cms_WV: 9362
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9362 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 520 | K | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility's evacuation plan, review of National Fire Protection Association (NFPA) guidelines, and policy review, the facility's quality assessment and assurance committee failed to develop and implement appropriate plans of action to correct deficiencies of which its members should have been aware in the areas of maintenance and housekeeping services. The QAA committee failed to implement a plan to ensure all doors identified as emergency egresses were able to be opened without impediment, especially in view of staff's awareness that a door identified as an emergency egress in the A-wing dining room had, once or twice before in past years, been sealed shut door due to corrosion at the threshold. This same door, which was labeled an emergency exit, was identified as an emergency exit on the facility's emergency evacuation plan, and was identified by staff as an exit to be used if it were necessary to evacuate this part of the facility, was unable to be easily opened when tested on [DATE], resulting in a finding of immediate jeopardy. The QAA committee also failed to identify quality deficiencies, and implement plans of action to correct these quality deficiencies, related to housekeeping services that were inadequate to prevent the spread of an infectious organism and maintenance services that failed to maintain a clean, comfortable, and sanitary interior for the residents. Facility census: 51. Findings include: a) During an interview with a family member who wished to remain anonymous, an allegation was made that staff members were smoking outside the A-wing dining room doors, causing smoke to enter the dining room. Following receipt of this complaint, an attempt was made, on 09/29/11 at 2:20 p.m., to exit the A-wing egress doors to inspect for evidence of smoking outside this door. The egress door failed to open after multiple attempts by this surveyor. - Assistance was sought from two (2) male housekeeping leads (Employees #91 and #92). Employee #91 directed this surveyor's attention to the red lettering printed on the door instructing to push on the door for 30 seconds. Pressure was applied with an alarm sounding for approximately 30 seconds, when the magnetic lock could be heard to disengage from the top of the door. However, increasing pressure applied to the door failed to open it. Employee #91 again pushed on the door for approximately 30 seconds with the alarm sounding when the magnetic lock could be heard disengaging. Employee #91 was unable to open the door. After multiple tries, Employee #91 exerted increasing force upon the door. After hearing a cracking sound, Employee #91 stated he did not want to break the door. After one (1) more strenuous jerking / pushing motion, the door opened with a loud cracking sound. It was noted that the threshold plate had rusted and corroded to the point that it had sealed the door shut and prevented it from opening as designed. Employee #91 was then noted to have to pull the door towards him with an audible scraping sound in order to get the door to shut. - The activity director (Employee #56), who was present in the room, was then asked to simulate having to open the door due to a fire and a need to evacuate residents in the dining room. She was unable to force the door open. This surveyor also pushed on the door until the magnetic locking device disengaged but was unable to force the door open. - Observation of the dining room found this was the only door in the dining room designated as an emergency egress with the accompanying signage. Review of the floor plan posted on the wall outside the A-wing dining room noted a red arrow directing staff, residents, and visitors to exit through this door. An interview with the director of nursing (DON - Employee #55) was conducted at the A-wing nursing station at 2:35 p.m. on 09/29/11. When asked which door would be utilized in the case of an emergency evacuation, the DON indicated the door marked with the exit sign which had been sealed shut by rust and corrosion of the threshold plate. - The program manager of the OHFLAC life safety program was contacted at 2:50 p.m. on 09/29/11 and apprised of the findings related to the emergency egress door located in the A-wing dining room. The life safety program manager determined that, if a door was designated as an emergency egress, and the door could not be opened, this constituted a finding of immediate jeopardy. - The director of support services (Employee #95) and the DON were informed by the team leader at 3:05 p.m. on 09/29/11, that the failure to assure the emergency egress doors were operational placed any residents and staff who may be in the dining area, nursing station, or adjacent hallways, in immediate jeopardy of harm or death should a fire or other disaster require evacuation. The facility removed the rust and corrosion from the threshold plate, and the door was determined to be functional at 3:10 p.m. on 09/29/11. - A follow-up interview was conducted with Employee #95 and the maintenance lead (Employee #97) at 10:29 a.m. on 10/04/11. This interview elicited that the facility had no formal policy related to safety maintenance. Concerning the emergency egress door located in the A-wing dining room, Employee #95 reported that this same door had sealed shut once or twice over the years, as they salt heavily during the winter where it gets icy. He stated the salt is very corrosive and will actually cause the concrete to expand. When asked if the facility had developed a schedule of inspections of the door in light of past problems to assure it was operational, he stated they had not. He did relay that the facility contracts with a vendor for inspections of the components of the smoke alarm and fire suppression systems, and he had contacted the vendor's representative, who informed him they had not opened the door either. Employee #97 stated, during this same interview, that he only checks the alarm and to see if the magnetic locking system releases. He stated he does not actually open the door when conducting these tests. He further stated that it could have been as long as two (2) years since that door had actually been opened. - Review of NFPA 101 (Life Safety Code) Section 7.1.10.1 found the following language: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. (See also citation at F323.) -- b) Random observations, conducted on 09/29/11 at 12:20 p.m., noted a housekeeping cart outside the room of a resident in contact isolation related to a [DIAGNOSES REDACTED] infection. The room was posted with signage directing staff and visitors to see the nurse before entering the room. - A housekeeper (Employee #100) was asked to describe how to clean this particular room. She stated she would use Virex to clean the surfaces and floors. She further stated she would clean that room, then clean one (1) or two (2) more rooms, before changing her mop head or mop water. She was unable to provide information concerning training in disinfecting rooms and/or preventing the spread of [DIAGNOSES REDACTED] spores within the facility. - An interview with the housekeeping lead (Employee #91) was conducted at 2:00 p.m. on 09/29/11. When informed of the observation and interview conducted with Employee #100 at 12:20 p.m. on 09/29/11, Employee #91 verified that the cleaning product Employee #100 utilized to clean rooms contaminated with [DIAGNOSES REDACTED] spores was not effective against the spores. He further stated that the mop head, mop water, and cleaning cloths were to be changed immediately after cleaning a room contaminated with [DIAGNOSES REDACTED] spores. - Review of the facility's policy titled Cleaning of rooms with [MEDICAL CONDITION] (with an effective date of 06/08/09) found no clear and specific cleaning procedures to ensure that members of the housekeeping staff cleaned contact isolation rooms contaminated with [DIAGNOSES REDACTED] spores in a manner to prevent the spread of this infectious organism throughout the resident environment. (See also citation at F441.) -- c) Observations and staff interview found the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior for the residents. This was true for sixteen (16) of thirty-three (33) resident rooms. 1. Beginning at approximately 3:20 p.m. on 09/26/11, an environmental tour for the facility's interior revealed the following issues on C-wing and B-wing: - Room C-102 - the cove base was loose from the wall around the sink, and the metal corner bead was loose on the corner between the closet and the sink. - Room C-105 - the cove base was loose from around the wall, and deep scratches and gouges were observed on the wooden door leading into the room. - Room C-103 - scrapes and scratches were visible on the walls, deep gouges were seen on the bathroom door, and a hole was observed in the tile on the floor in front of the door leading to the bathroom. - Room B-105 - the wooden door leading into the room was scratched and with deep gouges, and a hole was observed in the tile in the floor. An interview was conducted with Employee #89 (a maintenance worker) on 09/29/11 at 1:15 p.m., who was advised of the room numbers in which each of the above deficient practice was observed. - 2. The following issues were found on A-wing: - Room A-110 - scratches and scuff marks were seen on the corridor and bathroom doors. - Room A-103 - paint was peeling from the facings on the corridor and bathroom doors. - Room A-106 - observation found dirty windows, torn window screens, rust on the bottom of the heating / air condition unit as well as peeling paint on the door facing. - Room A-105 - observation found a hole in the closet door and a broken outlet cover. - Room A-109 - deep scratches were seen on the bathroom door. - Room A-104 - deep scratches were seen around the bathroom door. - Room A-108 - several scratches / scuffs were seen on the wall near the window. - 3. The following issues were found on B-wing: - Room B-103 - Observation of this room, on 09/27/11 at 4:34 p.m., revealed a broken, missing chunk of flooring at the entrance to the bathroom; a large piece of cove base missing behind the first bed; and the corridor door had areas of broken wood on it. - Room B-107 - Observation of this room, on 09/27/11 at 4:37 p.m., revealed a closet door with a torn and jagged wooden piece protruding; the corridor door was nicked, with multiple scratches marring the surface. - Room B-106 - Observation of this room, on 09/27/11 at 4:48 p.m., revealed the cove base covering torn loose on the wall just outside the room; the interior bathroom door and the interior of the adjoining bathroom door were both very scratched and marred. - Room B-108 - Observation of this room, on 09/27/11 at 4:51 p.m., revealed the wall outlet to the cable connection was not fastened to the wall, and a hole was seen in the wall beside the outlet. - Room B-101 - Observation of this room, on 09/27/11 at 4:56 p.m., revealed the corridor door had areas of broken wood along the edges. (See also citation at F253.) | 2015-11-01 |