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Based on medical record review, policy review and staff interview the facility failed to ensure the nursing staff developed a nursing care plan for each patient. This affected eight patients of all medical records reviewed (Pt #10, 11, 12, 13, 14, 15, 16, and 17).

Findings include:

Review of policy number 1.66 titled "Emergency Department Nursing Standards Manual" completed on 10/04/12 revealed the nursing responsibilities in the provision of care at triage is to determine the patient's initial care plan and initiate advanced nursing interventions as applicable. This was verified by Staff E on 10/04/12 at 1:20 PM.

Review of medical record for Pt. #10 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of chest pain and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #11 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of laceration of middle finger and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #12 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of shaky/reaction and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #13 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of inflammation of right ear and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #14 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of eye pain and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #15 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of bronchitis and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #16 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of nausea/vomiting and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

Review of medical record for Pt. #17 completed on 10/02/12 revealed an emergency room visit date of 09/30/12 with a diagnosis of abdominal pain and a release date of 09/30/12, no nursing plan of care was noted in the patient record. This was verified by Staff D on 10/02/12.

The medical record review for Patient #32 was completed on 10/03/12. The 56 year old patient was admitted with a diagnosis of chronic obstructive pulmonary disease, sleep apnea and diabetes mellitus (high blood sugar). The nursing care plan did not list goals for diabetes mellitus. The patient had documented blood sugar readings ranging from 114 through 346 since his admission to the facility on 10/01/12. The American Diabetes Association suggests blood sugar target ranges of 70-130 mg/dl for adults with diabetes. Staff #A verified the findings on 10/03/12.

Review of the facility's policy number 5.14 Nursing Plan of Care was reviewed on 10/04/12. The policy stated the plan of care was to address active patient problems and be individualized based on the patient 's need.

Based on medical record review, policy review and interview, the facility failed to ensure consent for treatment was obtained for two (Patient #10 and #13) of 10 emergency department medical records reviewed. The facility's active census at the time of the survey was 193.
Findings include:
1.) The medical record review for Patient #10 was completed on 10/02/12. The patient was treated in the emergency department on 09/30/12 for a diagnosis of chest pain. The facility performed radiology procedures and laboratory tests on the patient on 09/30/12. The medical record did not have a signed consent for treatment.
2.) The medical record for Patient # 13 was completed on 10/02/12. The patient was treated in the emergency department on 09/30/12 for a diagnosis of ear infection. The facility completed an assessment of the patient and prescribed medications for the patient on 09/30/12. The medical record did not have a signed consent for treatment.
Staff #E verified the findings on 10/04/12.
The facility's policy number 5.1, Informed Consent was reviewed on 10/04/12. The policy stated all examinations or treatment procedures require the consent of the patient or someone authorized to consent on behalf of the patient. The policy states the general consent for the hospital services is to include consent to examine, touch and view the patient.

REMAINS CITED
Based on observation of medication pass, interview and policy review, the facility failed to use two forms of identification to identify one patient (Patient #41) of seven patients who received medication. The facility's active census at the time of the survey was 193.

Findings include:

Observation of a medication pass for Patient #41 was completed on 10/03/12. Staff G called the patient by name but did not identify the patient prior to the administration of a medication using two forms of patient identification.
Staff A witnessed and verified the findings on 10/03/12.
The facility's policy number 9.1 Medication Administration was reviewed on 10/04/12. The policy stated a patient must be identified prior to the administration of any medication using two forms of patient identification.

Based on review of dietary policy and procedure manual, interview of dietary managers, and tour of the dietary department it was determined the dietary director failed to ensure tray line temperature checks were completed per policy during each meal preparation. The hospital census was 193.

Findings include:

Tour of the dietary department was completed on the morning of 10/02/12 with food service management staff. Observation of the tray line occurred at noon. Interview of employee F revealed food temperatures are checked three times on the food line. Review of the tray line temperature logs measurement #6, for the month of September revealed checks were inconsistently recorded one or two times per meal with four meals having no temperature checks recorded as noted on 09/10/12 lunch, 09/17/12 lunch, 09/23/12 lunch, and 09/28/12 dinner. Missing documentation on the tray line temperature logs was verified by employee E on 10/04/12 at approximately 10:30 AM.

Based on the life safety code inspection conducted between 10/01/12 and 10/04/12, it was determined the hospital was not maintained in a manner safe from fire. This had the potential to affect all those utilizing the hospital's facilities. The patient census at the beginning of the survey was 193.

Findings include:

Please refer to the following Life safety code violations:

The facility failure to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating.
The facility failure to ensure the hazardous areas were constructed with at least a one hour fire resistance rating.
The facility failure to ensure exit access was arranged so that exits were readily accessible at all times in accordance with section 7.1.
The facility failure to ensure that patient room doors were arranged so that patients could open the door from inside without using a key.

The facility failure to ensure the automatic sprinkler system, provided complete coverage for all portions of the building specifically in regards to location of sprinkler heads mounted at least 18 inches above any possible obstruction.

The facility failure to ensure the sprinkler system, was continuously maintained in reliable operating condition in regards to cleaning dust and debris from the sprinkler heads and ensuring the escutcheon rings were in place.

The facility failure to ensure fire extinguishers were not obstructed from view and had monthly inspections according to the National Fire Protection Association (NFPA) 10 Chapter 1-6.6 and 4-3.4.2.

The facility failure to ensure the large mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were located in a room protected as a hazardous area when not attended.

The facility failure to properly store medical gases in accordance with the National Fire Protection Association requirements.

Additional life safety code deficient areas were noted with facility failure to conduct quarterly testing of the sprinkler system, the facility failure to complete quarterly fire drills at the ambulatory surgery center and improper storage under a stairwell.

Based on the life safety code inspection conducted between 10/01/12 and 10/04/12, it was determined the hospital was not maintained in a manner safe from fire. This had the potential to affect all those utilizing the hospital's facilities. The patient census at the beginning of the survey was 193.

Findings include:

Please refer to the following Life safety code violations:

K25, which addressed the facility failure to ensure that smoke/fire barriers were constructed to provide at least a half hour fire resistance rating.
K29, which addressed the facility failure to ensure the hazardous areas were constructed with at least a one hour fire resistance rating.
K38, which addressed the facility failure to ensure exit access was arranged so that exits were readily accessible at all times.

K43, which addressed the facility failure to ensure that patient room doors were arranged so that patients could open the door from inside without using a key.

K56, which addressed the facility failure to ensure the automatic sprinkler system, provided complete coverage for all portions of the building specifically in regards to location of sprinkler heads mounted at least 18 inches above any possible obstruction.

K62, which addressed the facility failure to ensure the sprinkler system, was continuously maintained in reliable operating condition in regards to cleaning dust and debris from the sprinkler heads and ensuring the escutcheon rings were in place.

K64, which addressed the facility failure to ensure fire extinguishers were not obstructed from view and had monthly inspections according to the National Fire Protection Association (NFPA) 10 Chapter 1-6.6 and 4-3.4.2.

K75, which addressed the facility failure to ensure the large mobile soiled linen or trash collection receptacles with capacities greater than 32 gal were located in a room protected as a hazardous area when not attended.

K76, which addressed facility failure to properly store medical gases in accordance with the National Fire Protection Association 99 requirements.

K130, which addressed additional deficient areas such as facility failure to conduct quarterly testing of the sprinkler system, the facility failure to complete quarterly fire drills at the ambulatory surgery center and improper storage under a stairwell.

Based on observation and policy review, the facility failed to develop and implement policies for the proper storage of trash for one of six facility floors observed.

Findings include:

Observation of the sixth floor utility room was completed on 10/02/12. The utility room had six large bags of trash sitting on the floor.
The facility's policy number 3.25, Solid Waste Removal was reviewed on 10/04/12, however, the policy failed to address procedure for proper trash storage prior to transportation.

Based on facility tour and staff interview the facility failed to check patient care items for expiration dates and dispose of the expired items. This affected all patients of the facility.

Findings include:

During the tour of the emergency department on 10/01/12 at approximately 4:30 PM, observation was made of expired items in a cabinet labeled "ER consultation forms". This included three 20 gauge angio caths with an expiration date of 06-2008, three 18 gauge angio caths with an expiration date of 09-2009, and five 18 gauge angio caths with an expiration date of 02-2012. This was verified by Staff A on 10/01/12 at approximately 4:45 PM.
During the tour of cleansing area/storage for the OR on 10/01/12 at approximately 1:55 PM, observation was made of one "medium viscosity bone cement" with an expiration date of 2012-06 located on a storage shelf. This was verified by Staff B on 10/01/12 at approximately 2:00 PM.

During tour of the intensive care unit, pod A, on 10/14/12 at approximately 9:35 AM, an observation was made of expired items in a lower storage cabinet of the medication room. This included one half of a box of 22 gauge "Portex Hyper-dermic needles" with an expiration date of 01-2012. This was verified by Staff C on 10/04/12 at approximately 9:40 AM.