in the MOB- West electrical room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain means of egress. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could not be provided. The Facility Maintenance Director Witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain vertical openings. Findings include: On 5-17-18 at approximately 9:35 am it was observed through observation and inspection that spray combustible foam is used to fill through penetrations inside the shaft of elevator #6. On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that the shafts for elevator #5 and elevator #6 do not appear to be constructed as required by the approved plans. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview the facility failed to maintain Hazardous Areas. Findings include: On 5-17-18 at approximately 10:55 am it was observed through observation and inspection that an area in Jefferson surgical Urology has been converted into a combustible storage area. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain anesthetizing locations . Findings include: On 5-22-18 at approximately 5:11 am it was observed through observation and inspection that the anesthesia control valves in OR#7 are obstructed by storage. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the sprinkler system. Findings include: On 5-17-18 at approximately between 8:30 am and 3:00 PM it was observed through observation and inspection that throughout the building sprinklers have an accumulation of dust. On 5-17-18 at approximately 10:24 am it was observed through observation and inspection that ceiling tiles and sprinkler escutcheon rings are missing in the old Roanoke Orthopedic Area. On 5-17-18 at approximately 10:40 am it was observed through observation and inspection that the ceiling grid has been removed in the sprinklered Jefferson Surgical Communications Room. On 5-22-18 at approximately 5:03 am it was observed through observation and inspection that several of the covers for the concealed sprinkler heads have been painted and that a non approved plastic collar has been installed in OR#1. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain smoke barriers. Findings include: On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that there are unprotected through penetrations to the smoke barrier wall of the TV storage room on the Second floor. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain smoke barrier doors. Findings include: On 5-17-18 at approximately 10:01 am it was observed through observation and inspection that there are the corridor door to the TV storage room on the Second floor is not self closing. On 5-17-18 at approximately 1:07 PM it was observed through observation and inspection that the double corridor smoke doors do not close completely to reduce the passage of smoke by the OR stairwell. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to conduct fire drills. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held as required. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain a risk assessment. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that a formal and documented risk assessment procedure performed by qualified personnel could not be produced. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the roof construction of the Tank Farm outside enclosure is of combustible materials. (NFPA 99 2012 5.1.3.3.2 #3) On 5-8-18 at approximately 11:24 am it was observed through observation and inspection that the Tank Farm outside enclosure has only one means of entry/exit. (NFPA 99 2012 5.1.3.3.2 #3) The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems categories. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show what category of gas and vacuum piped systems is utilized by the facility. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the entry door to the Tank Farm outside enclosure does not have a sign containing the minimum verbiage. The Facility Maintenance Director witnessed this evidence by observation and interview.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and inspection the facility failed to maintain gas and vacuum piped systems. Findings include: On 5-7-18 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation for the Medical gas, vacuum, WAGD, or support gas systems indicates the systems were tested on ,d+[DATE]-[DATE]. The testing documents report deficiencies, and documentation could not be produced to show that they have been corrected The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the electrical system. Findings include On 5-17-18 at approximately 10:38 am it was observed through observation and inspection that there are extension cords being used as permanent wiring in the MOB wing OB/GYN second floor office. ( NFPA 70 2011 590.1) On 5-17-18 at approximately 10:39 am it was observed through observation and inspection that there are power strips plugged into other power strips in the MOB wing OB/GYN second floor office. On 5-17-18 at approximately 10:40 am it was observed through observation and inspection that an extension cord is being used as permanent wiring above the ceiling in the MOB wing OB/GYN second floor office lobby. ( NFPA 70 2011 590.1) On 5-17-18 at approximately 1:05 PM it was observed through observation and inspection that a junction box is missing the approved cover above the ceiling of the Electrical room MOB - West second floor OR. ( NFPA 70 2011 314.25) On 5-22-18 at approximately 5:02 am it was observed through observation and inspection that medical grade power strips are plugged one into another in OR#1. On 5-22-18 at approximately 5:05 am it was observed through observation and inspection that an electrical service panel is obstructed by an Anesthesia cart in OR#5 and OR#11. ( NFPA 70 2011 110.26) On 5-22-18 at approximately 5:05 am it was observed through observation and inspection that an electrical service panel is obstructed by the Da Vinci Surgical System in OR#8. ( NFPA 70 2011 110.26) On 5-22-18 at approximately 5:17 am it was observed through observation and inspection that the breakers in electrical service panel IPL are not labeled in OR#11. ( NFPA 70 2011 230.2 (E) ) On 5-22-18 at approximately 5:21 am it was obse
Based on observation and inspection the facility failed to maintain electrical systems. Findings include: On 5-22-18 at approximately 5:00 am it was observed through observation and inspection that a written record of the risk assessment is not being maintained and available for inspection. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to test receptacles. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the generator system. Findings include: On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain electrical equipment. Findings include: On 5-17-18 at approximately 10:38 am it was observed through observation and inspection that there is patient-care-related electrical equipment plugged directly into a power strip within the patient care vicinity in the MOB wing OB/GYN second floor office. On 5-17-18 at approximately 10:53 am it was observed through observation and inspection that there is patient-care-related electrical equipment plugged directly into a power strip in the patient care vicinity in the Jefferson Surgical Urology Exam room 10. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain gas equipment. Findings include: On 5-8-18 at approximately 11:22 am it was observed through observation and inspection that the Tank Farm outside enclosure is within 20 feet of other combustible structures. (NFPA 99 2012 11.3.2.3) On 5-8-18 at approximately 11:23 am it was observed through observation and inspection that the Tank Farm outside enclosure contains an accumulation of combustible dead leaves. (NFPA 99 2012 11.3.2.3) The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the construction type of the building. Findings include: On 05/08/2018 at approximately 1:28 pm it was observed through observation and inspection that the 2 hr fire barrier has unprotected penetrations by the old CTAC at the Lobby door. The Facility Maintenance Director witnessed this evidence through observation and interview.
Based on observation and inspection the facility failed to maintain the building construction type. Findings include: On 05/08/2018 between approximately 8:30 am and 3:00 pm it was observed that the 2 hour fire separation between floors was modified from its original approved construction. Alterations to the ceiling include, fire rated tiles replaced with non-rated tiles, lighting not tented, and utilizing the interstitial space as a return air plenum. On 05/08/2018 at approximately 1:38 pm it was observed through observation and inspection that a speaker in the ceiling outside of the Admin. Offices is not tented as required by UL G202. On 05/08/2018 at approximately 2:32 pm it was observed through observation and inspection that the ceiling tiles in the rated assembly are painted with pictures in the Respond call area. Also ceiling tiles have been replaced with with wood panels in the ceiling grid. On 05/08/2018 at approximately 2:32 pm it was observed through observation and inspection that there is flex duct not connected to anything in the plenum ceiling in the Reception area. On 05/08/2018 at approximately 2:20 pm it was observed through observation and inspection that there are unprotected through penetrations to the two hour fire barrier above the door going from the Respond area into the Lobby. On 05/09/2018 at approximately 9:17 am it was observed through observation and inspection that the rated ceiling assembly is not being maintained around elevator #3. On 05/09/2018 at approximately 9:28 am it was observed through observation and inspection that the smoke barriers are not being maintained on both side of the corridor between Valley Gastro and the Allergy Center. On 05/09/2018 at approximately 9:28 am it was observed through observation a
Based on observation and inspection the facility failed to maintain emergency egress. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that provided documentation indicated that the annual fire door inspection was completed in January of 2018 and all the doors failed. Documentation for corrections could only be provided for 3 floors of the main hospital. On 05/09/2018 at approximately 10:15 am it was observed through observation and inspection that the egress corridor is used a storage area in the Allergy area. On 05/09/2018 at approximately 2:05 pm it was observed through observation and inspection that the egress corridor is used a storage area in the Quad Lobby. On 05/09/2018 at approximately 2:58 pm it was observed through observation and inspection that the egress corridor is used a storage area in the back corridor. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain egress doors. Findings include: On 05/08/2018 at approximately 2:20 pm it was observed through observation and inspection that the egress door going from the Respond area into the Lobby has loose panic hardware. On 05/09/2018 at approximately 3:04 pm it was observed through observation and inspection that the egress door exiting the Board Room requires more than 5 pounds of force to operate. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain exit signage. Findings include: On 05/08/2018 at approximately 4:28 pm it was observed through observation and inspection that there is no exit sign in the old Admin. area. On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard has no exit sign. On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard doors going from the corridors do not have NO EXIT signs posted on them. ( NFPA 101 7.10.8.3) On 05/09/2018 at approximately 1:30 pm it was observed through observation and inspection that the exit sign is not being maintained in Dr. Leggetts corridor. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain vertical openings. Findings include: On 05/08/2018 at approximately 1:59 pm it was observed through observation and inspection that there is wood blocking used as part of the elevator shaft construction on the first floor. On 05/08/2018 at approximately 2:10 pm it was observed through observation and inspection that there are unprotected through penetrations to stairwell #3 on the first floor. On 05/08/2018 at approximately 2:12 pm it was observed through observation and inspection that the CMU block wall is not complete inside of stairwell #3 on the first floor. On 05/08/2018 at approximately 2:15 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator shaft on the first floor. On 05/08/2018 at approximately 2:16 pm it was observed through observation and inspection that there are unprotected steel beams inside of the elevator shaft on the first floor as part of the shaft construction. On 05/09/2018 at approximately 2:04 pm it was observed through observation and inspection that there are unprotected through penetrations to the elevator shaft in the elevator lobby on the second floor.
Based on observation and inspection the facility failed to maintain hazardous areas. Findings include: On 05/08/2018 at approximately 2:48 pm it was observed through observation and inspection that a office in the old Admin. area has been turned into a combustible storage room. On 05/09/2018 at approximately 10:18 am it was observed through observation and inspection that the Allergy electrical room door is not self closing. On 05/09/2018 at approximately 10:55 am it was observed through observation and inspection that the Unit 6 Laundry room door does not self close or latch. On 05/09/2018 at approximately 3:16 pm it was observed through observation and inspection that there are unprotected through penetrations to the 1 hour rated wall of the soiled utility room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the fire alarm system. Findings include: On 05/08/2018 at approximately 2:48 pm it was observed through observation and inspection that the smoke detector is installed too close to the wall in the old Admin. area. On 05/09/2018 at approximately 2:26 pm it was observed through observation and inspection that a heat detector is not properly installed in the Dietary Office. It is loosely suspended by the wire. The Facility Maintenance Director witnessed this evidence through observation and interview.
Based on observation and inspection the facility failed to install sprinklers properly. Findings include: On 05/09/2018 at approximately 10:54 am it was observed through observation and inspection that the unit 6 Electrical room has no sprinkler protection. On 05/09/2018 at approximately 11:20 am it was observed through observation and inspection that the EVS Office /Electrical room has no sprinkler protection. On 05/09/2018 at approximately 11:24 am it was observed through observation and inspection that the second floor enclosed courtyard has no sprinkler protection. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain monitoring of the sprinkler system. Findings include: On 05/09/2018 at approximately 10:11 am it was observed through observation and inspection that the sprinkler control valves are not chained or supervised in the Electrical/ Sprinkler room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the sprinkler system. Findings include: On 05/09/2018 at approximately 10:12 am it was observed through observation and inspection that there are sprinkler piping hangers that have come loose in the Electrical / Sprinkler Room. On 05/09/2018 at approximately 10:23 am it was observed through observation and inspection that a sprinkler escutcheon ring is missing in the Allergy supply closet. On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that ceiling tiles are missing in Rooms 609, 608, 607, 606, 604, 602 and 601. On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that there are holes in the hard ceiling in Rooms 609, 608, 607, 606, 604, 602 and 601. On 05/09/2018 at approximately 10:48 am it was observed through observation and inspection that a non- listed trim ring is in use in Rooms 609, 608, 607, 606, 604, 602 and 601. On 05/09/2018 at approximately 10:57 am it was observed through observation and inspection that the ceiling grid in the Staff locker room is falling down and that ceiling tiles are missing. On 05/09/2018 at approximately 11:08 am it was observed through observation and inspection that the concealed covers for the sprinkler heads have been painted over in Unit 5 Room PAV 2-87, 88 and Room PAV 2-97, 98. On 05/09/2018 at approximately 11:11 am it was observed through observation and inspection that a gap at the concealed sprinkler cover in Unit 5 Room PAV 2-87, 88 is using tissue to fill the gap. On 05/09/2018 at approximately 1:13 pm it was observed through observation and inspection that escutcheon rings are missing in the Adolescent corridor. On 05/09/2018 a
Based on observation and inspection the facility failed to maintain corridor doors. Findings include: On 05/09/2018 at approximately 9:40 am it was observed through observation and inspection that there are unprotected through penetrations to the corridor door going into the Hearing Clinic. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview the facility failed to maintain the construction of smoke barriers. Findings include: On 05/09/2018 at approximately 9:28 am it was observed through observation and inspection that the smoke barriers are not being maintained on both side of the corridor between Valley Gastro and the Allergy Center The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain smoke barrier doors. Findings include: On 05/09/2018 at approximately 9:51 am it was observed through observation and inspection that the self closing devices have been removed from the smoke barrier corridor doors in the ENT patient care corridor. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain clearance of combustibles. Findings include: On 05/09/2018 at approximately 2:41 pm it was observed through observation and inspection that combustibles are stored within 3 feet of the Kiln in the Art Room. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to provide an approved evacuation and relocation plan. Findings include: On 05/09/2018 at approximately 1:06 pm it was observed through observation and inspection that documentation could not be provided to show that Unit 1 has an approved evacuation and relocation plan. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to conduct fire drills. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that fire drills were held for the months of March 2017, April 2017, September 2017, October 2017, and March 2016 thru October 2016. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain combustible decorations. Findings include: On 05/09/2018 at approximately 2:40 pm it was observed through observation and inspection that documentation could not be provided to show that the combustible decorations suspended from the ceiling in the Art Room meet the following: Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain the electrical system. Findings include: On 05/08/2018 at approximately 1:44 pm it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover in the Lobby. On 05/08/2018 at approximately 2:10 pm it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover by the first floor stairwell. On 05/09/2018 at approximately 9:17 am it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover by elevator #3. On 05/09/2018 at approximately 9:40 pm it was observed through observation and inspection that an extension cord is being used as permanent wiring in the Hearing Clinic Office. On 05/09/2018 at approximately 9:56 am it was observed through observation and inspection that there is a junction box above the ceiling that is missing the approved cover above the water fountain. On 05/09/2018 at approximately 3:00 pm it was observed through observation and inspection that there is a junction box missing the approved cover in the EVS Office by the Dryers. On 05/09/2018 at approximately 10:40 am it was observed through observation and inspection there are electrical connections not inside a junction box above the ceiling on the second floor unit 6. On 05/09/2018 at approximately 1:45 pm it was observed through observation and inspection that the electrical panel in the Unit 3 supply room is obstructed by storage. On 05/09/2018 at approximately 2:29 pm it was observed through observation and inspection that a junction box is missing a knockout in the Dietary Office.
Based on observation and inspection the facility failed to test receptacles. Findings include: On 05/07/2018 at approximately between 8:30 am and 3:00 pm it was observed through observation and inspection that documentation could not be provided to show that receptacles have been tested after initial installation, replacement or servicing. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and interview it was determined that the facility failed to maintain the generator system. Findings include: On 05/07/2018 between approximately 8:30 am and 3:00 pm it was observed through observation and inspection that the facility could not provide documentation to show that the main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are not being maintained and readily available. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation and inspection the facility failed to maintain electrical equipment. Findings include: On 05/09/2018 at approximately 2:18 pm it was observed through observation and inspection that a chest freezer in the Kitchen has a broken ground plug. The Facility Maintenance Director witnessed this evidence by observation and interview.
Based on observation, interviews and document review, hospital staff failed to ensure patients ordered blood glucose testing received care in a safe setting by ensuring control tests were completed and/or test strips were in date for 2 of 5 units selected to sample. The findings include: The surveyor inspected fingerstick blood sugar devices, test strips and control solutions on the following units: 5 East, 5 West, 3 Center, 3 West and 3 East. On 5 West, Level One test controls were out of date on 2/21/17, in one test supply container. Level One and Level Two were out of date on 4/11/17 in a second test supply container. The manager of the unit disposed of the out of date supplies immediately. On 3 East, the testing strips (Stat strips) were not dated with open or discard dates, which makes it impossible to determine if the test strips can be used. The DFU's (directions for use) were obtained from the manufacturer's web site and were provided to the surveyor by Staff Member #10, the Accreditation Coordinator/Quality Mgmt. Staff Member #10 stated the information provided could be used to determine compliance. The DFU's read in part STAT STRIP (50 strips/vial) * 24 month stability from date of manufacture. Expire in 180 days or 6 months when opened. Date vials with date opened and 6 month expiration date. Initial vial. For QC (quality control vials) % QC vial has 24 month stability from date of manufacture. Date QC vial when opened: 90 day or 3 month expiration after opened. Hospital policy POC: Nova Statstrip Glucose Meter Bedside Glucose Testing PolicyStat ID: 32. Last revised 1/2017, Expiration 1/2019, reads in part as follows: Under Equipment and Materials *StatStrip Glucose Test Strips - expire 180 days after opening; date each vial *StatStrip Glucose Control Solutions - expire 90 days after opening; date each bottle The above information was shared with the management team prior to exit on 5/9/18, DFU were provided to the survey team at that time. No other information was provided.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews, clinical record review and review of hospital policies, it was determined staff failed to release a patient from restraints at the earliest possible time for 2 of 2 patients who were restrained when the survey team entered the hospital. (Patient #19 and Patient # 20) The findings include: The clinical record of Patient #19 was reviewed on 5/1/18. Patient #19 was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. On 5/1/18 at approximately 8:01 a.m. an order was obtained to place soft upper bilateral restraints on the patient, the reason for restraint was listed as non-violent, attempting to remove medical interventions. Per hospital policy patients will be monitored every 15 minutes and assessed for continued need for restraints every 2 hours while they remain restrained. Hospital staff use the Patient Monitoring Form to document the 15 minute checks. Noted on the form are instructions to Document the type of precaution and document minimally every 15 minutes (20 for restraints). Documentation on the patient monitoring form was completed by registered nurses from 8:00 a.m. until 7:00 when the restraints were removed. At approximately 3:00 p.m. on 5/1/18 the surveyor visited the patient; checked for the proper application of restraint, noted the patient was sleeping and intubated, and spoke with family who were present in the room. Both a parent and the patient's fiancee` confirmed they had been informed of the need for restraints just prior to the surveyor's arrival to the unit. Both family members stated the patient had woken up and didn't understand the intubation tube and was trying to remove it. Both family members stated they did not want the patient restrained any longer than needed, and that he had been sleeping for a long time. During the review of the clinical record, which was completed while on the unit, the surveyor noted the 15 minute documentation on the Patient Monitoring Form documented the patient as combative and insomnia at 8:00 a.m. but after that time the documentation stated the patient was sleeping with family and/or staff in the room through the 3:00 p.m. timeframe (which was when the surveyor arrived to the floor). The surveyor asked Staff Member (SM) #48 if family members had approached him/her about removing the restraints, SM #48 replied that he/she had not been told of the family's concern. SM #48 was asked what the criteria could be for the removal of the restraints and he/she stated it would be when the patient was no longer tying to remove medical devices and/or being combative. The surveyor pointed out to SM #48 that the patient had been documented as sleeping since 8:15 that morning and with either staff or family in the room. SM #24 asked how often the patient would be assessed for the removal of the restraints he/she replied it would be at least every 2 hours. The 2 hour assessments documented the patient behavior as non-violent Attempts to remove.It should be noted that SM #48 documented both the 15 minute checks and the 2 hour assessments. It was brought to the attention of SM #48 that the documentation was conflicting and it would be reasonable to believe the 15 minute checks would give more information about the patient's behavior. SM #48 stated his/her agreement with this statement. And stated the removal of the restraints would be discussed with the treatment team. The surveyor witnessed the family members being informed of the intent of the staff. On 5/7/18, the surveyor was provided with documentation of the removal of the restraint at 7:00 p.m. on 5/1/18. 2. The clinical record of Patient #20 was reviewed on 5/1/18. Patient #20 was admitted at 9:15 p.m. on 4/25/18 after being transferred for cardiology coverage available at this hospital. Patient #20 was admitted with a diagnosis of [DIAGNOSES REDACTED]. On 5/1/18 at approximately 8:01 a.m. and order was obtained to place soft upper bilateral restraints on the patient, the reason for restraint was listed as non-violent, attempting to remove medical interventions. Per hospital policy patients will be monitored every 15 minutes and assessed for continued need for restraints every 2 hours while they remain restrained. Hospital staff use the Patient Monitoring Form) to document the 15 minute checks. Noted on the form are instructions to Document the type of precaution and document minimally every 15 minutes (20 for restraints). Documentation on the patient monitoring form was completed by registered nurses from 8:00 a.m. until 7:00 when the restraints were removed. At approximately 3:45 p.m. on 5/1/18 the surveyor visited the unit and found restraints had been discontinued at 2:07 p.m. that day. Surveyor review of Patient Monitoring Record completed by the assigned nurse, found that Patient #20 had been placed in soft bilateral upper extremity restraints on 4/29/18 at 7:00 p.m. for attempts to remove medical devices. Every 15 minute documentation reveals the patient was in room and sleeping from 7:00 p.m. on 4/29/18 until 10:45 a.m. on 4/20/18. Documentation reveals the patient as agitated for a 1 hour period from 11 a.m. to 12 noon when documentation shows the patient again in room asleep from 12:15 p.m. on 4/30/18 until 2:00 p.m. on 5/1/18. Visitors were documented as being with the patient from 7:30 am until 2:00 p.m. on 5/1/18. Based on this documentation Patient #20 was in restraints for a total of 43 hours with only 1 hour of documentation supporting the need for restraints, and documentation showing the patient in room and asleep for 25 hours and 45 minutes after the brief period of agitation occurred. The 2 hour assessments documented by the registered nurse have the patient behavior as non-violent Attempts to remove. The aforementioned conflicting documentation was discussed with SM #43, the director of the unit. It was brought to the attention of SM #48 that the documentation was conflicting and it would be reasonable to believe the 15 minute checks would give more information about the patient's behavior. With nursing documenting both the 15 minute checks and the 2 hour assessments, the lack of consistency in documenting the patient's behavior resulted in the failure to support the continued need for restraints was discussed with SM #43. SM #43 agreed the documentation was conflicting. Review of hospital policy Patient Restraint/Seclusion, PC.13.329.00.0, last revised 06/2017 and expiring 06/2020 contained the following information in part: 11. Discontinuation of Restraint/Seclusion: The patient in restraint or seclusion in evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period. SM #10, the Accreditation Coordinator/Quality Management, provided the surveyor with education materials related to restraint that had been a part of an action plan for restraint documentation. Data was provided or November 2017 to April 2018. However, the plan focused only on documentation and the surveyor was unable to find any education related to discontinuing the restraint at the earliest possible time. The above information was shared with the management team on 5/1/18 at the end of day meeting and again prior to exit on 5/9/18. No further information was provided to the survey team.
Based on a review of hospital documents and interviews, it was determined the hospital staff failed to use data collected regarding assessments and monitoring of patients who received blood transfusions to identify opportunities for improvement and to implement changes to achieve sustained improvements. The findings were: The surveyor met with the Vice President (VP) of Quality & Risk and the Director of Patient Safety on 05/08/18 at 1:50 p.m., for a discussion/review of the hospital's quality program. At the end of the meeting, the surveyor discussed the findings from the review of three (3) clinical records of patients having received blood transfusions. The VP of Quality & Risk acknowledged having an awareness of those findings. The surveyor requested to review any current performance improvement projects related to assessments/monitoring/vital signs for patients receiving blood transfusions. The VP of Quality & Risk stated there was a performance improvement project for that and he/she would make the data available for surveyor review. During a meeting with the hospital's leadership team at the end of the day on 05/08/18 at 4:45 p.m., the VP of Quality & Risk provided the surveyor with data for a performance improvement project related to patient monitoring and safety during blood transfusions. The surveyor reviewed the data for the performance improvement project related to patient monitoring and safety during blood transfusions, on 05/09/18 at 9:20 a.m. The Monthly Quality Outcomes Report data for January, February, March and April, 2018 included tracking of data for Blood Administration Compliance/Transfusion Record Complete (BCTA) [the EHR electronic health record]. The stated benchmark or goal was listed as 100% and the hospital's data was listed as (January 2018) 72%, (February 2018) 76%, (March 2018) 68%, and (April 2018) <50%. The aforementioned results (values) for January, March, and April were colored red, and February was colored yellow. The document included the following information under Color Code... Blue = Increasing Toward Goal, Yellow = Declining Below Goal, and Red = Below Goal > 2 Monitoring Cycles. The document included, MONTHLY ACTION PLAN - required for ALL Red Status; and/or Yellow Status Trends Over 2 Months. The document included an area for monthly entries under a section titled, STRATEGY FOR IMPROVEMENT. That section included no entries for January 2018, starting a QI project to help track transfusion vitals for February 2018, assessments/vital signs not addressed for March 2018, and Requested to have vital sign documentation added to the agenda at the next Nurse Director Meeting. Provided along with this data were emails dated January 18, 2018 and February 19, 2018, from The Blood Bank Supervisor to the Director of Patient Safety. Those emails relayed the concerns of the Blood Bank Supervisor related to the findings of the hospital's internal audits for compliance with vital signs and monitoring during blood transfusions. The email dated January 2018 read, in part, as follows: One of the items I have to report on the quality report card is transfusion vital documentation.... Due to the new documentation I am no longer able to see the same things as before so I am unable to track the vital signs. I would like to go ahead and start monthly audits for each floor regarding transfusion vitals. Does this sound like an acceptable thing to do? Also, in the transfusion policy for nursing it states when they should do the vitals and that the information will be documented in BCTA [the EHR]. This rarely happened before and is not happening now.... The surveyor met with the Blood Bank Supervisor and the Director of Laboratory Services on 05/09/18 at 1:30 p.m. The Blood Bank Supervisor stated he/she was/is the staff member responsible for completing and submitting the aforementioned Monthly Quality Outcomes Report. The Blood Bank Supervisor described that he/she completes the data in the dashboard and submits it electronically on a monthly basis to the quality department. The Blood Bank Supervisor provided data for the surveyor to review for the last quarter of 2017, which identified the following: the Blood Administration Compliance/Transfusion Record Complete (BCTA) results were listed as (November 2017) 74.4% and colored yellow, and (December 2017) 43.7% and colored red. The report revealed that for September and October of 2017 the values were colored blue and were >80%. The Blood Bank Supervisor stated this indicator had been an issue more than a year ago, but had achieved sustained improvements until a steady decline which was identified as beginning in November of 2017. The Blood Bank Supervisor and the Director of Laboratory Services both described not having access to key data elements within the electronic health records, which hinders the ability to gather the required data for the Monthly Quality Outcomes Report. The surveyor met with the VP of Quality & Risk on 05/09/18 at 10:05 a.m. He/she stated during the discussion there had been enormous turnover in leadership over the last 3 to 4 years and some positions multiple times. The VP of Quality & Risk stated that had led to new leaders/managers having multiple areas of concern and had to prioritize. The VP of Quality & Risk stated, having been in his/her current position since April of 2017, the Director of Quality in place when he/she started this position left 3 months later, and since then he/she had been doing both jobs. The VP of Quality & Risk acknowledged he/she was first aware that blood transfusion assessments/vital signs were an issue of concern when the surveyor identified it as such. The VP of Quality & Risk did not recall this issue or the aforementioned collected data making it to the quality program in regards to being a topic of discussion and/or deciding upon actions to be taken to bring about improvements. He/she acknowledged the quality program failed to use the data collected, regarding assessments and monitoring of patients who received blood transfusions, to identify opportunities for improvement and to implement changes in a timely manner to achieve sustained improvements. The VP of Quality & Risk stated, we deserve to take a hit on that. The surveyor met with the hospital's Chief Nursing Officer/CNO on 05/09/18 at 11:00 a.m. The CNO acknowledged he/she was also first aware that blood transfusion assessments/vital signs were an issue of concern when the surveyor identified it as such. The CNO stated, we do need to fix it.
Based on a review of clinical records, facility policies, and interviews, it was determined the hospital's nursing staff failed to perform required nursing assessments and monitoring for the identification of possible reactions or adverse outcomes during blood transfusions, as required by the hospital's policy, for three (3) of three (3) patients sampled for blood transfusions (Patient #6, #7, and #8). The findings were: The surveyor reviewed the hospital's policy titled, Transfusion: Blood and Blood Products (Policy ID # 79) on 05/02/18. The policy included, in part, the following: Purpose: Prevent and/or alleviate complications secondary to blood and blood product replacement procedures. Provide guidelines for administering blood and blood components with the maximum degree of safety.... Patient Monitoring and Vital Signs: Vital Signs for blood administration must be obtained no more than 15 minutes before beginning the transfusion.... Vital signs will be repeated at 15 minutes [after the transfusion is started] and every hour as long as the patient remains stable. The nurse will document vital signs in BCTA in [the electronic health record]. The nurse will assess the transfusion and the patient's response at least every hour and PRN [as needed]. The clinical records of Patients #6, #7 and #8 were reviewed, with SM #17 and #18 serving as navigators of the EHR (electronic health record). The findings of the record reviews were as follows: Patient #6's clinical record contained evidence the patient received a unit of PRBCs (Packed Red Blood Cells) on 05/02/18 which started at 2:39 a.m. and ended at 4:54 a.m. The record contained evidence the patient's vital signs were last monitored and assessed for changes at 3:56 a.m. The record failed to contain evidence the patient's vital signs were monitored between 3:56 a.m. and one hour later when the transfusion ended at 4:54 a.m. The record contained evidence the patient's vital signs were not monitored again until 8:02 a.m. Patient #7's clinical record contained evidence the patient received two (2) units of PRBCs (Packed Red Blood Cells) on 05/02/18. The first unit of PRBCs started at 4:27 a.m. and ended at 7:11 a.m. The EHR failed to contain evidence the patient's vital signs were monitored at no more than 15 minutes before, or at any point during the transfusion of the first unit. SM #17 and SM #18 facilitated a review of the Blood Bank Transfusion Record which provided evidence the registered nurse documented pre transfusion vital signs at 4:18 a.m. and 15 minute vital signs at 4:45 a.m. on that paper document. After the 4:45 a.m. vital signs, there was no evidence the vital signs were monitored for the remaining 2 hours and 26 minutes of the transfusion which ended at 7:11 a.m. The vital signs were next documented at 7:25 a.m. The second unit of PRBCs started at 10:52 a.m. and ended at 2:03 p.m. The record failed to contain evidence the patient's vital signs were monitored between 1:08 p.m. and one hour later when the transfusion ended at 2:03 p.m. The record contained evidence the patient's vital signs were not monitored again until 3:46 p.m. Patient #8's clinical record contained evidence the patient received five (5) units of PRBCs (Packed Red Blood Cells) from 04/30/18 to 05/02/18. There was missing documentation/omitted monitoring identified with four (4) of the five (5) units. The first unit of PRBCs were transfused on 04/30/18 starting at 5:45 p.m. and ending at 9:26 p.m. The record contained evidence the 15 minute vital signs were monitored 6:00 p.m. and the next set of vital signs were monitored at 7:23 p.m., 23 minutes late. The second unit of PRBCs were transfused on 04/30/18 starting at 8:07 p.m. and ending at 10:54 p.m. The record contained evidence the patient's pre vital signs were monitored at 7:23 p.m., 44 minutes before beginning the transfusion and exceeding the no more than 15 minutes before beginning the transfusion required per the above described policy. The fourth unit of PRBCs were transfused on 05/01/18 starting at 4:29 p.m. and ending at 6:57 p.m. The was no evidence the patient's pre vital signs (monitored no more than 15 minutes prior to beginning the transfusion) were obtained. The 15 minute vital signs were monitored at 4:44 p.m. and the next vital signs were monitored at 5:54 p.m. (10 minutes late). The fifth unit was transfused on 05/02/18 starting at 10:20 a.m. and ending at 12:30 p.m. There was evidence the pre transfusion vital signs were monitored at 10:15 a.m. and the 15 minute vital signs at 10:30 a.m. After the 10:30 a.m. vital signs, there was no evidence the vital signs were monitored for the remaining 2 hours of the transfusion which ended at 12:30 p.m. The vital signs were next documented at 1:08 p.m. The surveyor met with the hospital's Accreditation Coordinator on 05/04/18 at 11:15 a.m. and discussed the clinical record review findings. The Accreditation Coordinator was informed the monitoring and assessments of patient's receiving blood transfusions was not identified to be in accordance with the hospital's policy. The Accreditation Coordinator acknowledged the described findings were not in accordance with the hospital's policy and expectations. The surveyor met with the hospital's Accreditation Coordinator again on 05/07/18 at 3:40 p.m. and discussed the monitoring and assessments of patient's receiving blood transfusions. The Accreditation Coordinator acknowledged there was no additional evidence to provide.
Based on interviews and the review of documents, it was determined the facility staff failed to document food safety training for dietary contract employees (who prepares/handles food) for three (3) of three (3) sampled dietary staff personnel files. The findings include: On the afternoon of 5/8/18, the facility's dietary services were reviewed. Three (3) names of individuals with food preparation responsibilities were selected from the dietary schedule for education/training review. On 5/8/18 at 3:38, the Director of Food/Nutrition stated the employees were provided on the job training but no documentation of the training was available. During this interview it was discovered that two (2) employees were currently in training for food preparation; the Director of Food/Nutrition reported no orientation check-off list was being used by the two (2) employees currently being trained for food preparation. The Director of Food/Nutrition reported that all dietary staff receive monthly training on different topics. The following information was found in a facility policy with the 'function' identified as Surveillance, Prevention and Control of Infection (with an effective date of December 1996 and a revised/reviewed date of November 2012): On the Job Training [sic] and in-services shall include but are not limited to: A. Personal hygiene and proper hand-washing. B. Causes of Food Borne illness. C. Proper cleaning and maintenance of equipment and utensils. D. Sources and transmission of infection. E. Use of HACCP controls. F. Gloves, [sic] and hand-washing importance and techniques. (HACCP (Hazard Analysis and Critical Control Point) is a system to address food safety.) The agreement/contract between the facility and the food service included the following statement: Training Programs: Vendor shall provide a formal in-service training program to enhance the development of service employees. Vendor shall maintain accurate records of training sessions. On the morning of 5/9/18, the Director of Food/Nutrition (with the Accreditation Coordinator present) reported that due to changes in management in the dietary department not all of the employee training documentation could be found. The Director of Food/Nutrition stated some, but not all, of the employee files kept by previous Directors of Food/Nutrition had been found. The aforementioned absence of dietary staff training was discussed, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk. The Accreditation Coordinator confirmed that as stated earlier by the Director of Food/Nutrition some food safety training had been found but not all training for all employees who prepare food was available.
Based on observation, interviews, and facility document reviews, facility did not meet the Condition of Participation related to Physical Environment. The findings include: 1. Multiple standard level citations were noted on the Life Safety Code survey. 2. On the health survey, it was noted the facility failed to have documentation of fire drills done by facility staff since June 2017. 3. On the health survey, review of the dietary department revealed the facility staff failed to ensure food items were stored appropriately in the dietary department's refrigerators.
Based on interviews and the review of documents, it was determined the facility staff failed to ensure monthly fire drills were documented. The findings include: Review of the facility's fire drill documentation, on 5/9/18, failed to provide evidence of a fire drill occurring since June of 2017. The following information was found in a facility policy and procedure titled Life Fire Safety Management Plan (with an effective date of 06/1995 and a last revised date of 06/2017): The Safety Officer is responsible for conducting required fire drills. Drills are conducted once per shift per quarter in each building defined as a health care occupancy by the Life Safety Code ... All drills are documented, with the subsequent positive and negative findings shared with departmental and facility leadership so as to appropriately be addressed. The facility's Director of Facilities Management (DFM) was interviewed on 5/9/18 at 1:45 p.m. The DFM acknowledged that no fire drills had been documented since June of 2017. The DFM reported the fire drill had been the responsibility of the facility's security department. The DFM reported that fire drills had occurred at the facility but due to changes in the facility's security department that the documentation could not be found. The DFM reported he/she was unsure if upcoming fire drills had been scheduled but that two (2) fire drills were being planned. The missing fire drill documentation was discussed, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk.
Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure food items were stored appropriately in the dietary department's refrigerators. The findings include: Observations, on the afternoon of 5/8/18, of the facility's refrigerators in the dietary department revealed the following items were not labeled and dated to indicate when they were no longer to be used: an opened package of sliced roast beef, an opened package of cubed ham, an opened package of diced tomatoes, a tray of unbaked muffins, and ten (10) salads (on two (2) trays). The facility's Director of Food/Nutrition was present for the observations. The Director stated the opened items should have been dated; he/she stated the trays of the salads and unbaked muffins should have been dated. The following information was found in a facility policy and procedure with a 'policy description' of Refrigerators and Nourishment Areas (with an effective date of August 1900 and a last reviewed/revised date of December 2011): ... B. Patient food must be labeled and dated. Prepared items should not be kept for more than 48 hours. C. Employee food must be kept in a separate refrigerator. Items must be dated and labeled. Commercially prepared and packaged items that have not been open [sic] may be stored in the refrigerator or freezer. Other items stored for greater than 3 days should be discarded. ... During an interview on 5/8/18 at 3:10 p.m., the facility's Director of Food/Nutrition confirmed this policy would apply to the aforementioned observations of undated/unlabeled food items. The failure of the facility staff to appropriately date stored food items was discussed for a final time, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk.
Based on observations, interviews and hospital document review, it was determined hospital staff failed to follow the policy for surgical attire worn within the semi-restricted and restricted areas of the surgical environment, for two (2) of two (2) observations made. The findings include: On 5/8/18 the surveyor observed a surgical procedure performed in Operating Room (OR) 10 at approximately 2:30 p.m. Among those present in the room were the Certified Registered Nurse Anesthetist (CRNA), an X-ray technician (Staff Member (SM) )#47) the Manager of the OR (SM #45) and the surveyor. While making observations the surveyor noted the CRNA and the X-ray technician were wearing earrings which were not covered by their hair coverings, and further observed the X-ray technician not to be wearing shoe coverings. SM #45 was asked what the expectation was regarding jewelry in the surgical area, he/she replied that it would need to be removed or covered. The surveyor asked SM #45 to look around the room in relation to exposed earrings, SM #45 confirmed the surveyor's observation. SM #45 was also asked about the lack of shoe coverings in the surgical area, he/she stated that shoes that were dedicated to wear on in the surgical area would not require shoe covers but all other shoes would. SM #47 was asked if he/she went to other areas of the hospital or if he/she only served the surgical areas. SM #47 replied that he/she went to all areas of the hospital as needed, SM #47 was then asked if the shoes he/she was wearing were dedicated only to be worn in the OR. SM #47 replied that they were not. He/she was then asked if anyone had spoken to him/her about wearing shoe coverings. SM #47 stated that no one had mentioned it but that it would probably be a good idea. The above observation was shared at the end of day meeting on 5/8/18 with management staff. No further evidence or comments were provided. On 5/9/18, the surveyor was observing the end of an ECRP (Endoscopic retrograde cholangio-pancreatography) diagnostic procedure in ENDO (endoscopy) Room #34 at approximately 1:05 p.m. in order to follow the process of cleaning the scope. During observations the surveyor noted the CRNA and the X-ray technician were wearing exposed earrings. Following the process for cleaning the scope did not provide the survey with the opportunity to speak with the staff. The above observation was share with the management team prior to the exit on 5/9/18. The surveyor asked the management team to clarify if the ENDO rooms were considered to be a surgical area and if they would follow the same policy for attire. The Surgical Attire, 661-235 last revised 5/2018 and expiring 5/2021. The policy states in part: G. All personnel entering the semi restricted and restricted areas of the surgical suite should confine or remove all jewelry. 2. Other jewelry (e.g., watches, earrings, and piercings) should be removed or totally confined within the scrub attire. I.5. Fluid-resistant shoe covers are considered part of PPE and must be worn when it can be reasonably anticipated that splashed or spills may occur. The management team was given time to clarify the policy. SM #27 stated that it was not likely there would be a separate policy for the endo rooms. SM #10 later informed the survey team that the policy would be the same for the endo rooms as for the surgical rooms.
Based on staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to ensure a presurgical history and physical had an update in one (1) of six (6) surgical records reviewed. (Patient #3). The findings were: Patient #3's clinical record was reviewed on 8/26/15. The record contained a draft history and physical (H&P) which had been dictated by the surgeon on 01/14/2015 at 10:38 (a.m.) and transcribed on 01/14/15 at 11:28 (a.m.). Patient #3's surgery was scheduled for the following day, 01/15/15. The patient's clinical record also contained a signed version of that same H&P that showed the surgeon had authenticated and electrically signed it on 01/20/15. Documentation of the Preop Assessments showed the registered nurse (R.N.) marked Y (yes) to the question, H and P completed within last 30 days and available and also marked Y (yes) to the question H and P updated completed and available. However, the clinical record failed to contain evidence of an update to that H&P. There was a form titled, History and Physical Interval Note which read in part, Standard: History and Physical must be Updated prior to surgery for patients having surgery the day they are admitted , even if H&P was completed the day before. A hard copy of the update must be on the medical record prior to surgery. H&P's (sic) greater than 30 days old must be repeated. This form provided an area for the physician to note there were No Changes/Additions to the H&P or for the physician to note there had been changes and to describe those changes. In Patient #3's clinical record, this form was blank. The facility's Director of Surgical Services was interviewed by the survey team on 8/27/15 at 10:45 a.m. He/she stated that it's the circulator in the operating room (OR) who is supposed to check for the H&P and the update and that the H&P update form was supposed to be completed. When the Director was shown Patient #3's blank History & Physical Interval Note (H&P update form), he/she stated the form was printed out for every patient however it was not always completed, or filled in, since it was not required for all cases. The R.N. circulator who documented the presence of the H&P and update in Patient #3's clinical record was unable to be interviewed. The R.N. no longer worked at the facility at the time of the survey. The facility's Chief Medical Officer (CMO) was interviewed by the survey team regarding Patient #3's H&P update on 09/01/15 at 3:00 p.m. The CMO initially stated he/she felt the H&P did not need an update since the patient's surgery was within 24 hours of the H&P dictation. When the regulation requiring an update to the H&P was explained, the CMO stated he/she understood the rationale behind the H&P update requirement and agreed completely. The Director of Surgical Services was interviewed a second time regarding the H&P update on 09/01/15 at 3:40 p.m. He/She stated an update to the H&P would be expected and acknowledged the only H&P update form found in Patient #3's record was blank. The facility's policies and procedures related to H&P's were reviewed on 09/01/15. One policy title, General Surgical Care, 661-052 with a last revision date of 12/2013 read in part, D. OPERATING ROOM POLICIES... 3. A history and physical may be dictated or completed within 30 days before admission. Significant changes in the health history and physical examination and necessity for the procedure/care must be updated on the day the procedure is performed. Any changes in the patient's condition prior to surgery will be documented in the progress notes, or on the History and Physical. If there are no significant changes in health history, this may be documented as No Change. It shall be the responsibility of the operating surgeon to see that such physical examinations have been completed. A second policy titled, Pre-Operative/Pre-Procedure Preparation with a last revision date of 11/2013 read in part, POLICY:... 7. History and Physical which has been updated within 24 hours (one day) of procedure. If a History & Physical has been done within thirty (30) days, an interval note may be made on the History and Physical Update form (sic) or progress note by the attending practitioner to update any changes that may have occurred.
Based on interviews and record reviews, it was determined that the facility staff failed to document that care was provided as planned/directed by physicians for 1 of 4 sampled patients (Patient #2). The findings include: Patient #2's clinical record contained the following physician orders: - On 2/27/15 at 1:50AM, an order for incentive spirometry to be used every hour while awake. (Incentive spirometry is a device used to improve lung function.) - On 2/27/15 at 3:49PM, an order for foot pumps to be used while in bed. (Foot pumps are medical devices used to prevent blood clots after surgery.) - On 2/27/15 at 3:49PM, an order for ice to be applied to the affected limb or extremity as tolerated. These three aforementioned orders were not discontinued during Patient #2's stay in the facility; the patient was transferred to a long term care facility on 3/6/15. Review of Patient #2's clinical record failed to reveal evidence of the implementation of the incentive spirometry order and the foot pump order. No evidence was found of discontinuation or clarification of the incentive spirometry and/or the foot pump orders. During an interview with the facility's Director of Quality (DoQ) on 5/6/15 at 9:35AM, the DoQ reported that no documentation was found to indicate the incentive spirometry order had been implemented. During an interview with the facility's Compliance Coordinator on 5/5/15, the Compliance Coordinator reported that foot pumps would not be used at the same time as SCDs (Sequential Compression Devices); Patient #2's documentation indicated that the patient had SCDs ordered and in use during his/her hospital stay. On 5/6/15 at 11:25AM, the Compliance Coordinator reported that a clarification order for the foot pumps was not found. Documentation indicating an ice application was used for Patient #2 was found only once in the clinical documentation. The following documentation was found in a nurse's note dated 2/28/15 at 5:22AM: ... ICE APPLIED TO RIGHT HIP AS MD (medical doctor) ORDERED ... The facility staff provided the survey team with the following information found in a Lippincott Procedures document entitled 'Cold Application'; it included the following information: Documentation ... Record the time, date, and duration of cold applications; type of device used (ice bag or collar, K pad, or chemical cold pack); site of applications; temperature or temperature setting; the patient ' s temperature, pulse, and respirations before and after application; skin appearance before, during, and after application; signs of complications; and the patient ' s tolerance of the treatment. Neither this nurse's note nor the physician's order identified how long the ice was to be applied. The nurse's note did not document the patient's response to the application of the ice.
Based on observation and interview it was determined that the facility failed to install ABHR's in accordance with all requirements. Findings include: On 12/1/11 at approximately 11:27 am it was observed that an alcohol based hand rub dispenser is positioned over a light switch in the Soiled Utility Room on 6E. The above was observed and confirmed by the Director of Engineering and the Safety Officer.
Based on observations, staff interviews, medical record reviews, policy and procedure reviews and process of complaint investigation, it was determined the facility failed to meet this Condition of Participation: Patients Rights to protect and promote the rights of each patient. Refer to Tags A-0131, A-0144, A-0145 for details.
Based on medical records, staff interviews, policy and procedure review, and during the course of a complaint investigation, it was determined the facility failed to provide evidence 3 of 5 patients made informed decisions related to leaving the facility against medical advice. (Patient #8 , #9, #11). Finding were: Five medical records of patients who left the facility against medical advice (AMA) were reviewed on August 22, 2011. The facility's policy for patients leaving AMA included completing a form titled, Waiver of Responsibility for Discharge to be signed by the patient and witnessed by staff. Two of the five records failed to contain the patient's signature or witness' signature indicating the patients were making an informed decision related to leaving the facility AMA (Patient #8 and Patient #11). One of the five records noted the patient refused to sign the AMA waiver but failed to contain the witness' signature (Patient #9). On August 19, 2011 Nurse #4 who assigned to Patient #9 when the patient left AMA, was interviewed. The nurse acknowledged she wrote on the AMA waiver, Patient refused to sign and that she did not sign the witness signature area. When the surveyor asked why she did not sign as a witness, the nurse stated, I didn't think I was supposed to sign it unless I was witnessing the patient's signature and when she refused, I just wrote she refused. During an interview with the Vice President of Quality and Risk Management on August 22, 2011, she acknowledged a need for staff re-education related to the facility's policy titled Leaving Against Medical Advice. The facility's policy titled, Leaving Against Medical Advice states in part, In the event the patient or the person responsible for the patient refuses to sign the waiver the patient's medical record should be documented with a statement signed by the physician and duly witnessed, setting forth the circumstances, reasons, and warnings against the premature departure.
Based on observations, staff interviews, medical record reviews, policy and procedure reviews and during the course of two complaint investigations, it was determined the facility failed to ensure a safe environment for 2 of 11 patients (Patient #2 and Patient #9). Patient #2 alleged she was assaulted in her room. Patient #9's whereabouts were unknown after leaving the facility against medical advice. The findings include: 1. Patient #2 informed the behavioral health nursing staff she had been sexually assaulted by another patient on July 21, 2011. The facility's staff subsequently had the patient assessed by forensics at the facility's emergency department (ED). A video tape documented a male patient entering Patient #2's room at 00:27:30 on July 21, 2011. The facility staff reported the incident to local authorities. Note: Contributing to the facility's failure to provide a safe environment was inadequate night shift staffing on the Intensive Treatment Unit (ITU) within Behavioral Health Services. There were two nurses assigned to the ITU for night shift on July 20, 2011 with a patient census of 17. Note: Please refer to Tag A-0392 for details related to inadequate staffing. The facility's Behavorial Health Services is located in a separate building on the facility's main campus and is divided into three separate units: Acute Adult Unit (AAU), Intensive Treatment Unit (ITU) and an Adolescent/Pediatric Unit. Three MFIs toured the ITU on August 16, 2011 and observed two rooms (room 306 and 307) that exist on a hall that is not visible from the nurse's station. Patient #2 was admitted to room 306. On Thursday August 18, 2011 Nurse #1 who was assigned to the ITU on night shift (which began on July 20, 2011 at 11 p.m. and extended into July 21, 2011 at 7:30 a.m.) was interviewed via phone by two MFIs . When asked about staffing and patient acuity, she stated, We were stressed, we had quite a few psychotic patients on the floor that night and they can go off at any time. The nurse recalled that shortly after the shift began, she was caring for a patient who was beginning to act out and had to call for a second nurse to assist her in the patient's room. Nurse #1 eventually left that room to retrieve medication and when she arrived at the nurses' station, she encountered Patient #2. The nurse recalled Patient #2 telling her, That big black boy tried to rape me. Nurse #1 told the MFIs, I'm not sure now whether she used the word rape or attack. Nurse #1 assisted Patient #2 and called the night shift supervisor. The nurse stated the supervisor came to ITU promptly and was informed of the allegation. She also said that security had left that night although they are usually there until 1 a.m. When asked about the physical layout of ITU, specifically the hall including Patient #2's room, she stated that she didn't like that area because, you're out by yourself. The second nurse working in the ITU on July 20, 2011 night shift was unable to be interviewed since she no longer worked at the facility. On Thursday August 18, 2011 the night shift supervisor of the behavioral health services who was working on July 20, 2011 was interviewed via phone by two MFIs . She stated that when Nurse #1 called for assistance on ITU, she was on another unit within behavioral health services assisting with 3 admissions. When asked about her thoughts on the physical layout of the unit, especially where Patient #2's room was located she stated, You can't see down that far, that room is isolated. This supervisor also indicated that security is usually on site every night until 1a.m. but on the night of July 20, 2011 they weren't onsite at the time of the event. The physician on call for behavorial health services on July 20, 2011 was interviewed by one MFI on August 18, 2011. In discussing the physical layout of the ITU, the physician stated that there is part of the floor you can't see and if staff are busy attending other patients, it can be a high risk. The medical director of behavioral health services was interviewed on Wednesday August 17, 2011 by one MFI. He acknowledged the layout of ITU was not ideal. On Wednesday August 17, 2011, the Vice President of Quality and Risk Management was interviewed by one MFI. She said, The geographical layout of the ITU is not conducive to full visualization of the department from a central location, particularly on one end of the patient care area. This end of the unit is more secluded and is most remote from the nurse's desk. During the survey process the facility management shared a surveillance video with three MFIs. The video showed a male (Patient #1) entering Patient #2's room at 00:27:30 on July 21, 2011 and exiting at 00:29:43. At 00:29:49 the surveillance video showed Patient #2 exiting her room and walking in the direction of the nurses station. The case is currently under investigation by local authorities. The facility's policy titled, Patient Rights and Patient Responsibilities was reviewed. The policy included the Patient Rights, #17. To expect security, personal privacy, a safe environment, and confidentiality of information, except as otherwise required by law or according to the terms of the Medial Center's Consent For Treatment. 2. Patient #9 left the facility against medical advice (AMA) on June 10, 2011. The facility's staff walked with the patient and her son out of the unit to the elevator. The patient's son left Patient #9 in the facility's lobby while he got the car. When the son returned to the main entrance with the car, Patient #9 was no longer in the lobby. Security was notified and began looking for the patient. The unit in which Patient #9 had just left AMA received a call from a nearby hotel saying Patient #9 was at that hotel. Nurse #4 who was assigned to Patient #9 on June 10, 2011 dayshift was interviewed on August, 19, 2011 by one MFI with the facility's Manager of Risk and Patient Safety present per the nurses' preference. The nurse stated she had familiarized herself with Patient #9's medical record and also recalled Patient #9. The nurse described the patient as alert and oriented to person, place and time. The patient told the nurse her name and voiced a question about why she was having to remain in bed. Nurse #4 informed Patient #9 why the physicians wanted her to remain in bed. The nurse stated that after she mentioned the patient's daughter had informed the staff about the patient's history of falls, the patient informed the nurse she did not agree with her daughter and recalled one fall she had at home that was because her pant leg got caught on her chair. Nurse #4 then said her impression of Patient #9 was that she was restless because she was used to doing her own thing, that although she was in her 80s, she appeared in her 60s and insisted on doing her hair and makeup. The nurse told the MFI, Patient #9 was being monitored for her cardiac condition, she was being given the same medications she was on at home and although she had a heparin lock (Intravenous access- IV), she was not on any IV fluids. The nurse continued saying that suddenly, Patient #9 was dressed with her monitors off and she was ready to go. The nurse offered the patient some medication to calm her but the patient refused saying, Absolutely not. Nurse #4 said that after she offered Patient #9 the medication, the patient's affect toward the nurse changed and the patient wanted to leave the facility. The nurse asked the patient to sit down so she could remove the heparin lock and the patient sat down for the heparin lock removal. The nurse then called the patient's daughter twice and her son to notify them the patient wanted to leave against medical advice (AMA). Nurse #4 said both family members indicated they wanted the facility to hold their mother and the nurse explained they were unable to hold her. The family told the nurse they had been wanting their mother worked up for possible dementia and was hoping it could be done during this admission. The nurse continued by saying the patient's son told her, I'm not coming to get her. Nurse #4 stated the patient's daughter didn't want to come get her either and told the nurse that the family had called APS (Adult Protective Services) previously on their mother but that the patient had passed a small initial test and then refused further dementia testing. Nurse #4 told the patient's daughter she'd have the case manager (CM) speak with her about Patient #9 and the nurse said the CM came right away to speak with the daughter. Nurse #4 said that while she was on the phone with the daughter, the patient became more restless and wanting to leave. Patient #9's son called and told the nurse he was in the parking lot but would not come up to the unit although the nurse stated he did show up on the unit. She recalled the son told Patient #9 he would not take her home, that he wanted to have a discussion with her. Nurse #4 said she told the patient's son that Patient #9 was not being discharged , that she was insisting on leaving AMA since her physicians were wanting to perform more studies. The nurse said that while the patient's son was standing there, Patient #9 moved him out of the way with her arm and took off out of the room. The son followed his mother and the unit's manager went out with them. Patient #9's daughter called and the nurse told her the patient had left with her son and the unit manager. The nurse said the daughter reiterated how they wanted mental testing done and Nurse #4 reinforced that they could not hold Patient #9 since she was alert and oriented to person, place and time but that the family could always bring their mother back to the ED if necessary. The daughter mentioned to the nurse that the family would have to get APS involved when the patient got home. Nurse #4 stated that after hanging up with the daughter, she went to check on Patient #9 when she saw the unit's manager who informed her the patient and son had left going down the elevator. The unit's manager told Nurse #4 that she told the patient and son twice to return to ED if needed. Nurse #4 said she sat down to chart and approximated that 10 minutes had passed when she received another phone call from Patient #9's daughter saying the patient's son had called to say their mother was lost; He'd left her in the lobby to get the car and she was not in the lobby when he returned. Nurse #9 called the facility's security. The nurse recalled that after hanging up with security, she received a call from a local hotel telling her Patient #9 was there and that she could not remember her son's phone number. The nurse then called security to inform them of the patient's whereabouts and then called the patient's daughter to tell her the patient had been found. When asked why no one from the facility escorted the patient completely out of the facility, the nurse said she was unaware of any policy or procedure that required staff to escort patients out and in this case, there was no time for any discharge routine like providing the patient discharge instructions which she would have attempted to give her even though she was leaving AMA. The nurse stated that Patient #9 was adamant about leaving; The nurse said, We weren't going to be able to hold her much longer if her son hadn't shown up. She was leaving. The nurse added that if the patient had left the unit alone, she would have had to call security. Nurse #4 said that she had called Patient #9's physician who said since the patient was not on any critical drips, they could not hold her. The nurse did not recall any discussion about the patient's mental status with the physician. Nurse #4 said she never thought the patient was demented, she just thought the patient was head strong and recalled the patient saying, I've lived with my body all of these years and I know it better than these doctors. MFI interviewed the CM twice, once on August 18, 2011 and again on August 19, 2011. The CM stated that her encounter with Patient #9 leaving AMA was brief, maybe 5 minutes. She said the nurse called and requested her to come talk with patient's family on the phone. The CM stated she immediately began talking with the daughter-in-law on the phone and told her the patient had the right to leave since she had not been diagnosed with dementia. The family member told her the patient had missed her psych appointments. The CM said although she never went into Patient #9's room, she could tell from the nurse's desk the patient was agitated, very angry and wanted to go home. The CM stated she never talked with the patient's son either but felt his actions indicated he was angry too. The CM stated she called APS and spoke with someone there who was familiar with Patient #9 and gave no indication there was a reason to keep the patient against her will. The manager for Cardiac Care Unit (CCU) was interviewed on August 18, 2011 at 10:55a.m. The manager recalled going to talk with Patient #9 after Nurse #4 informed her the patient wanted to leave. The manager told the MFIs that Patient #9 was very alert, her gait was steady, she was walking around the room and was oriented. The manager said she wouldn't describe the patient as agitated, she was describe her as persistent and did not want to be in the hospital. The manager said when she walked out of the unit to the elevator with the patient and son, there was tension between the son and patient. She said the son was aggravated with the patient and the patient was aggravated with her son, recalling the patient said to her son, We're not talking about this anymore. You're taking me home and we'll talk about it later. The manager stated she felt the staff had done all they could do to keep her admitted saying, I was not willing to restrain her. Dementia did not get mentioned. The hospitalist assigned to care for Patient #9 was interviewed on August 22, 2011 at 2:08 p.m. The physician recalled the patient and said she was admitted by cardiology for complaint of chest pain on June 9, 2011. The patient had initially refused to be admitted but later changed her mind however the patient kept wanting to leave. The physician recalled the nursing staff contacting her on June 10, 2011 to inform her Patient #9 wanted to leave AMA. The physician said she told the staff to do appropriate paperwork for AMA because they couldn't keep her. When the physician got to the unit, Patient #9 was still there so she went to see the patient. She said the patient got very angry with the physician's questions but the patient was not having delusions or hallucinations. The Vice President of Quality and Risk Management was interviewed on August 22, 2011 at 3:40 p.m. and said the facility did not have a policy requiring patients to be escorted to the door regardless of whether the patient was discharged or decided to leave AMA. She said their practice is to escort a discharged patient to the door but with patients deciding to leave AMA, they attempt to have them leave with someone like a family member. Patient #9's medical record was reviewed initially on August 17, 2011. The record documented the patient was originally seen in the facility's ED on June 9, 2011. The ED note dated June 9, 2011 at 8:07 p.m. documented the patient notified the cardiologist that she did not want to be admitted but when presented with AMA papers to sign, the patient said she was willing to stay if she did not have to remain in the ED bed. The patient was advised she would be admitted to CCU and therefore would be in a different bed and the patient was then willing to stay. The CCU nurse's notes dated June 9, 2011 at 10:00 p.m. documented, Pt (patient) is alert andoriented (sic) and abel (sic) to mae (sic) strong hand and foot strenght (sic). Another CCU nurses' note dated June 10, 2011 at 5:20 a.m. documented, Pt is oriented and cooperative at this time. Nurse #4's notes were reviewed for June 10, 2011. The nurse's notes were consistent with the information provided during Nurse #4's interview on August 19, 2011. The nurse documented her conversations with the patient regarding leaving AMA and the reasons to stay, several conversations she had with the son and daughter as well as a hospitalist and cardiologist. Nurse #4's nurse note documented in part, Son came to floor and told patient he wanted to talk to her but he would not take her home. Patient stated, ' I don't care. I am going home anyway' and started walking toward the doors. Son and (unit manager) followed patient out the door. Son informed by (unit manager) twice, that if they needed to bring her back for any reason to bring her back to the emergency department. Daughter was also instructed over the telephone to bring patient to the Emergency Department if needed. Son-in-law called wanting the staff to make the patient stay. Informed son-in-law the staff could not physically make the patient stay. Patient was getting more aggressive as the day progressed. A case management (CM) note dated June 10, 2011 at 2:33 p.m. documented, Patient left AMA. Family is very angry/upset. Son called to take patient home. Spoke with son and daughter-in-law on the phone. Daughter stated that APA (sic) is working with patient but there is nothing further they can do. Patient has not shown up for psychiatric appointments and therefore does not have a definitive diagnosis of dementia. Ativan offered multiple times by RN. (Hospitalist) contacted by (a second CM). According to (Hospitalist), patient's (sic) troponins are trending down. patient (sic) is not on critical drips. Therefore, patient cannot be TDO (Temporary Detainment Order). Patient apparently escaped from son who left her alone in the lobby. Security called. At 3:50 p.m. on the same day, the same CM documented, Spoke with (APS supervisor) at APS in (local county). Son-in-law had already contacted this lady and was quite upset with her as well. according (sic) to (APS supervisor). (APS supervisor) concurs there is nothing further we can do as this patient does not have a diagnosis of dementia. Spoke with (facility's CM supervisor) who also advised that I leave a message with forensic nurse. Left message with (forensics) on 6/10/11.
Based on staff interviews, medical record reviews, policy and procedure reviews and during the course of a complaint investigation it was determined the facility failed to prevent Patient #2 from an alleged assault. The findings include: Refer to Number 1 write-up under tag A-0144 and tag A-0392 The facility's forensic nurse on call July 20, 2011 was interviewed by one MFI on Wednesday August 17, 2011. The forensic nurse stated that during her assessment of Patient #2, the patient was quiet and gave short answers. The nurse also said the patient presented with a flat affect and made no eye contact. Patient #2 told the forensic nurse a big black boy was on top of me having sex. The forensic nurse stated swabs and smears were taken but no results were available upon the conclusion of the investigation. Patient #2's medical record was reviewed throughout the investigation. The physician on call for behavorial health services on July 20, 2011 had written a progress note dated July 21, 2011 at 10:34 a.m. which documented the physician met with Patient #2 and the patient informed the physician she had been sexually assaulted the night before. The progress note documented that after Patient #2 informed the behavorial health staff of the sexual assault, the patient was immediately sent for forensic evaluation and that detectives and or police were also present. Nurse #1 documented at 12:30 a.m. on July 21, 2011, The patient was observed at the nurse's station crying and stated, 'That big black boy tried to rape me. I woke up and he was on top of me.' Notified supervisor at that time and informed her of accusation. She came to speak with patient. Notified security to come to (behavorial health services). Patient spoke with supervisor and M.D. notified. Patient sent to ER for evaluation. Patient #2's medical record included an Emergency Department Triage Assessment conducted on July 21, 2011 at 1:30 a.m. The assessment documented the patient stating, I woke up and some guy was on top of me. It happened so fast. It's like a nightmare. Where was everybody while this was going on? The facility's policy titled, Patient Rights and Patient Responsibilities included a listing of patient rights. #16 under Patient Rights stated, To be free from all forms of abuse or harassment.
Based on staff interviews, review of staffing and scheduling assignments and staffing matrix plan, and during the course of a complaint investigation, it was determined the facility failed to meet adequate staffing schedules/assignments to ensure Patient #2's right to receive care in a safe setting. Refer to tag A-0392 for details.
Based on staff interviews, staffing plan and matrix, and during the investigation of a complaint it was determined the facility failed to provide adequate numbers of staff to ensure the safety of Patient #2. The findings include: The survey process included the review of adequate staffing as it related to the alleged assault of Patient #2. On Thursday August 18, 2011 Nurse #1 who works in the facility's ITU (Intensive Treatment Unit of Behavorial Health Services) was interviewed via phone by two MFIs. When asked about staffing and patient acuity related to night shift on July 20, 2011 (beginning at 11 pm July 20, 2011 and extending until 7:30 a.m. on July 21, 2011) the nurse stated, We were stressed, we had quite a few psychotic patients on the floor that night and they (the psychotic patients) can go off at any time. The nurse recalled specifically that on that night, shortly after beginning her shift, she was caring for a patient who was beginning to act out. She had to call a second nurse for assistance with the patient acting out. When asked whether any other staff was available, she stated that there was just the two of them working in ITU that night which was not unusual. She added that the nursing supervisor was assisting in a different unit and that security had already left that night. When asked how often she felt the unit was understaffed, she stated that during the three years she has worked in the behavorial health services of this facility, she would estimate 50% of the time she felt there was inadequate staffing. On Thursday August 18, 2011 a night shift supervisor of the behavioral health services was interviewed by two MFIs via phone. During the course of this interview, she stated that on July 20, 2011 night shift, we did not have enough staff. She said, Staffing is always tight on night shift but now (after the July 21, 2011 event) the staffing ratio is four to one (four patients to one staff member). When asked how long night shift staffing had been an issue she replied, We've addressed it for a long time because we've lost staff and we weren't getting replacements. This supervisor also indicated that security is usually on site every night until 1a.m. but on the night of July 20, 2011 security was gone before 1 a.m. She added that currently, security is present 24 hours a day. The physician on call for behavorial health services on July 20, 2011 was interviewed by one MFI on August 18, 2011. The physician indicated that the census and acuity was high and the staffing was not adequate prior to July 20, 2011. The medical director of behavioral health services was interviewed on Wednesday August 17, 2011 by one MFI. When asked about staffing ratios, the medical director stated that he felt a census of 15 or more patients on ITU with two staff working night shift was inadequate. When asked about the fact that on July 20, 2011 there were two staff members assigned to provide care for 17 patients on ITU, he stated there was not enough staff that night. The dayshift supervisor of behavioral health services was interviewed on August 18, 2011. When asked about staffing adequacy she stated, It's tight when census is high. The Vice President of Quality and Risk Management was interviewed by one MFI on August 17, 2011. She stated, Structured and consistent methods for determining staffing ratios based on volume and acuity were not utilized, which resulted in inconsistent staffing levels that were sub-optimal. She also stated, Backup staffing was primarily dependent on the Shift Supervisor. The VP added that, Additional staff positions had been approved and posted to accommodate increases in patient volume, but not yet hired. During an interview with the Vice President of Behavioral Health Services and the Clinical Director of Behavioral Health Services, the clinical director stated that the patients were coming faster than they were staffed for and that even prior to July 20, 2011 the facility was advertising and interviewing to fill needed vacant positions. She stated the facility continues to try and fill vacant positions. Throughout the complaint investigation and survey process, the facility's administrative staff provided several different staffing matrix tools for Behavorial Health Services. Until the last day of the survey it remained unclear which tool was being utilized on July 20, 2011. The MFIs requested the final clarification for the facility's staffing process as of July 20, 2011 and the matrix the facility provided covered a census up to 40 patients. For the night shift on July 20, 2011 there was a census of 41 patients within the behavioral health services. Actual staffing ratios between the dates of July 16, 2011 through July 20, 2011 were reviewed. The census for ITU was 15 or greater on 4 of the 5 of those nights shifts; The ITU had two staff members assigned each of those nights. During the interview with the medical director on August 17, 2011 he indicated that with a census of 15 or more on ITU, he would like to see 3 staff on night shift. Please refer to tag A-0144, write up #1 and tag A-0145
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