HospitalInspections.org

Surveyor #3

Based on interview and personnel file review, the Hospital failed to develop and implement a process to ensure staff were appropriately credentialed for tasks being performed as required by State law. More specifically, the hospital required Emergency Department Technicians (ED Technician) to obtain a Health Care Assistant (HCA) credential. The HCA credential did not cover the scope of their assigned duties.

Failure to ensure that personnel have the proper credentials to perform their assigned job duties risks provision of health care by unqualified persons.

Findings:

1. An interview with ED Technician #1 on 12/14/2011 at 10:10 AM revealed that his/her job duties included the following:
? Stocking room carts
? Stocking supply storage areas
? Performing EKGs
? Application of splints
? Bandaging
? Wound Care/irrigation/wound dressing application
? Performing blood glucose testing
? Point of care testing
? Assists with patient care tasks (dressing, undressing, toileting)
? Transports patients/assists with ambulation
? Assisting nurses and doctors as needed
? Responding to codes

2. Review of ED Technician #1's job description/evaluation revealed that additional duties included foley catheter insertion (indwelling, straight cath and mini cath), discontinuation of indwelling catheters, discontinuation of peripheral IV (intravenous) sites.

The job description/evaluation did not specify the type of credential required for the role of ED Technician.

3. An interview with the interim ED Director on 12/13/2011 revealed that an HCA credential was required for all ED Technicians. The ED Director stated that foley catheter insertion and removal was not one of the ED Technicians job duties.

4. Review of personnel files on 12/15/2011 at 9:00 AM confirmed that ED Technician #1 had a Health Care Assistant "A" credential that allowed him/her to perform venous and capillary invasive procedures for blood withdrawal but the credential did not cover the scope of his/her assigned duties. According to the Director of Human Resources the Emergency Department employs nineteen (19) ED Technicians with the same credential (ED Technician #1-#19).

The Director of Human Resources confirmed the above findings.

Surveyor #1

I.
Based on medical record review, the hospital failed to ensure that evidence existed to show that Medicare patients received a copy of the standardized notice "An Important Message from Medicare" upon or within two (2) days of admission for 4 of 4 Medicare patients reviewed for the beneficiary notice (S6, S8-S10).

Failure to ensure that patients receive their rights, as required, places these patients at risk of harm related to a discharge that may be accomplished prior to the patient being ready for discharge.

Findings:

1. Per review of Patient #S8's medical record, the patient was admitted with Medicare benefits on 12/10/2011. The record contained the notice titled "An Important Message from Medicare" that was signed by the patient, however the dating of the signature was in someone else's handwriting.

2. Per review of Patient #S6's medical record, the patient was admitted with medicare benefits on 11/22/2011. The record contained the notice titled "An Important Message from Medicare" that was not signed by the patient. The record also contained the form that is supposed to be given to Medicare patients just prior to their discharge to inform them of their discharge rights. This form was signed by the patient, however the dating of the signature was in someone else's handwriting with their initials next to it.

3. Per review of Patient #S9's medical record, the patient was admitted with Medicare benefits on 12/8/2011. The record contained the notice titled "An Important Message from Medicare" that was not signed by the patient, but by an individual identified as a "child" of the patient. This signature was not dated or timed. The admission form has areas for initialing receipt of the "An Important Message from Medicare" form that was also not initialed by the patient or the person signing the above paperwork.
The record also contained the admitting form that provides for: a) Consent to Medical Care; b) Release of Patient Information; c) Assignment of Insurance Benefits; d) a Financial Agreement; e) Charity Care information; and f) the written acknowledgment of receipt of "Patient Rights" and "Notice of Privacy Practices". These last two areas were initialed by the patient's "child" and not by the patient. There was also no date or time of the signature.
The record contained a duly executed "Durable Power Of Attorney for Health Care" allowing the patient's child to make health care decisions; however, it clearly stated that it did not become effective until the patient had been deemed "mentally incompetent" or had "lost decision-making capacity". The hospital could not provide evidence of any condition that would have allowed someone else to be signing for the patient.

4. Per review of Patient #S10's medical record, the patient was admitted with Medicare benefits on 12/2/2011. The record also contained the admitting form that provides for: a) Consent to Medical Care; b) Release of Patient Information; c) Assignment of Insurance Benefits; d) a Financial Agreement; e) Charity Care information; and f) the written acknowledgment of receipt of "Patient Rights" and "Notice of Privacy Practices". These last two areas were initialed by the patient's signature was not dated or timed by the patient but by the "witness" whose handwriting was the same for both signatures.
The record also contained the notice titled "An Important Message from Medicare" that was not signed by the patient, but signed by the "spouse". The hospital could not provide evidence that any person, other than the patient, had been given the right to sign legal paperwork in the patient's name.
The above examples were verified during an interview with SS#1 on 12/12/2011.



21647


Surveyor #3

II.
Based on interview and review of hospital policies and procedures, the hospital failed to follow its' policy and procedure for informing patient's of their rights when admitted to the hospital according to 42 CFR 482.13(a)-(d).

Failure to inform patients of their rights limits the patient's ability to exercise those rights.

Findings:

1. Review of hospital policies related to patient rights revealed the following:

a. The hospital's policy and procedure entitled "Patient Rights and Responsibilities" (Effective 11/1/1973; Revised 11/29/2011) read as follows:

"Patient Rights & Responsibilities shall be made available to patients and/or surrogate decision-makers in the following manner:

Patients will receive a copy of patient rights and responsibilities at time of admission."

b. The hospital's policy and procedure entitled "Admitting" (Effective 11/1/1994; Revised 5/1/2009) read as follows:

"Patient will be given the "Patient Rights and Responsibilities" pamphlet and asked to initial the consent on the appropriate line."

2. Review of medical records for "Patient Rights and Responsibilities" revealed the following:

a. Per review of medical records on the Specialty Campus by Surveyor #1, the patients on the Geropsych Unit had a copy of their rights in their chart, which was the same one given to them upon admission. A review of this printed document showed that the rights given to these patients were not the same rights given to patients admitted on the Main Campus.

The Geropsych Unit Manager stated that these patients had "special rights" and thus a different patient rights document had been developed and distributed.

b. Per review of medical records on the Specialty Campus by Surveyor #1, the patients on the Rehabilitation Unit had a copy of their rights in their chart, which was the same one given to them upon admission. A review of this printed document showed that the rights given to these patients were not the same rights given to patients admitted on the Main Campus.

The Rehabilitation Unit Manager stated that these patients had "special rights" and thus a different patient rights document had been developed and distributed.

c. Review of the medical records of Infusion Patients receiving treatment in the Cancer Center by Surveyor #3 revealed that 6 of 8 patient records reviewed did not have evidence in the medical record of having received a copy of the patient rights pamphlet (Patients #E1-#E6).

An interview with the manager of the Cancer Center on 12/13/2011 revealed that she/he had identified this as a problem and as of Monday, 12/12/2011, staff were giving the patient rights pamphlet to infusion patients and having patients initial the consent form on the appropriate line.

d. Medical records reviewed in the Cath Lab and in Interventional radiology by Surveyor #2 revealed that two (2) medical records did not have documented evidence of patient's acknowledging receipt of the patient rights pamphlet (Patients #V11, #V12).

Surveyor #3

Based on record review and review of policy and procedure, the hospital failed to provide documentation that patients admitted to the hospital were advised of their right to formulate an advance directive according to hospital policy.

Failure to obtain direction for life-sustaining treatment could result in resuscitating a patient and/or prolonging the patient's life against his/her wishes.

Findings:

1. The hospital policy and procedure entitled "Advance Directives" (Effective 12/1/1991; revised 11/13/2011) read as follows:

"[The Hospital] will provide each patient admitted as an inpatient, observation, same day surgery or in the emergency department with written information about their rights under Washington State Law (RCW 70.122), including the right to accept or refuse medical or surgical treatment, and the right to execute Advance Directives."

"Nursing asks on the admission assessment if the patient either has an Advance Directive or if they would like information."

"If they desire further information then the brochure is given and social worker is notified for further follow up with the patient."

2. During medical record review on 12/12/2011 to 12/15/2011, nine (9) patient records lacked evidence that the patients had been advised of their right to formulate an advance directive and offered information regarding advanced directives upon admission to the hospital (Patient #E2, #E7-#E10, #V2, #V9, #V11 and #V12).

Surveyor #3

Based on record review and review of medical staff bylaws, the facility failed to ensure that outpatient records contained adequate, pertinent information that promoted continuity of care in 3 of 8 records reviewed (Patients #E3, #E5, #E6).

Failure to ensure adequate information is present in patient records risks inadequate and/or inappropriate care and treatment.

Findings:

1. Review of "Rules and Regulations of the Medical Staff" (Revised 11/2006), under the section entitled "Medical Records" part d read as follows: "History and Physical examinations are required for all admissions to the hospital and are to be completed within 24 hours of admission."

2. Review of medical records in the Cancer Center on 12/14/2011 revealed the following:

a. Patient #E3 was a 30 year-old patient who was admitted to the outpatient infusion center (Cancer Center) on 10/21/2011 for lab draws and removal of 500 ml's of blood (phlebotomy) every two weeks.

There was a History and Physical in the patient's medical record dated 12/12/2011. The History and Physical was not in the patient's record within 24 hours of admission for outpatient treatments.

b. Patient #E5 was a 63 year-old patient who was admitted to the outpatient infusion center (Cancer Center) on 11/15/2011 for a series of "Ramicade" infusions (a treatment for patients with autoimmune diseases).

There was no History and Physical in the patient's medical record.

c. The same was found in the medical record of Patient #E6.

3. An interview with the Cancer Center Manager on 12/13/2011 revealed that the physician history and physical was not a required part of the medical record for outpatient infusion patients (patients receiving treatments other than chemotherapy).

Surveyor #3

Based on interview and record review, the hospital failed to develop a process for planning nursing care in the outpatient infusion area (Cancer Center).

Failure to develop and update a nursing care plan for patients receiving ongoing infusions or treatments limits the nurse's ability to recognize and treat complications of the patient's treatment regimen.

Findings:

1. Review of the medical record of 7 outpatient infusion patients revealed the following:

Patient #E6 was a 56 year-old patient admitted on 10/6/2011 for a series of medication infusions for treatment of Rheumatoid Arthritis. A treatment plan had been developed by the patient's physician. A nursing care plan based on the patient's individual nursing care needs had not been developed.

The same was found in the medical record of Patient #E3, #E4, and #E5.

2. During an interview on 12/13/2011 at 11:50 AM, the Cancer Center manager confirmed that the Cancer Center had no process for development of care plans for patients receiving outpatient infusions in the Cancer Center.

Surveyor #1

Based on medical record review, administrative staff interview, and review of policy and procedure, hospital pharmacy services failed to ensure that physician orders for drugs and/or medications were followed, as written, for 2 of 32 records reviewed (Patients #S1, S2).

Failure to ensure that drugs/medications are administered only with a physician order places all patients at risk of harm related to the administration of drugs/medications that were not specifically ordered by a physician.

Findings:

1. Per record review, Patient #1 was seen in the Emergency Department (ED) on 11/29/2011, with diagnoses including alcohol abuse. The physician ordered observations for acute alcohol withdrawal symptoms and subsequent medication of the patient, based on the assessment. The "Alcohol Withdrawal SCPCP" form showed an assessed score of "6" at 11:00 AM. The physician orders stated that the patient was to be given one (1) mg. of Lorazepam for this score. A review of the "Medication Administration Record" did not reveal that this dose was actually given to the patient. The record did not contain any information to show that the order had been rescinded.

2. Per record review, Patient #S2 was admitted on 11/29/2011 with diagnoses including alcohol abuse. The physician ordered observations for acute alcohol withdrawal symptoms and subsequent medication of the patient, based on the assessment. The "Alcohol Withdrawal SCPCP" form showed an assessed score of "21" at 10:30 PM. The physician orders stated that the patient was to be given three (3) mg. of Lorazepam for this score. A review of the "Medication Administration Record" (MAR) showed that the licensed nurse administered only two (2) mg. of Lorazepam. The record did not reveal why the full dose was not given, nor evidence that the order had been rescinded or changed.
The patient was re-assessed in one hour with a score of "5". The physician orders stated that the patient was to be given one-half (0.5) mg. of Lorazepam for this score. A review of the MAR did not show that the licensed nurse administered this dose, as ordered.
At 9:30 PM the assessed score was "5". The physician orders stated that the patient was to be given one-half (0.5) mg. of Lorazepam for this score. A review of the MAR showed that the licensed nurse administered one (1) mg. of Lorazepam rather than 0.5 mg. as the physician had ordered. The record did not contain any evidence that The record did not reveal why the ordered dose was not given, nor evidence that the order had been changed.


18001

References:
WAC 246-320-211 Pharmaceutical services. Hospitals must: (1) Meet the requirements in chapter 246-873 WAC ...
WAC 246-873-070 Physical requirements. (1) Area. The pharmacy facilities shall include: (4) Drug storage areas. Drugs shall be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security. (a) It is the joint responsibility of the director of pharmacy and the director of nursing to ensure that drug handling, storage, and preparation are carried out in conformance with established policies, procedures, and accepted standards.
Based on observation, interview, and record review, the facility failed to manage pharmaceuticals in accordance with regulations, licensing requirements, and approved policies and procedures.

Failure to do so resulted in risk of diversion of narcotics and administration of contaminated or otherwise sub-therapeutic medications.

Findings include:

Part I
On 12/12/11 during tour of the 4 Alderwood Telemetry unit the front medication room was surveyed. Surveyor #2 found a locked drawer containing a bottle of controlled drug (narcotic) tablets which had been labeled as supplied by an outside pharmacy, dated 5/23/11. Staff #V1 did not recognize the patient name on the label and could not state why the drug was in the drawer or when the person had potentially been a patient on the unit. Further discussion revealed that the drug was not secured or tracked per controlled substance law requirements and facility policy. It was not logged or documented in any way, or counted at each change of shift. The key to the drawer was in the custody of whichever nurse was fulfilling the charge nurse role on a given shift.

Part II
On 12/12/11 during tour of the 4 Alderwood Telemetry unit both medication rooms were inspected. Surveyor #2 found in each room a pill splitter which had not been cleaned after use; they were soiled with a white powdery substance. In the front medication room, a mortar and pestle apparatus was found similarly soiled, and the pestle was broken, with tape and residue affixed to the broken ends. Survey of the room by Surveyor #5 on 12/13/11 revealed that the situation had not been corrected.

Part III
On 12/14/11 Surveyor #2 toured the Cardiac Cath area. A warming cabinet for contrast media (dye used during tests) was examined. Several different types of contrast media were stored in the cabinet and a variety of dates were marked on the vials, ranging from 12/11/11 - 1/12/11. The surveyor engaged the three cath lab staff present in a discussion of the process for tracking the dates and temperatures for the warmed agents. Each of the three staff members provided a different explanation of the procedure and meaning of the dates on the vials. This lack of clarity regarding the policy for when vials were outdated was verified by Staff #V2. Facility policy entitled "Contrast: Administration/Reaction/Storage" revision dated 9/20/10 reads in part: "Iodinated contrast media will not be stored in a contrast warmer for more than 28 days. Contrast will be taken out of active inventory if in the warmer for 29 or more days."

Part IV
During environmental rounds of the ED on 12/13/11 Surveyor #4 found an opened bottle of intravenous nitroglycerine solution in the janitorial mop sink in the "waste" room, rather than being secured in or disposed of in the medication area. This was verified by Staff #V4. No policy was provided which would permit medications to be stored outside secure medication areas.
.

Reference:
Facility policy entitled "Medication Order Writing Standards" , effective date 3/1/11, reads in part: "At a minimum an order should include: date and time of order when written.

Based on interview and record review, the facility failed to document physician orders according to policy.

Failure to do so places patients at risk for errors in medication administration, with potential to experience debility.

Findings include:

1. On 12/13/11 Surveyor #2 reviewed an inpatient medical record (Patient #V3), focusing on physician orders. Four orders were found to have been taken verbally or over the telephone by staff between 12/6-10/11. These orders had not been authenticated (or verified, in writing) by a practitioner by the time they were reviewed on 12/13/11. Per Staff #V5 facility policy requires authentication within 24 hours.

2. On 12/14/11 Surveyor #2 reviewed an inpatient medical record (Patient #V4), again focusing on physician orders. Between 12/9-13/11 thirteen verbal or telephone orders had been written but not authenticated.

3. On 12/15/11 Surveyor #2 reviewed 8 medical records for recent patients in Same Day Surgery, Cardiac Cath Lab, and Interventional Radiology. Six records were incomplete as to the time one or more physician's orders had been written (Patients #V5-V8, V11, V12). Similar findings were noted by Surveyor #3 for four Infusion Center Patients.

4. Surveyor #1 reviewed four patient records, focusing on physician order completeness (#S4-7). Each record contained between three and thirteen telephone orders which had been documented within a two month time span of the hospital survey. The majority had not been authenticated according to facility policy, since they were only initialed, but not signed, dated, and timed, to permit evaluation of when the authentication occurred.
.

Based on interview and record review, the facility failed to administer a blood transfusion according to facility policy.

Failure to follow policy for this high risk procedure places patients at risk for debility and potential death related to transfusion errors and reactions.

Findings include:

On 12/14/11 Surveyor #2 reviewed the medical record of Patient #V4. The patient was routinely receiving dialysis treatments, and a physician's order was noted to transfuse the patient during dialysis on 12/10/11 with two units of packed red blood cells. Examination of the dialysis run sheet and other medical record documentation did not reveal evidence that the first of the two ordered units had been given; there were no notations that it had been started or completed, or whether there were signs of complications. The run sheet showed vital signs taken at 30 minute intervals, whereas the blood transfusion policy stipulates that they be taken prior to initiating the transfusion and fifteen minutes afterwards. The only reference to blood transfusions on the run sheet was that the responsibility for the second unit had been given over to the unit staff caring for the patient. Staff #V1 verified the findings in the patient record.

Surveyor #1

I.
Based on medical record review and administrative staff interview, the Medical Record Services failed to ensure that the record contained the patient's progress and response to medications and services in regards to completing physician ordered patient assessments for 2 of 2 records reviewed for specialty patient care (Patient #s S3 and V4).

Failure to ensure that all assessments and documentation of the patient's progress and response to medications and services places all patient's at risk of harm related to the inability to accurately track how a patient is responding to treatments.

Findings:

1. Per record review, Patient #S3 was a 40 year old admitted on 12/9/2011 with diagnoses including substance abuse. Per review of the pre-printed physician order forms, a form was found titled "Physician Detoxification Orders" initiated on 12/10/2011. This form contained orders, in paragraph 5, that detail assessments and re-assessments of vital signs and "CIWA" scoring for alcohol withdrawal symptoms. It also contained laboratory tests to be completed and seventeen (17) medications to be administered. The form contained further, an order for completion of the "Opiate Withdrawal" pre-printed order form. A review of the medical record did not provide evidence that any of the "CIWA-Ar" scoring had been documented, since admission (three days ago). An inquiry was made to the Detox Unit Manager on 12/13/2011, who asked a licensed nurse about the missing information and was told that they did not assess the patient using the CIWA-Ar scale even though it was ordered by the physician because the patient was not expected to have alcohol withdrawal symptoms.
There was no documentation in the record that the physician had been notified of the unit's decision to not follow certain parts of the pre-printed order form, nor of any changes to the orders that would allow staff to not assess the patient, using the CIWA-Ar scale, as ordered.

2. Per record review, Patient #V4 had a physician order written on 12/11/2011 that specified the patient was to have a weight loss goal of "1-2 kg as tolerated" for the hemodialysis treatment period. This particular treatment was to be 2 hours rather than the usual 4 hours. A review of the dialysis nurse run sheet documented the patient lost "4" kg during the run. Staff# VV2 was interviewed and stated that s/he believed an error was committed in pre-dialysis weighing because the run sheet documented a fluid loss of 2.2 liters, which would be inconsistent with the documented weight loss of 4 kg. Staff# VV2 was requested to provide any protocols or conversion tables which would equate weight and fluid loss during dialysis, but none was received as of the survey exit date.

II.
Based on medical record review, the Medical Records department failed to ensure that the record contained completed orders, as established by the Medical Staff, for 14 of 32 records reviewed for order accuracy (Patient#s L1-L4, S2, S15, V4-V8, V11, and V12).

Failure to ensure that the medical record contains completed physician orders places all patients at risk of harm related to the potential that orders might not be implemented in a timely manner.

Reference: A) Per review of hospital Medical Staff Rules and Regulations, on page 3 paragraph IV. Medical Records, subparagraph b. it states, "Entries in all medical records shall include: i. A date and time..."; and B) Per review of hospital policy & procedure titled " Medication Order Writing Standards " , effective date 3/1/11 reads in part: ... " 4) At a minimum an order should include: ... date and time of order when written " .

Findings:

1. Per record review, Patient #L1 was a 30 year old receiving serial treatments for hereditary Hemochromatosis from the Infusion Center. The physician order for treatment was signed and dated, but did not contain a "time" the order was written.

2. Per record review, Patient #L2 was an 81 year old receiving serial treatments for Osteoporosis from the Infusion Center. The physician order for treatment was signed and dated, but did not contain a "time" the order was written.

3. Per record review, Patient #L3 was a 63 year old receiving serial treatments for Crohn's disease from the Infusion Center. The physician order for serial treatment was signed and dated, but did not contain a "time" the order was written.

4. Per record review, Patient #L4 was a 56 year old receiving serial treatments for Rheumatoid arthritis from the Infusion Center. The physician order for treatment was signed and dated, but did not contain a "time" the order was written.

5. Per record review, Patient #S2 was a 45 year old admitted on 11/29/2011 and who was placed into physical restraints on 11/30/2011. The "Medical Healing Restraint" order form was signed and dated by the physician, but the signature line did not contain a "time" of the action.

6. Per record review, Patient #S15 was a 28 year old admitted on 11/28/2011 and who was placed into physical restraints on 11/29/2011. The "Physician's Orders for Behavioral Restraints" form was signed by the physician, but the signature line date and time sections appeared to have been completed by the licensed nurse. The handwriting was an exact fit and did not match the physician's script style. Thus, the physician did not date and time his/her own signature block.

7. Per record review, Patient #S11 was a 69 year old admitted on 11/8/2011 and who had orders for physical restraints on 11/8/2011 at 7:40 AM. The "Physician's Orders for Behavioral Restraints" form was signed by the physician, but the signature line date and time sections appeared to have been completed by the licensed nurse. The handwriting was an exact fit and did not match the physician's script style. Thus, the physician did not date and time his/her own signature block.
The above process was repeated on the physician order sheet completed at 11:40 AM on 11/8/2011.

8. Per record review, the following patient records had incomplete physician orders related to no date and/or time on multiple orders Patient#s V4-V8, V11 and V12.



18001

Based on review of records the facility failed to assess pain levels or document actions taken to address pain for patients in various areas of the facility, according to their policy.

Failure to do so places patients at risk of suffering unnecessarily, prolonged recovery, and a diminished quality of life.

Findings include:

1. Per Staff #V5 the facility policy is to use one of several objective rating scales for evaluating the patient's experience of pain, and the effects of the interventions to relive the pain. All are based on a 1-10 scale, with "10" being the worst pain ever suffered.

2. Surveyor #2 on 12/15/11 reviewed medical records of eight patients who had undergone surgery and other interventions. For three of these (#s V5, V7, V11) staff did not document inquiring, or document doing so on an objective scale, and also did not consistently document results of any interventions.

3. Surveyor #3 reviewed an Emergency Department (ED) record on 12/13/11 which did not demonstrate assessment or treatment of high-level pain, and no notations were found in the record to explain the lack of attention to the patient's reported pain for Patient E#11. The patient reported at triage a pain score of 9 on a 1-10 scale on presentation to the ED. Though the physician wrote a prescription for pain medication upon discharge from the ED, nothing had been prescribed or given to the patient during his/her stay, and the only other pain assessment was done when the patient left. This assessment was identical to triage (9/10).

Based on observation the facility failed to ensure that the requirements of the State food service regulations were being followed. More specifically, Washington State Retail Food Code Working Document, Chapter 246-215 WAC, a modification of the 2001 FDA Food Code hereafter referred to as the "Working Document".

Failure on the part of the facility to implement the requirements of the food service regulations puts patients, staff and visitors of the facility at risk of food borne illness.

References: Washington State Retail Food Code Working Document, Chapter 246-215 Washington Administrative Code (WAC) Modification of 2001 FDA Food Code.

Findings include:

1. During a survey of the kitchen operation at the Specialty Center on 12/14/2011, at 10:20 AM, Surveyor #4 used the hospital's calibrated kitchen product thermometer to measured the cold foods in the sandwich refrigerator. Surveyor #4 observed that the ham slices and the tuna salad on the cold table were at 50 degrees Fahrenheit not at the required temperature of 41 degrees Fahrenheit or less. This finding (50 degrees F) was verified by dietary staff (L1) on 12/14/11 at 10:40 AM (see Chapter 3-501.16 Potentially Hazardous Food, Hot and Cold Holding).

2. On 12/14/2011, at 11:45 AM during a tour of the Specialty Center Kitchen Surveyor #4 observed frozen chicken tenders thawing in a pan under cold running water in the bottom of the three compartment sink. Surveyor #4 observed the three compartment sink was directly drained to the sewer without the proper air gap between the three compartment sink and the sewer waste drain. This allowed for the possible cross-contamination of any food in the bottom of the three compartment sink during a sewage back up. (see Chapter 5-402.11 Backflow Prevention)

3. On 12/14/2011, while in the Main Campus Kitchen, Surveyor #5 observed a food service employee L#2 in the process of preparing a breakfast meal. The employee left the preparation station to retrieve eggs from the refrigerator. While doing so the employee was wearing gloves which were not changed upon returning from the refrigerator. While still wearing the same gloves the employee once again left the preparation station and returned from the refrigerator with some ham. As before the employees gloves were not changed upon returning from the refrigerator. The employee then removed bread from a package while still wearing the same gloves that had made contact with a potentially contaminated surface i.e. the refrigerator door handle. (see Chapter 3-304.15 Gloves Use Limitation)

4. On 12/14/2011, while in the Main Campus Kitchen, Surveyor #5 observed a gloved food service employee L#3 in the process of replenishing sliced tomatoes (a ready to eat item). While doing so the employee made contact with the handle of a service cart (a potentially contaminated surface) and then the tomatoes. (see Chapter 3-304.15 Gloves Use Limitation)

5. On 12/14/2011, Surveyor #5 checked the calibration of analog stem thermometer by comparing its reading against the surveyor's digital stem thermometer (calibrated at the time of the comparison). The facility's thermometer and that of the surveyor were placed in a bath of ice water. The facility's thermometer gave a reading of 60 degrees Fahrenheit while that of the surveyor was 43 degrees Fahrenheit. (see Chapter 4-502.11 Good Repair and Calibration)

Based on observation the facility failed to adequately safeguard medical supplies so as to ensure that they are safe and protected against damage or contamination.

Failure on the part of the facility to ensure the safety and quality of medical supplies puts patients at risk of harm.

Findings include:

1. On 12/13/2011, Surveyor #5 noted that in the 2 Cedar pharmacy storage area that certain medical supplies (potassium chloride and sodium chloride) stored on pallets were located under a sewer line.

2. On 12/13/2011, Surveyor #5 noted in that in the 2 Cedar main storage area that various supplies were located under a sewer line(s).

Based on observation, interview, and record review, the facility failed in certain ways to develop and carry out a system for controlling infections.

Failure to do so places patients at risk of contracting health acquired infections, with resulting pain, suffering, increased costs, extended hospital stays, and potentially death.

Findings include:

Part I

On 12/13/11 between approximately 9:30 -10:40 AM Surveyor #2 observed preparations for and completion of an operative procedure. The following breaches of infection control were noted:
? Staff #V6 picked up a roll of tape from the floor without performing hand hygiene afterwards;
? Staff #V7 placed part of his/her hand inside the neck of the sharps container when discarding a syringe without performing hand hygiene afterwards;
? The patient "security strap" on the Operating Room (OR) table fell to the floor twice during preparation for the procedure, and without cleansing/disinfecting was wrapped around the patient;
? Staff #V8 lifted the linen hamper lid by hand rather than using the foot pedal and then changed gloves without performing hand hygiene. S/he then proceeded to have patient contact;
? Following the procedure Staff #V9 removed contaminated gown and gloves, did not perform hand hygiene, but donned new gloves and proceeded to wet a towel from the back table and wipe blood stains from patient;
? In the post anesthesia care unit Staff #V7 removed gloves without performing hand hygiene, then went to perform tasks at the drug dispensing cabinet and the patient record;
? Staff #V10 dropped the cap from a pen on the floor, retrieved it and put it back into use without disinfecting it or performing hand hygiene;
? Staff #V10 removed gloves without performing hand hygiene before proceeding with patient care;

Part II

1. On 12/12/11 Surveyor #2 observed a portable ultrasound machine brought to a patient care unit, to bring into a patient room to perform a test. The surveyor observed numerous fingerprint marks on the touch screen of the machine, as well sundry soiled or marked areas. The surveyor observed the tech cleaning the touch screen prior to taking it into the patient room, but was not able to continue watching what other cleansing might have taken place.

2. On 12/14/11 Surveyor #2 interviewed Staff #V11 regarding standard procedure for such situations. Staff #V11 stated that the machine was cleaned prior to entering a patient room (nothing was said about cleaning it when leaving the patient ' s room). S/he stated the areas of the machine cleaned included the patient interface and "high touch" areas. Observation of the machine, confirmed by Staff #V11, revealed numerous pitted, scratched areas, as well as areas where adhesive residue could not be removed, and raised the question as to how well the machine could be cleaned between patients.

Part III

On 12/14/11 Surveyor #2 observed full, clean oxygen e-tanks being stored, prior to patient use, in the dirty utility room, thereby resulting in a strong cross-contamination situation.

Part IV

On 12/13/2011 at approximately 3:00 PM, Surveyor #5 toured the surgical unit and noted a back pack on the floor of OR #3 near the anesthesia machine. At the time of the finding the surveyor was informed that it was the policy of the unit that personal items such as back packs needed to be placed in a cleanable bag (i.e. plastic bag.) The back pack noted was not in a cleanable bag.

Part V
On 12/13/2011, Surveyor #5 observed a Respiratory Therapist enter and leave two separate patient rooms on the 4th floor medical unit without "gelling" in or out (performing hand hygiene) as is required by policy.

Part VI
On 12/13/2011, Surveyor #5 observed Staff #V12 enter Room A402 which contained a patient under enteric precautions for Clostridium difficile. The physician entered the room without wearing gloves and a gown, as was required by policy, and then exited the room without washing his/her hands, also required by policy.

Based on record review of patients having undergone interventional procedures, the facility failed to document discharge instructions for 2 of 2 reviewed patients(Patients #'s V11 and V12).

Failure to do so renders the medical record incomplete and fails to document any preparations made or instructions given for post-hospital care.

Findings include:

On 12/14/11 records for two patients who received care in the Cardiac Cath and Interventional Radiology areas were reviewed by Surveyor #2. Each record documented that discharge instructions were reviewed with the patient and/or representative. However, the instructions given to the patient were not outlined in the record.

Based on record review of patients having undergone surgical procedures, the facility failed to document complete post-anesthesia evaluations for 6 of 6 records reviewed for this issue (Patients #'sV5-V10).

Failure to do so renders the medical record incomplete and fails to document any potential concerns related to anesthesia administration.

Findings include:

On 12/14/11 Surveyor #2 reviewed records for six patients who underwent surgery between 11/2-21/11. Each record contained an intra-operative anesthesia record that had a box measuring approximately 1" X 3" at the bottom to document the patient's condition on arrival in the recovery room. This box included spaces to document vital signs, level of consciousness, whether there had been any complications, and practitioner authentication.

Review of the six records found 3 of 6 were incompletely filled out. There were no spaces or cues to document other parameters of post-anesthesia recovery recommended as standard by the American Society of Anesthesiologists (which include airway patency, nausea, vomiting, pain, and hydration status). No further notations were found in the patient records which addressed the post-anesthesia evaluation of patient condition.