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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on June 11-13, 2012, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on review of Hospital policies, observation and staff interview, it was determined that for 1 of 1 Behavioral Health Unit, the Hospital failed to ensure patients' safety by providing each patient with electronically operated beds. Thus placing 22 of 22 patients on census on 6/12/12 at risk for self injury.

Findings include:

1. Hospital policy entitled, "Patient Rights and Responsibilities," (approval date 1/22/08) required, "Centegra Health System Patient Bill of Rights:..Clean and safe Environment - Centegra wants to give you a clean and safe environment..."

2. Hospital policy entitled, "Contraband: Room, Personal Belongings, and Personal Body Check," (approval date 2/12) required, "To ensure safety, the following items are not allowed ... Electronic Devices and/or Accessories."

3. On 6/12 12 between 8:45 AM and 10:00 AM an observational tour was conducted on the Hospital's In-Patient Psychiatric Unit. The Unit was a 24 bed unit with a census of 22 patients at the time of the survey. During the survey, it was observed that all rooms were furnished with electronically operated beds.

4. The Clinical Nurse Manager of Inpatient Behavioral Health was interviewed on 6/12/12 at approximately 10:00 AM. During the interview, the Manager confirmed that the Unit had hand crank beds in the past, however as the beds started to break down, the Hospital replaced the beds with THE CURRENT electric beds.

Based on review of Hospital policy, clinical records and staff interview, it was determined that for 2 of 2 (Pt. #6, & 7) records reviewed on the mother-baby unit, the Hospital failed to ensure patient care plans were individualized and updated to reflect individual patient needs.

Findings include:

1. The Hospital policy titled, "Interdisciplinary Plan of Care for Patients" (revised 12/04/11), required, "...will initiate and update plan of care for all in-house patients which reflects nursing diagnosis and individualized goal-oriented team care...goals developed shall be based upon nursing diagnosis, the team assessment of the patient and the physician's diagnosis..."

2. The clinical record of Pt. #6 was reviewed on 6/12/12. Pt. #6 was a 19 year old female admitted on 6/9/12 with diagnosis of post Cesarean Section, and Diabetes. The patient care plan initiated on 6/10/12 included post cesarean care, however the care plan failed to include the physicians' diabetes diagnosis.

3. The clinical record of Pt. #7 was reviewed on 6/12/12. Pt. #7 was a 21 year old female admitted on 6/10/12 with diagnosis of Normal Spontaneous Vaginal Delivery (NSVD) and Chronic Hypertension. The patient care plan initiated on 6/10/12 included the NSVD diagnosis, however the plan failed to include the physicians' Chronic Hypertension diagnosis.

4. An interview with the Interim Unit Manager (E #1) was conducted on 6/12/12 at approximately 11:00 AM. E # stated that care plans should be updated to include individual patient care needs.

Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 3 of 3 (Pt. #'s 4, 3 and 1) clinical records reviewed of patients receiving blood products, the Hospital failed to ensure the Transfusion Report Form was complete and included the indication for transfusion.

Findings include:

1. Hospital policy titled, "Transfusion of Blood Products", (revised 4/12/10), required, "Complete Transfusion Report Form by documenting the date and time transfusion began and completed".

2. The clinical record of Pt. #4 included that Pt. #4 was a 33 year old female admitted on 6/9/12 with the diagnosis of Thrombocytopenia. The clinical record included an order to infuse 2 units of platelets. The Transfusion Report Forms dated 6/9/12 at 2:08 PM and 6/10/12 at 10:52 AM, lacked documented indication for transfusion.

3. During an interview on 6/11/12 at 1:45 PM, the Interim Manager stated that it was the RN's responsibility to ensure all blanks on the Transfusion Report Form are complete.


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4. Pt #3 was a 61 year old male admitted on 6/10/12 with diagnoses of Anemia and Gastrointestinal Bleed. The clinical record for Pt #3 included a Blood Transfusion Form for 1 unit of Leucocyte Reduced Packed Cells dated 6/10/12 that lacked a completion time and indication for transfusion.

5. Pt #1 was a 27 year old female admitted on 5/24/12 with a diagnosis of Acute Cholecystitis. The clinical record for Pt #1 included a Blood Transfusion Form for 1 unit of Packed Red Blood Cells dated 6/5/12 that lacked a completion time at the time the record was reviewed on 6/11/12 at approximately 10:15 AM.

Based on review of the Hospital Medical Staff Bylaws and Rules and Regulations, Hospital's Letter of Attestation of Delinquent Records, and staff interview, it was determined that for 1 of 1 Medical Records Department, the facility failed to ensure medical records were completed within 30 days of discharge.

1. The Hospital Medical Staff Bylaws and Rules and Regulations (revised 5/4/10) included, "The medical record must be completed within thirty-(30) days following a patient's discharge."

2. The Hospital's Letter of Attestation of Delinquent Records dated 6/12/12 included, "The total number of delinquent medical records = 545".

3. The above findings were confirmed with the Supervisor of Medical Records during an interview on 6/12/12 at approximately 10:40 AM.

Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 2 Dietary Departments (West South Street Facility), the Hospital failed to ensure all food products were properly stored and not outdated.

Findings include:

1. Hospital policy entitled, "Food and Nutrition Services Food Storage," (approved 5/11) required, "Policy Statement: To maintain food safety and quality and to prevent waste, the Food and Nutrition Services shall ensure foods are stored in clean, dry, storage areas upon arrival to the facility...7. Items shall be 6" off of the floor and 18" below the ceiling."

2. Hospital policy entitled, "Food Product Shelf Life Guideline," (revised 11//22/10) required, "Purchased Products - Shelf Stable: Spices: 6 months - Keep in closed containers. Best used within 3 months."

3. On 6/12/12 between approximately 10:00 AM and 11:00 AM, an observational tour was conducted in the Dietary Department of the South Street location. During the tour the following observations were made:

- in the meat freezer, sliced meats, sausage, beef and cookie dough were stored approximately 3 to 5 inches from the ceiling

- in the walk-in meat freezer in the dry storage area meat products were stored approximately 3 inches from the ceiling

- in the vegetable freezer - asparagus, corn and green beans were encrusted with ice leaking from the freezer unit

- in the food preparation area approximately 50 containers of various spices were opened and undated.

4. The Dietary team leader was interviewed on 6/12/12 at approximately 11:00 AM and confirmed that the food items should be stored at least 18 inches from the ceiling, the vegetables were covered with ice and the spices should have been dated.

5. The Operations Manager Service Response Center and Nutritional Services was interviewed on 6/12/12 at approximately 2:15 PM. The Manager stated that the Hospital does not date and label spices.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on June 11-13, 2012, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 6/13/2012.

Based on review of the Hospital's Organ, Tissue and Eye Donation Agreements with an Organ Procurement Organization (OPO), and staff interview it was determined that for 2 of 2 agreements, the Hospital failed to ensure an agreement was established with an Eye Procurement Organization.

Findings include:

1. The Hospital presented an agreement dated 5/15/06 and entitled, "Organ and Tissue Procurement Agreement Between Gift of Hope and Tissue Donation Network and the Hospital" was review on 6/12/12 at 1:00 PM. The agreement covered the organ and tissue donation, but not eye donation.

2. The Hospital presented an agreement dated 9/19/2000 entitled, "Eye Donation and Procurement Agreement which was reviewed on 6/12/12 at 2:00 PM. However, the agreement was with another hospital and not the surveyed hospital.

3. On 6/13/12 at 10:45 AM, the Director of Patient Care was interviewed. The Director stated that the staff responsible for the Hospital's organ donation program left in February 2012 and the position has been vacant. However, the Director stated that she has temporarily assumed the role and confirmed that the Hospital did not have an agreement with an Eye Bank.

4. On 6/13/12 during the daily exit briefing, the Administrative Staff present confirmed that there is no contractual agreement with an Eye Bank.

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 3 of 3 (E#'s 4, 5 & 6) employees observed in the Surgical Department, the Hospital failed to ensure adherence to dress code.

Findings include:

1. Hospital policy entitled, "Attire For Semi-Restricted and Restricted Areas," (reviewed 3/12) required, "Procedure:1: a) Restricted area:..Head and facial hair shall be contained within protective covering...Mask shall be worn in restricted areas where open sterile supplies and equipment are present...d)...Jewelry shall not be worn in the operating room..."

2. On 6/13/12 an observational tour was conducted in the Hospital's Surgical Department from 7:00 AM until approximately 8:45 AM.

This was observed in OR #4:

The Certified Registered Nurse Anesthetist (E#6) entered the room wearing a surgical mask that lacked ties on the bottom of the surgical mask, thus was not securing his mask properly.
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This was observed in OR #5:

-The Anesthesiologist (E#4) caring for a patient was wearing a gold colored ring on each hand.
- The Surgeon (E#5) entered the room with approximately 1 to 2 inches of hair exposed from the back of the surgical cap.

3. The Operating Room Manager stated during an interview on 6/13/12 at approximately 8:00 AM that the expectations are rings should not be worn in the OR, hair should be covered, and the surgical mask should be secured.



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B. Based on review of Hospital policies, observation and staff interview, it was determined that for 1 of 1 Operating Room Suite. the Hospital failed to ensure expired sutures and medications were not available for patient use, potentially affecting all surgical patients on census.

Findings include:

1. Hospital policy titled, "Stock Rotation" (reviewed 12/11), required, "...rotate Storeroom stock to ensure patient safety...A. When new stock is received the clerk will restock the shelves checking for expired inventory."

2. Hospital policy titled, "Medication Storage Safeguards from Receipt to Administration" (revised 3/28/12), required, "...Managing Expired Medication...Expired medication shall be returned to Pharmacy for proper disposition, storage and reordering...."

3. During an observational tour of the OR suite on 6/13/12 between 7:00 AM and 8:00 AM the following were found:

*The Eye cart contained a box of 5-0 Ethicon suture, with 12 individually wrapped sutures, which expired on 1/2012.

*The Difficult intubation cart contained a bottle of Cetaccaine, a topical anesthetic spray, that expired on 9/2011.

4. The OR Manager, interviewed on 6/13/12, at approximately 8:00 AM, stated that expired sutures and medication should be checked for expiration and disposed.