PRINTED: 02/13/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 00 COMPLETED 150021 B. WING 11/15/2016 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 11109 PARKVIEW PLAZA DRIVE PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE, IN 46845 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE S 0000 Bldg. 00 This visit was for a State hospital S 0000 complaint investigation. Date of Survey: 11/15/2016 Facility Number: 005020 Complaint Number: IN00207181 Unsubstantiated: lack of sufficient evidence. Unrelated deficiency cited QA: 01/18/17 JL S 1118 410 IAC 15-1.5-8 PHYSICAL PLANT Bldg. 00 410 IAC 15-1.5-8 (b)(2) (b) The condition of the physical plant and the overall hospital environment shall be developed and maintained in such a manner that the safety and well-being of patients are assured as follows: (2) No condition shall be created or maintained which may result in a hazard to patients, public, or employees. Based on document review, observation S 1118 ISDH Citation TAG # S1118 - 03/10/2017 12:00:00AM and interview, the facility failed to ensure #IN00207181 Finding # 1: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. _____________________________________________________________________________________________________ State Form Event ID: 62U311 Facility ID: 005020 If continuation sheet Page 1 of 5 PRINTED: 02/13/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 00 COMPLETED 150021 B. WING 11/15/2016 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 11109 PARKVIEW PLAZA DRIVE PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE, IN 46845 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE that no condition shall be created or Description: Review of facility maintained which may result in a hazard data sheet for "Power Wash" detergent, indicated the following: to patients. A. The product contains "advanced blend of builders, surfactants, alkalis, Findings: anti-re-deposition agents". B. The product does not contain 1. Review of facility data sheet for bleach or additive for killing germs "PowerWash" detergent, indicated the 1. How are you going to correct following: the deficiency? If already A. the product contains "advanced blend corrected, include the steps taken of builders, surfactants, alkalis, and the date of correction. PBH will purchase and routinely antiredeposition agents" use detergent that has advanced B. the product does not contain bleach blend of builders, surfactants, or additive for killing germs alkalis, anti-re-deposition. Detergents loosen soil and also have some 2. On 11/15/2016, at 3:30 pm, microbial properties. accompanied by staff member # 5 I. Purchase and routinely use (Facilities Manager), while on tour of proper detergent. facility patient areas, the following was II. Education on proper detergent components and use observed: III. Audit on proper use of A. The B-East laundry room contained a detergent. utility sink, and a common household Finding # 2: washer and dryer. Description: The washer did not have a heat booster, in which the B. The washer did not have a heat water temperature would reach booster, in which the water temperature 160 degrees F. The washer would reach 160 degrees F. temperature is not C. The washer and dryer temperatures monitored. How are you going to correct the are not monitored. deficiency? If already corrected, D. There was no documentation to include the steps taken and the support that drums were cleaned - wiped date of correction. with bleach in between each different I. Will purchase and utilize a washier that temperature reaches patient laundering their clothes. 160 degrees F, with temperature E. There was not a posting- signage monitoring capabilities. State Form Event ID: 62U311 Facility ID: 005020 If continuation sheet Page 2 of 5 PRINTED: 02/13/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 00 COMPLETED 150021 B. WING 11/15/2016 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 11109 PARKVIEW PLAZA DRIVE PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE, IN 46845 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE with the process for laundering of patient II. Audit temperature monitoring. clothing found. Finding # 3: Description: There was not a F. There were 3 brown paper bags posting- signage with the process marked with patient room numbers that for laundering of patient clothing contained patient laundry, with 1 bag on found. the floor, 1 bag on top of the washer, and How are you going to correct the deficiency? If already corrected, 1 bag on top of the dryer; as well as include the steps taken and the patient laundry in the washer and in the date of correction. dryer. These were all 5 different patient's I. Create and display a sign that laundry- clothing. informs patients and co-workers on proper laundering processes. G. There was no evidence of bleach on II. Include the laundering process the unit for staff to use to wipe down in the policy. drums in between patient use. III. Audit adherence to the activates posted on the sign. Finding # 4: 3. Review of CDC guidelines, 2003 for Description: There is not an "Guidelines for Environmental Infection established policy & procedure for Control in Health-Care Facilities", on laundering of patient clothing. page 102, indicated "Disinfection of the How are you going to correct the deficiency? If already corrected, tubs and tumblers of these machines is include the steps taken and the unnecessary when proper laundry date of correction. procedures are followed: these I. PBH will update the infection procedures involve", b. "proper use of control policy to reflect proper laundering procedures. temperature, detergent and laudry II. Education will be provided to additives.", and "Soaps or detergents coworkers via in-service. loosen soil and also have some microbial properties. Hot water provides an 2. How are you going to prevent effective means of destroying the deficiency from recurring in microorganisms, and a temperature of at the future? least 71 C (160 F) for a minimum of 25 a. Nurse Leaders will audit 2 minutes is commonly recommended for laundering operations per day to verify the proper detergent is hot-water washing. A satisfactory being used, the temperature on reduction of microbial contamination can the washier reaches 160 degrees be achieved at lower water temperatures and is being monitored, and of 22-50 C (71.6 to 122 F) when the laundry sign is displayed and State Form Event ID: 62U311 Facility ID: 005020 If continuation sheet Page 3 of 5 PRINTED: 02/13/2017 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 00 COMPLETED 150021 B. WING 11/15/2016 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 11109 PARKVIEW PLAZA DRIVE PARKVIEW REGIONAL MEDICAL CENTER FORT WAYNE, IN 46845 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG DEFICIENCY) DATE cycling of the washer, the wash formula, instructions are followed. and the amount of chlorine bleach are b. Nurse leader will report audit findings and completion of carefully monitored and controlled at a education weekly to quality residual of 50-150 ppm during the management and the PBH chlorine bleach cycle." The facility has leadership team. not followed CDC guidelines- procedures 3. Who is going to be responsible for the numbers 1 for disinfection of washers and dryers. and 2 above, I.E. directors, manager 4. In interview on 11/15/2016, at 3:30 a. Nurse Leaders will be pm and 3:55 pm, with staff members # 5 responsible for education and compliance. (Facilities Manager), # 6 (QAS) and # 7 4. By what date are you going to (VP Nursing), the following was have the deficiency corrected? confirmed: a.