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Based on staff interview and record review, the hospital failed to ensure that all patients, both in-patient and out-patient, were offered a chance to provide or create an Advance Directive. This failed practice could lead to the hospital not knowing the wishes of a patient that was unconscious and/or dying. The findings are:

A. On 05/22/17 at 2:45 pm, during an interview, Patient Registration Clerk #2 stated that patients seen in the Emergency Department did not get information regarding Advanced Directives because they were providing Outpatient services.

B. On 5/22/17 at 4:00 pm, during an interview, Patient Registration Clerk #3 stated that patients seen through the Gastroenterology Clinic did not get information regarding Advanced Directives because they were providing Outpatient services.

C. On 05/24/17 at 10:00 am, during an interview, Patient Registration Clerk #4 stated that patients seen in the Infusion Clinic did not get information regarding Advanced Directives because they were providing Outpatient services.

D. On 05/24/17 at 10:15 am, during an interview, Patient Registration Clerk #5 stated that patients seen in the Cardiology Clinic did not get information regarding Advanced Directives because they were providing Outpatient services.

E. On 05/25/17 at 9:15 am, during an interview, Patient Registration Clerk #6 stated that patients seen for outpatient services did not get information regarding Advanced Directives.

F. On 05/30/17 at 10:00 am, during an interview, Patient Registration Clerk #7 stated that patients seen for outpatient services did not get information regarding Advanced Directives.

G. On 05/30/17 at 10:15 am, during an interview, Patient Registration Clerk #8 stated that patients seen through the Emergency Department did not get information regarding Advanced Directives because they were providing Outpatient services.

H. Record review of the hospital policy and procedure titled, "Advanced Directives," dated 02/20/17, read, "Ambulatory Care (Outpatient Hospital Settings): If the care, treatment, or services being provided, warrant discussion about a patient's Advanced Directives decisions, the ambulatory care area will communicate..." about Advance Directives.

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Based on observation and interview, the hospital(s) failed to provide a clean and sanitary environment for patients. Observations in Hospital #3's behavioral unit, an operating suite, patient rooms, and isolation procedures, revealed accepted cleaning and sanitary practices were not followed. All three (3) Infection Preventionists (IP) denied conducting their own surveillance of the kitchens (all 3), the behavioral unit at Hospital #3, or made their own observations on the patient floors. This failed practice could expose patients, families, and staff to potential illnesses and infections from cross contamination from unsanitary rooms.


The findings are:

A. On 05/30/17 at 10:30 am, during observation, a tour of the Emergency Department Behavioral Unit at Hospital #3 was conducted with facility's assigned Infection Preventionist. A black light (ultra violet light) was used to verify the cleanliness of 4 unoccupied rooms on the unit. The perimeter of each floor and walls reflected layers of microbial material, possibly urine, feces and blood. Blood, urine, feces and other human excretions luminesce (glow) under ultra violet light. It appeared that the floors reflected layers of material indicating the floors were not clean when waxed.

B. On 05/30/17 at 10:30 am during interview, tech #1 conducting the tour of the Behavioral Unit attached to the Emergency Department stated, "Housekeeping is short-staffed. They come three times per week,"

C. On 05/30/17 at 10:35 am during interview, the Infection Preventionist dedicated to Hospital #3 was asked when she did her surveillance of the unit. She stated, "I have never personally been in there [the unit],"

D. On 05/23/17 at 11:15 am during interview, IP #1 and #2 stated, "We do rounds with housekeeping and kitchen managers once a month as part of environmental rounds. We don't do any direct independent observations in those areas."

E. On 05/23/17 at between 11:05 am and 11:20 am, during observations on the 4th floor, outside a room with a Contact Precaution sign on the door and a cart with Personal Protective Equipment or PPE outside of the door, a woman was standing by the patient's bed without any PPE. She was seen coming out of the room and going into the common nutritional area for coffee for her and the patient. She did this twice. Multiple staff walked by and did not stop her from entering the room without PPE.

F. On 05/23/17 at 11:15 am during interview, the woman was entering the room again and she was asked if the staff had explained what the signage meant and what was in the cart at the door. She stated that no one had explained the use of the PPE to her. At that time, RN #10 stopped and explained to her the meaning of the sign, what the PPE was for and how to put it on. When asked, she stated that her husband, Pt #10 had been in the room since the evening before.

G. Record review of Pt #10's clinical record revealed that he had been placed in the room a shortly after 6:00 pm the day before.



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H. On 05/30/17 at 12:40 pm during an observation in the Emergency Department (ED), nursing staff was observed removing his gloves and throwing them towards the trash can outside a patient's room. Nursing staff missed the trash can, looked at the glove and walked away.

I. On 05/22/17 at 10:20 am during an observation on the 7th floor, housekeeping staff came out of room 779 wearing gloves, a gown, and shoe coverings. She removed her gloves and gown while still in the patient's room. She kept her shoe coverings on and walked down the hallway. (All PPE should be removed outside the room and thrown away)

J. On 05/22/17 at 10:35 am, a tear was observed on an emergency department bed. The condition of the bed makes it difficult to ensure proper disinfection of the bed.

K. On 05/22/17 at 10:36 am during interview, the Emergency Department Director confirmed there was a tear in the bed.

L. On 05/22/17 at 12:20 pm during an interview, a family member of patient in room 768 stated, "The hospital is the dirtiest I have ever seen, you should see the ED...there were urine drops on the floor...took them a while to mop it up...trash was overflowing."








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Based on record review and staff interview, the hospital failed to ensure that a death which occurred within 24 hours of being placed in restraints was reported to Centers for Medicare and Medicaid Services (CMS) for 1 (Pt #42) of 1 (Pt #42) sampled patients who had a vest restraint on within 24 hours of their death. The findings are:

A. Record review of Pt #42's clinical record revealed an order dated 02/03/17 for the vest restraint. Further review of Pt #42's clinical record revealed the order to discontinue all restraints was dated on 02/06/17 at 3:42 pm.

B. On 06/01/17 at 11:00 am, during an interview, the Clinical Risk Manager confirmed that Pt #42 had a vest restraint on on 02/06/17 and that he died on 02/07/17 at 1:50 am. This was within 24 hours of Pt #42 death. She further confirmed that CMS was not notified of this death.

Based on interview, observation, and record review, the Governing Body failed to appoint an active, engaged compliance officer to ensure compliance with CMS regulations for the three hospitals under the same provider number. This failed practice exposed the hospital(s) to non-compliance with the 23 Conditions of Participation. The findings are:

A. Record review of the Clinical Performance Committee and the Medical Executive Committee minutes did not reflect a designated and/or approved compliance officer for the 3 hospitals.

B. On 05/30/17 at 2:15 pm during interview, the Quality Director for the hospital system was asked if she was responsible for compliance with CMS regulations. She stated, "We have a compliance officer who is responsible for for compliance. That is not me."

C. On 05/30/17 at 3:15 pm during interview, the Risk Director was asked if she also was responsible for compliance with CMS regulations. She stated, "No."

D. On 05/31/17 at 3:15 pm during interview, the compliance officer for the Hospital System was asked how she kept the three hospitals in compliance with the federal regulations. She replied, "My team reviews compliance every three years." She was asked what she has done in the last year and she replied, "The last review was three years ago." She was then asked if she reviewed policies and procedures for compliance. She stated, "I do not review policies and procedures for the three hospitals...My primary responsibility are legal and financial compliance for the entire system."

E. Record review of the Clinical Performance Committee and the Medical Executive Committee minutes did not reflect a designated and/or approved compliance officer for the 3 hospitals.

F. Record review of Amended and Restated Bylaws of facility adopted April 19, 2007 and as amended by resolution adopted April 22, 2010 (p. 20, article 8(b):
"the Compliance and Audit Committee shall: ...
(iii) ensure that compliance is an integral part of the operations of [Hospital name] and each Affiliate;
(iv) promote a culture of compliance through [Hospital name] and each of its Affiliates,...
(vi) monitor, coordinate and report the compliance status to the [Hospital name] Board. ...

F. Record Review of Amended and Restated Bylaws adopted April 19, 2007 and as amended by resolution adopted April 22, 2010:
" (g) ...The Quality Committee shall
(i) ensure that quality is an integral part of the operations of [Parent System] and each Affiliate;
(ii) promote a culture of performance excellence throughout [Parent System] and all of its Affiliates and
(iii) monitor, coordinate and report the quality status to the [Parent System] Board."

Based on record review and interview, the hospital(s) failed to follow privileging protocols for Dieticians if they write orders. The Governing Body is responsible for ensuring these standards. This failed practice potentially exposes patients to incorrect diets. The findings are:

A. Record review of patient records indicated Dieticians are writing independent diet orders, and are not operating off strict protocols. The orders are developed based on an assessment by the dietician and then the orders are placed into the Electronic Medical Record or EMR (EPIC). There is no activation required by the physician. These individuals do not hold privileges for independent ordering of diets.

B. On 05/24/17 at 10:10 during interview, the Credential Manager stated, "Dieticians are not privileged." She also confirmed that Dieticians do write orders.

C. Record review of Medical Staff files indicated Dieticians are not privileged by the designated staff.

D. On 05/24/17 at 9:35 am during interview, R81, a dietician at Hospital #2 stated "I take care of dietary orders. Physicians write a dietary consult and the dietician writes orders based on the consult."

Based on record review and interview, the Director of Anesthesia Services failed to provide recommendations for privileges for providers who provide anesthesia services. Deep sedation privileges as defined by Centers for Medicare and Medicaid Services (CMS) as Monitored Anesthesia Care were granted to emergency department physicians without recommendation by the Director of Anesthesia services. Deep sedation requires intubation, a breathing tube and medical monitoring. This failed practice exposes patients to potential harm from unqualified physicians. The findings are:

A. Record review of physician credentials indicated no documentation of recommendations for anesthesia services by the Director of Anesthesia.

B. On 05/22/17 at 10:00 am during interview, the Manager of Medical Records confirmed the Hospital(s) could not produce documentation of recommendations for privileges for anesthesia services.

C. On 05/24/17 at 10:04 am during interview, the Credential Manager was asked about deep sedation. She stated, "I am unclear about the difference between deep and moderate sedation. We use a procedural sedation protocol."



33813

Based on record review and interviews, the hospital(s) failed to ensure that medical records are completed within 30 days after patients are discharged from the hospital(s). The findings are:

A. Record review of the hospital(s) medical records revealed that there were 1024 incomplete medical record on the day of survey. This delinquency count went from a low in July 2016 of 398 to the current 1024 consistently month to month. The yearly report indicated that the delinquency count has never been lower than 398.

B. On 5/22/17 at 2:00 pm during interview, the Health Information Management offered various explanations as to why the records were not current. One explanation was that certain items in the records counted, would not truly render those medical records incomplete at 30 days. The reason deficiency count was consistently deteriorating was not offered. Health Information Management stated that staffing was problematic and that the records could not be analyzed in a timely manner. They also stated that incomplete records were not being coded and billed to Medicare.

Based on interview and record review, the Hospital(s) failed to secure proper disposal of unused portion of controlled substances into containers authorized by the DEA. This failed practice exposed controlled substances to diversion (available to unauthorized persons). The findings are:

A. On 5/23/17 at 9:00 am during interview, the Inpatient Gastroenterology (GI) Lab Charge Nurse reported the method for disposing of (wasting) narcotics not used during a procedure is to "squirt the remaining narcotic (liquid/IV narcotics) into the sharps container with a witness." This was confirmed by the GI Director.

B. On 5/24/17 at 8:45 am, during interview with Staff M79, it was reported that the procedure for narcotic waste in hospital #1 and #2 Operating Rooms (OR) is "the locked box system which is checked out by anesthesia from the OR pharmacy, medications are used as needed during the operation or procedure and documented, then the box with the unused medications is returned to the OR pharmacy for reconciliation and wasting into a non-recoverable cactus sink system (Renders Partially Administered Controlled Substance Waste Unrecoverable, Non-retrievable, and Unusable). The box system is used at [Name of hospital #3] at night. The other areas such as the GI lab and nursing floors, which use narcotics for sedation and pain management require a witnessed waste of narcotics."

C. Record review of the Hospital(s) policy requires this discard be made into a sink The current practice is not in compliance with DEA Regulation 21 CFR 1317.75 which prohibits the discarding of unused controlled substances into any container not authorized by the DEA.

D. Record review of the Hospital(s) policy titled "Management and Accountability of Controlled Substances" dated 05/57/16, 26 pages, indicated the following:
1. [The Hospital System] Pharmacy is committed to full compliance with all laws, regulations and guidelines governing the acquisition, storage, dispersal and destruction of controlled substances."

Based on observation, interview, and record review, the hospital failed to maintain a sanitary environment in Hospital #3's Emergency room behavioral unit, the facilities three kitchens and an operating suite (see A-749).

Based on observation, interview and record review the facility failed to follow nationally accepted surgical standards of practice or other accepted professional standards of infection control or as stated in the facilities' policy (see A-951).

The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation for Infection Control.

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Based on observation and interview, the hospital(s) failed to provide a clean and sanitary environment for patients. Observations in Hospital #3's behavioral unit, an operating suite, the kitchens, and patient rooms revealed standard cleaning and sanitary practices were not followed. All three (3) Infection Preventionists (IP) interviews denied conducting their own surveillance of all 3 of the kitchens, the behavioral unit at Hospital #3, or their own observations on the patient floors. This failed practice could expose patients, families, and staff to potential illnesses and infections from cross contamination due to unsanitary rooms.

The findings are:

A. On 05/30/17 at 10:30 am during observation, a tour of the Behavioral Unit attached to the Emergency Department at Hospital #3 was conducted with facility's assigned Infection Preventionist. Observation was used to verify the cleanliness of 4 unoccupied rooms on the unit. Upon scratching the filth, the layers were visible suggesting the floors and walls were not cleaned when the wax was applied. It appeared that the floors reflected layers of material indicating the floors were not clean when waxed.

B. On 05/30/17 at 10:35 am during interview, the Infection Preventionist dedicated to Hospital #3 was asked when she did her surveillance of the behavioral unit off the emergency department. She stated, "I have never personally been in there [the unit]".

C. On 05/23/17 at 11:15 am during interview, IP #1 and #2 stated, "We do rounds with housekeeping and kitchen managers once a month as part of environmental rounds. We don't do any direct independent observations in those areas."

D. On 05/30/17 at 12:40 pm during an observation in the Emergency Department (ED), nursing staff was observed removing his gloves and throwing them towards the trash can outside a patient's room. Nursing staff missed the trash can, looked at the glove and walked away.

F. On 05/22/17 at 10:20 am during an observation on the 7th floor, housekeeping staff came out of room 779 wearing gloves, a gown, and shoe coverings. She took off her gloves and gown while still in the patient's (pt) room. She kept her shoe coverings on and walked down the hallway, all of which should be removed and discarded at the doorway.

G. On 05/22/17 at 10:35 am, a tear was observed on an emergency room bed. Torn beds are unable to be cleaned properly and are an infection risk.

H. On 05/22/17 at 10:36 am during interview, the Emergency Department Director confirmed there was a tear in the bed.

I. On 05/22/17 at 12:20 pm during an interview, a family member of patient in room 768 stated, "The hospital is the dirtiest I have ever seen, you should see the ED...there were urine drops on the floor...took them a while to mop it up...trash was overflowing."

J. On 5/30/17 at 10:45 Registered Nurse was observed placing tubes containing blood into her scrub pocket after completing a blood draw and begin walking down the hall.

K. On 05/30/17 at 10:50 am during interview, the Registered Nurse confirmed she should have placed the tubes in a biohazard container and that placing the tubes in scrubs' pocket was not standard practice. Standard practice is placement in a plastic lab bag, sealing it, and applying a label with the name, date and patient identification number.

L. On 05/23/17 at 9:00 am during observation in Hospital #1's operating room (#1), the following were observed:

1. One provider in a sterile operating room was not wearing protective eyewear when the provider was at risk of a splash.
2. The same provider had a beard but the beard was not fully covered.
3. One provider was noted to be wearing an external sleeveless "fuzzy" jacket, not approved as sanitary operating room attire.
4. Staff were observed not removing their gloves at the transition between clean and dirty procedures.

M. On 05/23/17 at between 11:05 am and 11:20 am, during observations on the 4th floor, while walking by a room with a Contact Precaution sign on the door and a cart with PPE outside of the door, there was a woman standing by the patient's bed without any PPE. She was seen coming out of the room and going into the common nutritional area for coffee for her and the patient. She did this at least twice. Multiple staff walked by and did not stop her from entering the room without PPE.

N. On 05/23/17 at 11:15 am during interview, the woman was entering the room again and she was asked if the staff had explained what the signage meant and what was in the cart. She stated that no one had explained to her. At that time, RN #10 stopped and explained to her what the sign meant and what the PPE was for and how to put it on. When asked, she stated that her husband, Pt #10 had been in the room since the evening before.

O. Record review of Pt #10's clinical record revealed that he had been placed the in the room shortly after 6:00 pm the day before this incident.

P. On 05/23/17 at 11:15 am during interview, a woman was entering the room again and she was asked if the staff had explained what the signage meant and what was in the cart at the door. She stated that no one had explained the use of the PPE to her. At that time, RN #10 stopped and explained to her the meaning of the sign, what the PPE was for and how to put it on. When asked, she stated that her husband, Pt #10 had been in the room since the evening before.




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P. On 05/23/17 at 1:30 pm during observation of hospital #1's kitchen, the following was discovered:

1. Items in refrigerators

i. 4 bags of potato wedges not dated or labeled
ii. 2 bags of bagels opened not dated or labeled
iii. opened tortilla packages not dated
iv. 2 personal water bottles found in work refrigerator
v. 1 personal container of pie found in work refrigerator
vi. 1 container of pork not dated or labeled

2. In the daily use refrigerator (used daily for new items) next to the grill, multiple items were not dated or labeled.

3. Observations for cleanliness found:

i. Grease traps for grill had a large amount of grease build up
ii. Floor was dirty, and a yellow brown color built up substance was noted next to ramps leading into and between refrigerators # 30, 31, 32 and 33

4. In dry food storage room:

i. Only a minority of items in the dry storage area were marked with a received by date or open date.
ii. 2 packages of spaghetti were opened and not dated

5. On 05/23/17 at 12:54 pm during interview, Kitchen #1 Manager stated that the daily fridge is cleaned out every day and everything should be marked when received and opened per hospital policy.


Q. On 05/25/17 during observation of Hospital Kitchen #2, the following was revealed:

1. In Serving Area refrigerator:

i. 2 large packages of green chile not dated
ii. 4 packages of diced chicken not dated
iii. Coca Cola dispenser filter had expiration date of 10/25/14

2. In Freezer:

i. 3 packages of chicken breasts not dated.
ii. 3 boxes of croissants not dated


R. On 05/30/17 at 10:00 am during observation of kitchen #3, there following was revealed:

1. In walk-in freezer:

i. 4 loafs of bread were found not dated
ii. 1 box full of flat bread (over 20 packages) found not dated
iii. 1 pastry sheet was unsealed and not dated
iv. sun dried tomatoes not sealed
v.. liquid egg container not closed and not dated

2. In refrigerator:

i. container of peas was uncovered
ii. container of corn was uncovered
iii. container of cooked roast was not sealed
iv. stick of butter was open and uncovered

3. In Sink:

4 packages of partially frozen ribs were found opened and uncovered

4. In Dry Storage:

i. package of walnuts opened and not dated
ii. package of cashews opened and not dated


S. On 05/23/17 at 11:00 am during interview, the Kitchen #3 Dietary Director confirmed that opened items should be covered and/or sealed and dated, and meat must be thawed in either the refrigerator or under cold running water and this was not how and where meat was typically thawed.

Based on observation, interview, and record review, the facility failed to follow surgical standards of practice. This failed practice places patients at increased risk for infection and staff at risk for injury.

A. On 05/22/17 at 10:30 am during observation in the main operating room (OR) and pre-operative (pre-op) area, an employee was observed in a semi-restricted procedural area wearing a fleece vest. Appropriate surgical attire in accordance with nationally accepted standards such those defined by the Association of periOperative Registered Nurses (AORN) and other professionally accepted standards, define Personal Protective Equipment as "protective clothing helmets, goggles or other garments to protect the wearer from infection and is manufactured and packaged to be clean as defined by with OSHA (Occupational Safety and Health Administration). The garment may be cleaned by the facility but personal clothing does not necessarily meet these requirements."

B. On 05/22/17 at 11:15 am during observation of surgery in OR 2, a staff member was observed working in the surgical field not wearing protective eyewear. This practice placed him at risk for a splash. He also had a beard that was not fully covered. The nationally accepted standard for OR attire requires that all personnel should cover head and facial hair, including sideburns and the nape of the neck, when in the semi restricted and restricted areas of the surgical suite

C. On 05/22/17 at 11:35 am, staff representing operating room management and infection control, confirmed the surveyors observations.

D. Review of the facilities policy Title: Surgical Attire in Sterile Semi-Restricted and Restricted Procedural Areas Reference Number, Current Effective Date: 02/24/2017, revealed the following: under heading "Cover Apparel 10. Non-surgical covers such as fleece jackets, vests, or blankets are not allowed". Under heading "Head and Facial Hair Covering 11. All personnel will cover all chest, head, and facial hair, including sideburns, beards and hairlines with scrub attire provided.

11.1 Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.

11.2 Additional use of a beard cover is required when facial hair is not contained within hood.

13. During invasive procedures, the mouth, nose and hair (skull and face) should be covered to avoid potential wound contamination.

19. Protective eyewear is required barrier against body fluid contamination in accordance with [Occupational Safety and Health Administration] OSHA requirements and must be changed or cleaned promptly when contaminated."