HospitalInspections.org

On 12/13/16 & 12/14/16 observation revealed that the facility had the following deficiencies:

K-133 (Multiple Occupancies - Construction Type),
K-161 (Building Construction Type and Height),
K-324 (Cooking Facilities),
K-341 (Fire Alarm System - Installation),
K-351 (Sprinkler System - Installation),
K-353 (Sprinkler System - Maintenance and Testing ),
K-362 (Corridors - Construction of Walls),
K-363 (Corridor - Doors),
K-521 (HVAC),
K-904 (Gas and Vacuum Piped Systems - Warning System),
K-911 (Electrical Systems - Other),
K-920 (Electrical Equipment - Power Cords),

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff P and Staff Q.

Based on observation and interview the facility failed to ensure that the building is maintained in a manner to ensure the safety and well-being of patients. This has the potential to affect all 2 in patients in facility.

On 12/13/16 at 12:56 PM observed multiple doors, all 3 patient rooms and doors to procedure room and nursery, had areas of chipped wood and it appeared that the door handle had been moved and old handle sites had areas of marred wood not allowing a smooth, cleanable surface. An interview was conducted with Registered Nurse D on 12/13/16 at 12:56 PM who confirmed that chipped wood was present.

On 12/13/16 & 12/14/16 observation revealed that the facility had the following deficiencies:

K-133 (Multiple Occupancies - Construction Type),
K-161 (Building Construction Type and Height),
K-324 (Cooking Facilities),
K-341 (Fire Alarm System - Installation),
K-351 (Sprinkler System - Installation),
K-353 (Sprinkler System - Maintenance and Testing ),
K-362 (Corridors - Construction of Walls),
K-363 (Corridor - Doors),
K-521 (HVAC),
K-904 (Gas and Vacuum Piped Systems - Warning System),
K-911 (Electrical Systems - Other),
K-920 (Electrical Equipment - Power Cords),

Please refer to the full description of the deficient practice at the individual K-tags. These observations are not compliant with 42 CFR 485.623. These deficiencies were confirmed at the time of discovery by a concurrent observation and interview with Staff P and Staff Q.

Based on observation, interview the facility failed to ensure that syringes are labeled, stored, drawn up for only one patient at a time, secured, biologicals are stored in original containers, and that mislabeled drugs are not available for patient use in 2 of 8 areas observed (Operating Room and Obstetric patient care area). This has the potential to affect 2 out of 2 inpatients at the facility.

During the interview Infection Preventionist (Staff T) on December 15, 2016 at 8:00 AM stated that the staff at the facility are to adhere to the standards of practice for infection control, from the following organizations: The Centers for Disease Control (CDC), The Association of peri-Operative Registered Nurses (ARON), World Health Organization (WHO), and Association for Professionals in Infection Control Epidemiology (APIC).

The Association for Professionals in Infection Control and Epidemiology (APIC) position paper: "Safe injection, infusion, and medication vial practices in health care" dated 2010 was reviewed on 12/15/16 at 10:35 AM. This document states under "Syringes and Needles" last point "Label all syringes containing medication if not immediately administered. Include patient identification information, names and amounts of all ingredients and the name or/initials of the person who prepared, date and time prepared, and beyond use date and time."

The Association for Professionals in Infection Control and Epidemiology position paper: Safe injection, infusion, and medication vial practices in health care dated 2010 reviewed on 12/15/16 at 10:35 AM. This document states under the category of "Syringes" point #7 "Do not prepare medication in one syringe to transfer to another syringe, i.e.: nurse draws up solution into syringe then transfers the solution to a syringe with a plunger removed or injected into the bevel of a syringe to then be injected into the patient."

Findings include:

Obstetrics:

On 12/13/16 at 12:50 PM on observation of Obstetric unit with Registered Nurse D in 2 of 3 patient rooms (1532,1533) had locked cupboards with medications in them. When requested to open medication cupboard Registered Nurse D was observed to retrieve the key to the cupboard from under a box of gloves sitting on a shelf in patient room. An interview was conducted with Registered Nurse D on 12/13/16 at 12:50 PM who stated keys to medications should be secured.

On 12/13/16 at 12:56 PM observed in "soiled instrument" room located behind nurses station in Obstetric area there was a box of medication (Hemabate-medication used to stop bleeding after birth) in refrigerator. The original expiration date on the outside of the box (3/16) was crossed out with a black marker and hand written was "3/19". Inside the box there were 4 ampules with an expiration date of 3/19. An interview was conducted with Registered Nurse D on 12/13/16 at 12:56 PM stated that box had original expiration had been crossed out and that medication was stored in an unsecured refrigerator.

Operating Room:

On 12/14/16 at 7:13 AM observed that there were 3 unsecured syringes with a clear solution on the counter of the operating room. Registered Nurse H was preparing medication (Epinephrine) at counter. Observation revealed 3 syringes lying on counter labeled with "Epinephrine" without patient name, date or time drawn up. An interview was conducted with Registered Nurse H on 12/14/16 at 7:13 AM stated that these were for the remaining cases of the day.

On 12/14/16 at 7:15 AM observed Registered Nurse H draw up Lidocaine (used as a local anesthetic) out of a glass ampule with a filtered syringe then took syringe to sterile field where Certified Ophthalmic Technician G had an empty syringe. Registered Nurse H inserted filtered needle into empty syringe hub and injected contents. Certified OphthalmicTechnician G placed syringe onto sterile field and did not label it. An interview was conducted with Registered Nurse J on 12/14/16 at 8:50 AM stated that medication transfer should not be done.

On 12/14/16 at 8:32 AM observation revealed in procedure room off sterile corridor in surgical services Registered Nurse H retrieved key for locked cupboard with medications from another unsecured drawer in procedure room. An interview was conducted with Registered Nurse H on 12/14/16 at 8:32 AM stated that key to medications should be secured out of patient care areas.

On 12/14/16 at 8:32 AM observation revealed in the procedure room an opened bottle of Gioniosoft (eye drops used during ophthalmic laser procedures) drops sitting on the counter, was not full and had no open date or initials on it. Simethicone (drops used for treatment of flatulence during endoscopy procedures) drops found in an unsecured drawer was not full and had no open date or initials on it. An interview was conducted with Registered Nurse H on 12/14/16 at 8:32AM stated that both medications were opened, used and had not been labeled with date and time of opening. Per review on 12/22/16 at 12:15 PM Compliance Officer/Health Information Manager A there is not a facility policy related to dating open drops.

Based on observation, record review, and interview, staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention of the facility and nationally recognized standards of practice in 8 of 9 departments observed (Medical Surgical Unit, Radiology, Emergency Department, Decontamination/Sterilization, Obstetrics, Operating Room, Pharmacy, and Dietary). This has the potential to affect 2 inpatients in the facility.

Findings include:

During interview Infection Preventionist Staff T on 12/15/16 at 8:00 AM stated that the staff at the facility are expected to adhere to the standards of practice for infection control, surgical services and decontamination/sterilization from the following organizations: The Centers for Disease Control (CDC), The Association of peri-Operative Registered Nurses (ARON), World Health Organization (WHO), and Association for Professionals in Infection Control Epidemiology (APIC).

Examples in Medical Surgical Unit:
On 12/13/16 at 12:30 PM observed 3 cardboard boxes and 2 plastic boxes containing clean supplies stored on the floor of the clean utility room on the medical surgical unit.
On 12/13/16 at 12:40 PM observed a 500 milliliter bottle of sterile water stored inside the blanket warmer on the medical surgical unit.
An interview was conducted with Assistant Chief Nursing Officer B on 12/13/16 at 2:55 PM. Assistant Chief Nursing Officer B stated the facility does not have a policy for storage of clean items and the items should not have been on the floor and have been moved. Assistant Chief Nursing Officer B also stated the facility does not have a policy related to sterile water in the blanket warmer and stated " it was not supposed to be there. "
Examples in Radiology:
On 12/13/16 at 1:00 PM observed two patient positioning wedges on the floor of the CT scan room and one patient positioning wedge on the floor of the ultrasound room. These findings were confirmed with Assistant Chief Nursing Officer B at the time of discovery.
An interview was conducted with Assistant Chief Nursing Officer B on 12/13/16 at 2:55 PM. Assistant Chief Nursing Officer B stated the facility does not have a policy for storage of clean items and the items should not have been on the floor.
Examples in Emergency Department:
On 12/14/16 at 8:30 AM observed cardboard shipping boxes containing clean supplies in the Emergency Department clean supply room.
Examples in Decontamination/Sterilization in Emergency Room:
The facility policy titled "Instrument Processing" dated 8/2/2011 was reviewed on 12/14/16 at 2:00 PM. This document states "Wear eye protection and gloves."
On 12/14/16 at 8:45 AM conducted interview with Nurse Manger Emergency Department M. Nurse Manager M stated instruments used in the Emergency Department are scrubbed and cleaned in the department using enzymatic cleaner before being sent to Sterile processing. Nurse Manager M stated staff only wears gloves when cleaning instruments.
Examples in Obstetric unit:

On 12/13/16 at 12:56 PM observed "soiled utility" room located behind the nurse's station contained both clean and dirty items. Refrigerator, blanket warmer, teaching/demonstration items located on left side of the room. On the right side, approximately 4 feet away, 2 compartment sink with shelves above it containing multiple cleaning chemicals. No Personal Protective Equipment present in the room for staff to wear during cleaning of the instruments. An interview was conducted on 12/13/16 at 12:56 PM with Registered Nurse D stated that "I wear my glasses, and gloves no apron..." no Personal Protective Equipment is worn during cleaning of instruments.

An interview was conducted on 12/13/16 at 12:56 PM with Registered Nurse D stated in "soiled utility" room behind nurses station they clean bloody instruments after a birth before taking to surgery area decontamination/sterilization. An interview was conducted on 12/13/16 at 12:56 PM Registered Nurse D stated "we put some water in this bucket, pour some of these granules in and put the instruments in....leave it for a while then rinse them off and take to sterilization".

The "granules" are labeled "Haemo-Sol", manufacturer's recommendations for use state "Haemo-Sol removes blood and other protein-based wastes quickly and entirely. Heat water and mix in Haemo-Sol. Soak items to be cleaned in Haemo-Sol solution for 10 minutes. Allow item to cool to a comfortable temperature and rinse well." An interview was conducted with Compliance officer A on 12/13/16 at 1:30 PM states there is no policy on cleaning instruments in the Birthing Suite.

Pre Op:

The facility policy titled "Hand Hygiene Policy and Procedure" dated 10/04/16 reviewed 12/15/16 at 8:35 AM. This document states in section B letter D indications for hand hygiene "After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting/moving patient)".

On 12/14/16 at 6:31 AM observed Licensed Practical Nurse U admitting Patient #16 for cataract procedure Licensed Practical Nurse U performed radial pulse and blood pressure then entered information into electronic medical record on computer without wearing gloves or performing hand hygiene. An interview with Infection Control Manager T on 12/15/16 at 8:00 AM confirmed it would be expected that staff would wear gloves during direct patient contact and be changed in between tasks (clean to dirty) with hand hygiene completed in between changing gloves.

Operating Room:

The facility policy #320-0004 entitled "Attire in the Operating Room" dated 1/26/16 was reviewed 12/14/16 at 10:30 AM. This document states in item #5 "a mask should fully cover both mouth and nose and be secured in a manner that prevents venting". Item #4 states "All head and facial hair must be covered with hair cover or hood. If male skull cap does not cover all hair, a bouffant cap or hood should be worn."

The facility policy #320-0005 entitled "Aseptic Technique in the Operating Room" dated 1/12/16 was reviewed 12/14/16 at 10:30 AM. This document states in item #3 letter G "arms should not be folded with the hands in the axilla" The facility policy #320-0004 and entitled "Attire in the Operating Areas" dated 1/26/16 was reviewed 12/14/16 at 10:30 AM. This document states in item #9 "Gown fronts are considered sterile from shoulder to table level on the front and on the front of the sleeve (axillary area is contaminated)".

The facility policy #320-0004 entitled "Attire in the Operating Areas" dated 1/26/16 was reviewed 12/14/16 at 10:30 AM. This document states in item #7 states "AORN defines sterile field as operative table, back table and at least 12 inches surrounding the perimeter to maintain the sterility of the field".

During interview Infection Preventionist Staff T on December 15, 2016 at 8:00 AM stated that the staff at the facility are to adhere to the standards of practice for infection control, surgical services and decontamination/sterilization from the following organizations: The Centers for Disease Control (CDC), The Association of peri-Operative Registered Nurses (ARON), World Health Organization (WHO), and Association for Professionals in Infection Control Epidemiology (APIC).
The Association of Peri-Operative Registered Nurses Organization (ARON) "2016 Guidelines for Perioperative Practice" was reviewed on 12/19/16 at 8:45 AM. This document states "When in the restricted areas, all nonscrubbed personnel should completely cover their arms with a long-sleeved scrub top or jacket."

The facility policy titled "Hand Hygiene Policy and Procedure" dated 10/17/13 reviewed 12/19/16 at 7:35 AM. This document states in section B letter D indications for hand hygiene "After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting/moving patient)".

The facility policy #320-0005 titled "Aseptic Technique in the Operating Room" dated 1/12/16 was reviewed on 12/14/16 at 10:30 AM. This document states under #5 letter A "All items should be delivered to the sterile field in a manner that prevents non-sterile objects or people from extending over the sterile field." and under #6 letter J "Items of doubtful sterility are considered unsterile and discarded."
The facility policy titled "Traffic Control in the Operating Room" dated 1/12/16 was reviewed on 12/22/16 at 12:15 PM. This document states under section C item #11 "At the end of the procedure, contaminated supplies will be contained on a transport cart and exit the OR using the door to the hallway. Contaminated supplies should not be transported through the sterile core."

The facility policy #320-0078 entitled "Health Care Industry Representatives in the Operating Room " dated 4/5/16 was reviewed on 12/14/16 at 10:28 AM. The document states "Literature must be provided for the proper processing of instruments. No instrument is to be put in use until the sterile processing technician has reviewed the process".

The facility policy #350-0008 entitled "Managing Loaner Instrumentation" dated 5/20/16 was reviewed on 12/14/16 at 10:30 AM. This document states "Loaner instruments/trays will be reprocessed/sterilized according to Burnett Medical Center's established sterilization protocols and following the device manufacturer's recommendations for sterilization."

Findings include:

Examples in Operating Room:

On 12/14/16 at 7:13 AM observed in the operating room Surgical Technician F and Registered Nurse H were wearing orange facial masks that were not tight against the face on left and right side venting out. An interview was conducted with Registered Nurse J on 12/14/16 at 8:50 AM stated that there should be no open sides on facial masks.

On 12/14/16 at 7:13 AM observed Registered Nurse J, Certified Ophthalmic Technician G, Certified Registered Nurse Anesthetist O, Physician K and Registered Nurse I all had ears and/or hair exposed from under head cover. Certified Ophthalmic Technician G and Physician K had on "skull caps" that did not cover sideburns or hair at the base of the head.

On 12/14/16 at 7:13 AM observed in the operating room Certified Ophthalmic Technician G standing in front of sterile field with sterile gown and gloves on with arms crossed at chest level and sterile gloved hands resting in axillary area. An interview was conducted on 12/14/16 at 11:18 AM Certified Ophthalmic Technician G stated "I know, I need to stop doing that."

On 12/14/16 at 7:13 AM observed in the operating room Certified Ophthalmic Technician G was standing next to sterile field against wall on left side of patient bed. After time out was done at 7:17 AM Certified Ophthalmic Technician G moved sterile table around head of patient bed and behind Physician K coming within approximately 3 inches of Physician K back. An interview was conducted on 12/14/16 at 11:18 AM Certified Ophthalmic Technician G stated that sterile table passed too close to Physician K's back.

On 12/14/16 at 7:15 AM observed in the operating room Certified Registered Nurse Anesthetist O had no jacket on during entire procedure, and undershirt visible at neck under scrub top. An interview was conducted with Certified Registered Nurse Anesthetist O 12/14/16 at 10:55 AM stated "there are no jackets my size in both male and female dressing rooms" and was in agreement that Staff O should be wearing a jacket to cover arms.

On 12/14/16 at 7:23 AM observed in the operating room Registered Nurse J removed jacket and hung it on chair for the remainder of the procedure and during room cleaning post procedure. An interview was conducted with Registered Nurse J on 12/14/16 at 8:50 AM stated that jacket should not have been removed but "it gets so hot in there".

On 12/14/16 at 7:16 AM observed in the operating room Registered Nurse J walking across the operating room carrying a bottle of sterile water, Physician K requested that Registered Nurse J adjust microscope for Physician K. Registered Nurse J set bottle of sterile water on the floor while adjusting the microscope. Registered Nurse J picked up bottle off the floor and proceeded to take sterile water bottle over to sterile field and poured into container onto sterile field. An interview was conducted with Registered Nurse J on 12/14/16 at 8:50 AM stated that the bottle of sterile water should not have been placed on the floor during procedure.

On 12/14/16 at 7:16 observed in the operating room Registered Nurse J was noted 3 times during procedure to move garbage receptacle to different locations in the room as other staff requested it without wearing gloves or performing hand hygiene after touching garbage receptacle. An interview was conducted with Registered Nurse J on 12/14/16 at 8:50 AM who stated gloves should have been on when touching receptacle. An interview was conducted with Infection Control Manager T on 12/15/16 at 8:00 AM stated it would be expected of staff to have gloves on before moving receptacle and hand hygiene performed after relocating receptacle.

On 12/14/16 at 7:33 AM observed in operating room that Registered Nurse I, Certified Ophthalmic Technician G, and Certified Registered Nurse Anesthetist O were frequently in and out of operating room, sterile corridor and post anesthesia care with the same mask on from procedure and hanging around the neck.

On 12/14/16 at 7:39 AM observed in operating room Certified Ophthalmic Technician G setting up sterile field on table was opening supplies onto sterile field. Certified Ophthalmic Technician G did not have sterile gown or gloves on and was repeatedly reaching over sterile field to drop items from packages. Certified Ophthalmic Technician G dropped an un-opened supply onto the floor and picked it up, opened package and dropped item onto sterile field. An interview was conducted with Certified Ophthalmic Technician G on 12/14/16 at 11:18 AM stated that he should not have used item that was dropped onto the floor.

On 12/14/16 at 8:15 AM observed Certified Ophthalmic Technician G take soiled eye instruments out of Operating Room across sterile corridor and handed to Sterilization Technician R for disinfection without instruments being covered. On receiving soiled instruments Sterilization Technician R used 2 clean containers and poured half a bottle of sterile water into each container. Sterilization Technician R used a "instrument cleaning cloth" received from Certified Ophthalmic Technician G. Each instrument was placed in one of the clean containers of sterile water and scrubbed. Then placed into second clean container. When Sterilization Technician R was questioned about the process used to clean the eye instruments stated "(Staff G) told me to do this. I just do what he/she tells me." An interview was conducted with Sterilization Technician R on 12/14/16 at 8:17 AM Staff R stated is unaware of eye instrument manufacturer's recommended cleaning instructions.

An interview was conducted with Certified Ophthalmic Technician G on 12/14/16 at 11:20 AM Staff G stated "We just do what the facility wants according to their policy." Certified Ophthalmic Technician G is a contracted employee with the company. On review of Xygent's contract reviewed 12/14/16 at 12:00 PM dated July 1, 2002, "is in the business of providing the equipment and supplies necessary to perform ophthalmic surgical procedures". Article 1 of contract "Xygent's Obligations" item B "Xygent agrees to provide certified surgical technician (Staff G) during the procedure to monitor the proper performance of the instrumentation and supplies" and item C "Xygent agrees to abide by the rules and regulations established by the hospital and other regulatory agencies as determined by local, state and federal officials". In Xygent contract under "Hospital's Obligations" item D #4 "Hospital agrees to designate and prepare space in their facility to perform cataract surgery. This space shall include, but is not limited to: Facility for, and responsibility of sterilization of reusable instrumentation between procedures."

An interview was conducted with Certified Ophthalmic Technician G on 12/14/16 at 11:25 AM "Staff G" had no copy of manufacturer's recommendations present.

Examples in Dietary Department:

On 12/14/16 at 1:05 PM observed in walk in freezer 6 packages of waffles sitting on top of a closed box and were not dated. A box of corn had the liner bag open and unsealed. The bag of kernels was open to air and the plastic of the bag extended out the top of the box. An interview was conducted with Dietary Manager V on 12/14/16 at 1:05 PM Staff V stated that waffles should have been dated and that corn was not properly sealed.

On 12/14/16 at 1:05 PM observed in bakery room debris was present on the counters, industrial mixer and floor. Per review of cleaning schedule "C3 Weekly Cleaning List for Kitchen Duties Week of 12/12/16" the list for Tuesday 12/13/16 had only 2 of 4 items completed. First 2 items were "sweep in the bakery under all counters and in corners and clean the bakery counters, backsplash, legs, and braces". An interview was conducted with Dietary Manager V on 12/14/16 at 1:05 PM Staff V stated in agreement that debris was present and cleaning was not performed.

Examples in Pharmacy:

On 12/14/16 at 3:00 PM observed in the Pharmacy that there is a dehumidifier located on floor in front of refrigeration unit. An interview was conducted with Pharmacist E on 12/14/16 at 3:00 PM who stated "we had a problem with humidity this summer and have had this since. We empty the container daily over there in the sink."

Staff was unable to locate filter when asked. The filter surface was covered with dust and unable be seen thru. An interview was conducted on 12/14/16 at 3:00 PM with Pharmacist E who confirmed that there was no policy in place for cleaning of the dehumidifier unit.












37420

Based on record review and interview the facility failed to ensure the reports are completed and authenticated by the provider within 30 days of discharge, in 1 of 2 Newborn Medical Records (20) out of a total 20 Medical Records reviewed. This deficiency directly affects Patient #20 and potentially affects all discharged patients.

Findings include:

The facility policy entitled "Rules and Regulations for Acute care" dated 4/4/16 Appendix B under section III letter N reviewed on 12/21/16 at 12:12 PM. This document states "All medical records shall be completed within thirty (30) days of the patient's discharge."

Patient #20's medical record review, on 12/14/16, revealed Patient #20 is a newborn on 11/1/16 at 4:18 PM. The Discharge Summary is charted on 11/2/16 at 2:35 PM. The Discharge Summary is not authenticated by the attending physician or midwife. Per interview with Compliance Officer/Health Information Manager A on 12/15/16 at 11:20 AM, the Discharge Summary should be signed before the 30th day after discharge.

This is confirmed in interview with Compliance Officer/Health Information Manager A on 12/14/16 at 3:00 PM, who confirmed they have 30 days to sign a report.

Based on record review and interview this facility failed to ensure a complete medical record including pain assessments in 1 of 3 patients receiving pain medication (#3); documenting all bottle feedings in 1 of 1 bottle fed infants (#18) and a timely newborn history and physical in 1 of 2 infants (#20), out of total universe of 20 patients. This deficiency directly affected Patients 3, 18, and 20 and potentially affects all 4 inpatients treated at the facility during the survey.
Findings include:
The facility policy titled " Pain Assessment and Management " dated 10/8/2016 was reviewed on 12/14/16 at 2:30 PM. This document states " Any patient care provider, from any department, who has implemented a pain control mechanism, shall reassess the patient within one-half hour to determine amount of pain control or relief achieved. "
Patient # 3 ' s medical record was reviewed on 12/14/16 at 2:10 PM. Patient #3 received Vicodin (pain medication) on 9/30/16 at 2:40 AM and on 10/1/16 at 5:36 PM. There is not a pain assessment at the time of administration or within 30 minutes of the administration of the pain medication.
An interview was conducted with Quality Director Staff N on 12/14/16 at 2:35 PM. Staff N stated a pain assessment should be done at the time the medication was given at within 30 minutes after.


18816

Findings include:

Per review of facility policy titled "Bottle Feeding the Infant" dated 10/20/2016 it states under Documentation "Chart type of formula and amount infant took in nurses notes. Document if amount is sufficient, if infant regurgitates or vomits, or if infant has poor suck in progress record."

Patient #18's medical record review revealed Patient #18 born on 12/13/16 was bottle fed. Bottle feeding records for Patient #18 state 1 ounce formula on 12/13/16 at 11:53 PM, and 1/2 to 1 ounce formula at 12/14/16 at 11:35 AM. The nursing note for the 11:35 AM feeding states "1/2 to 1 ounce each time." There are no other documented feeding times, or information related to infant response to the feedings during the11-1/2 hour timeframe. This is confirmed during interview with Assistant Chief Nursing Officer B on 12/14/16 at 3:00 PM, who agreed the feedings should be documented between midnight and 11:35 AM on 12/14/16.

Patient #20's medical record review revealed Patient #20 was born on 11/1/16 at 4:18 PM. The Newborn History and Physical is dictated on 11/2/16 at 2:56 PM, the Discharge Summary is charted on 11/2/16 at 2:35 PM, before the History and Physical. Per interview with Compliance Officer/Health Information Manager A on 12/15/16 at 11:20 AM, there are no Medical Staff Rules and Regulations for Maternity or Newborn History and Physicals, but agreed the History and Physical should be done more than 20 minutes prior to the Discharge Summary.

Based on interview the facility failed to ensure that the supervision in the Operating Room is by a staff member with experience in education, working in surgical services or specialized training in the provision of surgical services/management of surgical service operations. This deficiency has the potential to affect all surgical patients at this facility.

Findings include:

An interview was conducted on 12/15/16 at 12:10 PM Chief Nursing Officer S who stated after Supervisor of Operating Room retired in February 2016 the staff that was hired to replace the Supervisor did not want to have the role of supervision. Per Staff S, there was minimal staff with experience working in the Operating Room and no one wanted to take over supervisory position so Staff S assumed responsibilities. Staff S stated on interview that he/she does not have any Operating Room experience.

Based on record review, and interview the facility failed to have a Quality Assessment Program that is measurable with indicators to determine and used to evaluate improvement in 25 of 25 projects. This has the ability to affect all 2 inpatients admitted to the facility during the survey.

Findings include:

The facility policy reviewed 12/15/16 at 8:50 AM entitled "Quality Improvement Policy" #Q1001 dated 4/23/14 under Annual Quality Goals "Coordination of quality improvement activities within the facility into an integrated system. Identification and correction of facility wide problems. Establishment of priorities for investigating and resolving problems." And under Quality Improvement Action Plan "whenever action is undertaken to improve a process, the following elements should occur: planning of specific process changes; implementing process changes on a trial basis; measuring and assessing he effectiveness of actions taken; planning and testing a new action if initial actions are not effective; implementing successful actions on an Organization-wide basis"

An interview was conducted with Quality Coordinator N on 12/15/16 at 8:50 AM Staff N stated the Quality Assessment Program has multiple (25) projects currently being completed in all departments. Staff N provided a spreadsheet with all active projects. Per review of spreadsheet 6 of the 25 projects state completed under end date but do not have a completion date, ongoing monitoring and data collection, problem prevention and identification, identification and implementation of corrective actions, evaluation of corrective actions and measures to improve quality on a continuous basis. The projects have start dates from 3/13/14 thru 8/14/16 and no end dates listed on all 25 projects Quality Coordinator N states that each department does their own data collection and audits and report to her monthly. There is no goal/end date on collection of data, implementation of new procedures based on data nor reevaluation of implementation or new procedures placed based on data collection. Quality Coordinator N verbalized on interview the need for shorter goal dates, implementing process changes, completed projects, corrective actions and follow up on all Quality Assessment projects.