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Based on interview and file review, the facility failed to provide written notice of its decision in the resolution of a grievance for 1 of 1 (#28) grievances reviewed in which the grievance was submitted to the facility in writing. Findings include:

Interview with the Nurse Executive #1, on 4-28-10 at approximately 2:15 p.m., revealed that the facility had received a written complaint from patient #28, dated 11-24-2008, complaining about care provided during an inpatient stay. The Nurse Executive stated she called the complainant and provided this surveyor with documentation from the clinical record of the phone call to the complainant. The Nurse Executive stated there was no written response provided to the complainant regarding the investigation or the results of the grievance.

Based on record review and interview, the facility failed to document a discharge summary for 1 (#30) of 2 discharged patients with stays over 48 hours. Findings include:

Review of closed record #30 revealed that the patient was admitted on 3/19/10 for post-operative convalescence and required transfer to an acute care hospital on 3/22/10. There was no discharge summary located in the chart, either written or typed. Interview with the Director Health Information Department (medical records), on 4/29/10 at approximately 10:00, verified that there was no discharge summary. This Director stated that she thought discharge summaries were only required for stays beyond 72 hours.

Based on record review and interview it was determined that the facility failed to ensure completion of medical records within 30 days following discharge for 47 patients (6%) of patients discharged during the last quarter. Findings include:

On 4/29/10 at 1330 facility reports on patient records that were incomplete after 30 days was reviewed with the Director of Quality Assurance. Facility data indicated that the facility had 47 incomplete charts (6%) 30-days post discharge during the last quarter. This finding was confirmed with the Director of Quality Assurance.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on April 27, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated April 27, 2010, for Life Safety Code.

Based on interview and record review, it was determined that the facility failed to maintain proper humidity levels in the five operating rooms. Findings include:

Review of the daily O.R. Humidity log revealed that the humidity in the five operating rooms was low for 97 of the 175 daily entries for the months of March and April. Interview with the hospital CEO on April 28, 2010 at approximately 11:15 a.m. reveled that the facility was currently aware of the problem. The humidifier could not keep up to demand so the facility was in the process of consulting with the architect and installer on how to address this problem.

Based on observation, interview and record review, the facility failed to ensure that clean linens were stored in a sanitary manner and that employee handwashing protocol was followed, increasing the risk of patient infections. Findings include:

On 4/27/10 at 0945, during a tour of the pre/post operative area, a blanket warmer cart, filled with clean blankets, was observed in a room labeled for dirty storage. The lower tray of the cart was full of clean blankets, stored within 6 inches of soiled mops. This finding was confirmed by RN #1 and the OR (Operating Room) Manager.

On 4/27/10 at approximately 1245, the paper towel dispenser in the surgical scrub sink was observed to be stuck, necessitating manual cranking of a wheel in order to obtain a paper towel. When asked whether this was an isolated incident, the OR Director stated that the paper towel dispenser "tends to hang-up."

On 4/29/10 at 0900 the OR scrub sink paper towel dispenser was observed to be hung-up again, necessitating hand cranking in order to obtain a towel. This observation was confirmed by the OR Director.

On 4/29/10 at approximately 0925, paper towel dispensers were observed to be hung-up in patient rooms or bathrooms: #108, 110, #116 and #118. These observations were confirmed by the Nurse Executive. The Nurse Executive stated that employees know to rewash if a towel is not available after they have washed their hands.

On 4/29/10 at 0930, Aide #1 was observed washing her hands in the post-operative area at a sink with no paper towel sticking-out from the dispenser. After washing, the Aide cranked out a paper towel with a clean hand and walked away from the sink. This observation was confirmed by the Nurse Executive.

The facility policy and procedure titled "Clean Linen" states that clean, folded linens are transported to their designated area. It does not specify storage in a clean area. The facility policy titled "Hand Hygiene" states that employees should dry hands thoroughly with a disposable towel and use a towel to turn off the faucet.




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Based on observation and interview, it was determined that the facility failed to minimize the risks contributing to healthcare-associated infections.

Findings include:

On a walkthrough of the O.R. suite with the O.R. manager on April 27, 2010 at approximately 9:45 a.m. it was noticed that a blanket warmer holding clean linens was being stored in the soiled utility room in the PACU which increases the chance of cross-contamination of the clean linens. The blanket warmer was adjacent to the hopper sink and had mops and soiled linen also stored within this room. A facility tour with the infection control officer on April 28, 2010 at approximately 10:00 a.m. revealed that the blanket warmer was still being stored in the soiled utility room. When questioned why the clean linen and blanket warmer were being stored within the soiled utility room, the infection control officer stated that she was not sure and would follow up on that.