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Based on observation and staff interviews, the facility failed to maintain the personal privacy of patients presenting to the Emergency Department (ED). Findings include:

Cameras were observed in the ceilings in hallways of the Emergency Department during an environmental tour with the Director of Emergency Services on 8/19/2019. Per the Director of Emergency Services, the capacity of the ED could reach 18 patients, which would include the utilization of up to 5 stretchers in the hallways where patients could receive medical care and services.

During an interview at 2:15 PM on 8/20/2019, the Network Manager confirmed that five cameras were recording activity in the Emergency Department. The Executive Director for Quality confirmed that patients were not informed of the recording taking place in the Emergency Department and that patient assessments occurred in the hallways on stretchers, "all the time".

Based on observation and interview the hospital failed to store medical records in a manner that ensured protection from potential water damage. Findings include:

During a tour of the Medical Records Department on 8/20/19 at 9:42 AM with the Lead Analyst, the "Annex" room, "File Room", and "Volume Land" room areas contained multiple rows of medical records that were stored on open faced shelving located directly under exposed piping and sprinklers. The way the records were stored created an opportunity for potential water damage. The Lead Analyst confirmed this on 8/20/19 at 9:55 AM, and stated "charts could get wet".

Based on observation and staff interview, the facility failed to ensure medication was stored securely in all areas of the hospital. Findings include:

In the presence of the Director of Pharmacy, 2 ampoules of ammonia inhalant (respiratory stimulant used for the prevention/ treatment of fainting) were observed taped to the wall in a plastic bag above the head of the hospital bed in a patient room on the Birthing Center of the hospital on the morning of 8/21/2019. The bag had a piece of tape with the date of 6/22 written on it. The Director of the Birthing Center confirmed that 7 patient rooms and their adjoining bathrooms had ampoules of the ammonia inhalant taped on the wall so the medication would be, "readily available" if needed by a patient. The Director of the Birthing Center stated that staff took the medication from the large box of 10 ampoules in the locked medication room and wrote the expiration date on the bag prior to taping it to the wall in the patient rooms.

Upon observing the presence of the ammonia inhalant in the patient room, the Director of Pharmacy stated at 10:10 AM, "it should not be taped to the wall". The presence of the medication in an unsecured room potentially could have been accessed by by unauthorized individuals.

Based on observations and interviews the hospital failed to develop and maintain an environment that assured the safety and well-being of patients. Findings include:

1. During a tour of the Birthing Center on 8/19/19 at 12:30 PM with the Birthing Center Director, the clean utility room door was unlocked and contained 4 bottles of 4 oz of Hydrogen Peroxide, 3 bottles of 4% Chlorohexidine solution (disinfectant and antiseptic that is used for skin disinfection), lubricating jelly, lotions, soaps, and mouthwash. The dirty utility room was also unlocked and contained a container of Oxivir (one-minute disinfectant cleaner that has hydrogen peroxide as its primary active ingredient) wipes, a 946 milliliter (ml) bottle of Oxivir, a 1 gallon container and 2 quart containers of Renuzyme (high performance enzyme detergent), and a container of Clorox bleach wipes. Per interview with the Birthing Center Director at 1:04 PM, s/he stated that the doors to both the clean utility room and dirty utility room "have never been locked" to prevent unauthorized access.

2. The following was observed during a tour of the medical surgical unit on 8/19/19 beginning at 2:35 PM.

a. The "Respiratory Closet" adjacent to second floor nurse's station, which had no lock and was accessible to patients and visitors, had no signage to identify the presence of oxygen cylinders. This was confirmed by the nurse accompanying the surveyors on 8/19/19 at 2:45 PM.
b. The "Dirty Stock Room" adjacent to the second floor nurse's station, which had a Biohazard sign on the door was not secured. The nurse who accompanied surveyors during the tour confirmed on 8/19/19 at 2:45 PM that the room was accessible and has never had a locking mechanism to prevent unauthorized access by patients and visitors.
c. The "Dirty Stock Room" which contained biohazard trash containers, also included patient care equipment on the shelves. This included six "Hemo-Force" machines used for venous compression (to prevent blood clots) which were stored in plastic bags, 2 intravenous pump devices, and an "Air Pal" machine used to inflate mattresses to assist with moving patients. The nurse accompanying the surveyors stated, "I'm not sure why they are here.. they shouldn't be... they've always been here. I would not assume they have been cleaned. They would be wiped down before use."


3. The following was observed during a facility tour accompanied by the Director of Plant Services on 8/20/19 at 8:45 AM:

a. On the PCU, a dirty Utility Room, containing biohazardous waste, a sharps container, and soiled linen was unlocked and had no locking mechanism on the door.
b. The first floor care unit had an unlocked dirty Utility Room which contained soiled linen.

These observations were confirmed during the environmental tour with the Director of Plant Services.

Based on observation and staff interview, the facility failed to ensure there were procedures in place for the appropriate containment of trash in all areas of the hospital. Findings include:

During an environmental tour of the kitchen on 8/19/2019 at 10:10 AM, three garbage cans were observed near food preparation areas without covers. Garbage cans at a hand washing station and sink were also observed without covers. A 4:00 PM on 8/20/2019, the Director of Nutrition Services confirmed that there were five garbage cans in the kitchen that were, "sometimes covered, sometimes not" and there was no policy currently in place addressing the storage of trash in the kitchen.

Based on observation and interview the hospital failed to ensure that patient care supplies and equipment were maintained with acceptable levels of safety and quality. Findings include:

1. During a tour of the Birthing Center on 8/19/19 at 12:30 PM with the Birthing Center Director, rooms 225, 227, and 229 contained neonatal isolates/warmers that had opened packaging with resuscitation masks, opened tubing that was attached to the isolates/warmers, and opened packages of oxygen tubing ready for use. Each of these rooms also had separately opened packages that contained an oxygen mask and tubing that was attached to the wall mount at the head of the bed ready to be used by the expectant mother. There was no indication when the supplies were opened and how long they had been there in the rooms. Per interview at that time with the Birthing Center Director, s/he stated that all of the labor and delivery rooms were set up in the same manner so that the staff would have the equipment and supplies "at the ready". S/he further confirmed that there was no indication when the supplies had been opened and how long they had been in the rooms. Per interview on 8/21/19 at approximately 3:00 PM with the Director of Quality, s/he confirmed that s/he was aware of the above findings and stated, "They should not be opened and ready for use, it is not good practice".

2. During a tour on 8/19/19 at 1:25 PM of the peri-operative service locations accompanied by the nurse manager the following observations were made:

a. In the Sterile Supply Room a head extension positioning board used during surgical eye procedures was noted to have cracked vinyl in multiple areas.
b. In operating room #1 a slide board used to transfer patients on and off operating room table was observed to have cracked and ripped edges. A foot board, used in the operating room for surgical procedures was also noted to be in disrepair with cracks in vinyl.
c. In operating room # 2 a roller/slide board was also identified to have worn and torn edges.
d. In operating room #3 a door which exits to a corridor within the peri-operative location did not close tightly after staff entered or exited resulting in potentially canceling out the safety effects of the positive pressure system designed to keep regular germ-filled air out of the OR.


3. During a tour of the medical surgical unit on 8/19/19 at 2:25 PM, the "Dirty Stock Room" which also had a Biohazard sign present, contained patient care equipment that was outdated. Findings include:

a. A disposable forced air warming blanket had expired in October 2016.
b. An "Argyle Salem Sump" tubing had an expiration date of January 2017.

The nurse accompanying the surveyors on tour stated " I would not normally come in to pull clean supplies from this room."

Based on observations, staff interview and record review the Condition of Participation: Surgical Services was not met as evidenced by the hospital's failure to to ensure access to the operative; recovery area; and Central Sterile Processing was limited to authorized individuals.

During a tour on 8/19/19 at 12 noon accompanied by the manager of peri-operative services an elevator was observed to be unsecured creating potential access to the operative suites; endoscopy room; recovery areas and Central Sterile Processing by unauthorized individuals. Although all other entrances to the peri-operative area are secured requiring employee ID badge authorization to access the area, this specific elevator is unsecured and does not require ID badge authorization. The elevator opens onto 2 main hospital corridors utilized by the public but also opens directly into a corridor located within the peri-operative service location, creating easy access to this restricted location by anyone using the elevator. There is a small worn floor decal which states "Restricted do not enter area" located on the floor in front of the elevator with the intention of alerting unauthorized individuals not to enter the peri-operative services various locations. However, the failure to fully prevent unauthorized individuals from exiting from the elevator and accessing any of the locations within the peri-operative services creates a potential safety concern for both staff and patients. These observations were confirmed by the Director of Peri-Operative services at the time of the tour.

Based on observation and staff interview, the facility failed to ensure that outpatient services were maintained according to acceptable standards of practice. Findings include:

During an environmental tour with the RN Care Coordinator on the afternoon of 8/20/2019, an ampoule of ammonia inhalant (respiratory stimulant to prevent or treat fainting) was observed in an unlocked cabinet of exam room #7 of the obstetrics and gynecology outpatient clinic of the hospital. The exam room door was open without staff present, creating the potential for unmonitored access to the room by anyone present in the clinic. At 1:30 PM The RN Care Coordinator confirmed the presence of the ammonia inhalant and the Executive Director for Quality stated that the necessity for securing medication, "makes perfect sense".

Based on staff interviews the hospital failed to assure that a physician was designated as the Director of Respiratory Care Services. Findings include:

Based on interview with the Manager of Respiratory Services on 8/20/19 at 8:40 AM and 8/21/19 at 9:15 AM, no physician had been appointed as the Director of Respiratory Services following the departure of the previous Director. The Manager of Respiratory Services stated a that a hospitalist was designated by the previous Chief Nursing Officer but added "I don't know if it's even written anywhere." The Manager of Respiratory Services confirmed that the physician who oversees the blood gas lab does not function as the Director of Respiratory Services.

During interview on 8/20/19 at 11:20 AM, the Chief Medical Officer reported that the hospital has not had Director of Respiratory Care Services for the last four and five years.