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Based on review of Hospital policy, clinical records and staff interview, it was determined that for 2 of 8 (Pt. # 10 and #2) records reviewed with consents for procedures, the Hospital failed to ensure all consents were completed and signed by the physician as required by policy.

Findings include:

1. The Hospital policy titled "Consents and Authorizations" (last reviewed 3/11) required, "...Responsibilities of the Physician/Practitioner...The physician /practitioner shall provide the following information to the patients or the patient's Authorized Representative...the Physician/ practitioner performing the medical surgical Procedure or treatment shall sign the Informed consent form prior to the beginning of the procedure."

2. The clinical record of Pt. #10 was reviewed on 5/29/12 at approximately 10:40 AM while on the 3 East medical Unit. Pt. #10 was an 82 year old female admitted on 5/6/12 with a diagnosis of Acute Respiratory Distress. The record contained 2 incomplete consent forms:

*5/8/12 - Consent for blood transfusion lacked the date, time and the physician's signature.

*5/22/12 - Consent for Thoracentesis lacked the date, time and the physician's signature.

3. The clinical record of Pt #3 was reviewed on 5/29/12 at approximately 10:30 AM while on the Oncology Unit. Pt #3 was a 39 year old female admitted on 5/11/12 with diagnoses of Dyspnea, Anemia, and history of Colon Cancer. The record contained an incomplete blood consent:

* The consent for blood transfusion for Pt. #3 dated 5/20/12 lacked the physician's signature, date and time attesting to the fact that the transfusion was discussed with the patient.

4. The Nurse Manager of 3 East Medical Renal Unit was interviewed on 5/29/12 at approximately 11:30 AM. The Manager stated that the the consents should have been signed, dated and timed by the physician.

5. The Director of Adult Services stated during an interview on 5/29/12 at approximately 10:30 AM that Pt #3 that the consent lacked the physician's signature attesting to the fact that he had discussed the transfusion with the patient.

Based on clinical record review, Hospital policy, and staff interview, it was determined that in 1 of 8 (Pt #3) clinical records reviewed of patients that received blood product transfusions, the Hospital failed to ensure the transfusions were administered as ordered by the physician.

Findings include:

1. The clinical record of Pt #3 was reviewed on 5/29/12 at approximately 10:30 AM. Pt #3 was a 39 year old female admitted on 5/11/12 with diagnoses of Dyspnea, Anemia, and history of Colon Cancer. The clinical record contained a physician's order dated 5/20/12 that included, "type and cross 2 units packed red blood cells, transfused over 4 hours each." The transfusion records indicated that the first unit, #12 602440, was initiated on 5/20/12 at 4:30 PM and was completed at 7:40 PM (3 hours and 10 minutes). The second unit, #12 602448, was initiated at 10:00 PM and completed at 12:30 AM on 5/21/12 (2 hours and 35 minutes).

2. Hospital policy titled, "1110 Blood and Products," (last reviewed 4/2010) reviewed on 5/29/12 at approximately 11:20 AM included, "Guidelines:..E. Infusion (per unit)..5. Start the infusion slowly for 15 minutes or so, as ordered by the physician, then regulate the rate of flow according to the physician's orders..."

3. The Director of Adult Services stated during an interview on 5/29/12 at approximately 10:30 AM that Pt #3 did not receive her blood transfusion as ordered by the physician.

Based on review of the Hospital's Medical Staff Bylaws, Rules and Regulations, policy, documentation from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Bylaws, Rules and Regulations (approved on 6/23/11) reviewed on 5/30/12 at approximately 8:30 AM required, "...VIII.7 Automatic Suspensions:..4. Failure to Complete Medical Records. Medical records shall be completed within time periods stated in Medical Staff Rules, Regulations, and/or Policies."

2. Hospital policy entitled, "E. Health Information Services Department," (revised 1/27/11) reviewed on 5/30/12 at approximately 8:45 AM required, "B. Record Completion Process - medical records must be completed within 30 days of patient's discharge."

3. On 5/30/12 at approximately 10:40 AM, the Manager of Health Information System presented an attestation letter that included, "As of May 30, 2012, there are a total of 21 records identified as delinquent."

4. The Manager of Health Information System stated during an interview on 5/30/12 at approximately 10:40 AM that there are a total of 21 delinquent records.

Based on an observational tour, review of Hospital signage, and staff interview, it was determined, that for 8 of 25 open spice containers, 2 of 20 food containers, and 1 of 5 cooking pans, the Hospital failed to label food containers and properly clean equipment, potentially affecting 217 patients on census on 5/31/12.

Findings include:

1. On 5/31/12 between 9:50 AM and 10:50 AM, an observational tour was conducted in the dietary department with the Clinical Nutrition Coordinator. The following was observed -

- The dry storage room 8 of 25 open spice containers (Cajun Seasoning, Curry Power, Cayenne Pepper, White Pepper, Ground Mustard, Black Pepper, Thyme Leaves, and Cumin) did not include the date opened.

- The thaw and prep cooler 2 of 20 food containers (Chicken with Peppers and Carrots) were not covered.

- One (1) of 5 deep half pans, identified as "clean" contained a dried white substance.

2. A sign on the spice shelf in the dry storage area, dated 2/9/12, included, "Please fill in 'open' sticker when opening a new spice. Spices will be discarded after 1 year."

3. An interview was conducted during the tour with the Clinical Nutrition Coordinator on 5/31/12 between 9:50 AM and 10:50 AM. The Coordinator stated that the spice containers should have been dated, the food containers should have been covered, and the pan was not clean.

This was found in OR #2 -

3. A microscope table contained tape, tape residue and dust.

This was found in OR #17 -

4. The floor and walls contained nicks and cuts.

5. An interview was conducted with the OR Manager on 5/30/12 at 8:15 AM. The Manager stated the microscope table was dusty, the floor and walls did contain nicks/cuts and the stool was damaged.











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Based on observation and review of Hospital policy, it was determined that for 3 of 5 (OR #s 8, 2 and 17) operating rooms, the Hospital failed to ensure a sanitary environment.

Findings include:

1. During a tour of the Surgical Suite, conducted on 5/30/12 between approximately 6:30 AM and 8:30 AM, the following was observed:

- At 7:00 AM, in OR #8, a stool was observed with a leather seat that was torn at the edges with the foam cushion exposed and duct tape across the top rendering it unable to be effectively cleansed.

2. The Hospital policy entitled "Operating Room (OR) Sanitation" (reviewed 08/2009) required, "Furniture and equipment...should be scrubbed with a detergent-germicide solution and good mechanical friction."

Based on observation, Hospital policy, and staff interview, it was determined that for 1 of 1 anesthesiologist (A1) in Operating Room #8 (OR #8), the Hospital failed to ensure staff adherence to medication administration in accordance with policy.

Findings include:

1. The following was observed in OR #8:

- At 7:38 AM, A1 inserted the needle of a syringe into a medication vial without first cleansing the rubber stopper with an alcohol wipe.

2. The Hospital policy entitled, "Multi-Dose Medication Vial Handling and Dating" (reviewed 4/2010), required, "The rubber septum of the vial will be wiped vigorously with alcohol and allowed to dry prior to entry."

3. An interview was conducted with the Director of Surgical Services on 5/30/12 at approximately 8:30 AM. The Director stated that the Hospital's practice includes that medication vial rubber stoppers must be cleansed with alcohol prior to entry.