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Based on observation and interview the facility failed to ensure the confidentiality of patient records in the Emergency Department. Findings include:

On 2/8/10 at approximately 12:30 pm while touring the Emergency Department with the Emergency Department Medical Director and Clinical Manager a clipboard containing patient information was observed hanging outside of each patient room on the wall adjacent to the doorway. The clipboards contained patient's registration consents, patient information stickers used to label records and specimens, the physician history and physical, and an EMS record if applicable. It was confirmed by the Clinical Manager at the time of the observation, that the clipboards are a hard copy of the patient's medical record . The Clinical Manager stated "the charts usually hang outside the patient room or around the physician's station".

Based on record review and interview, it was determined that the facility failed to ensure that medical records were completed within the 30 day timeframe. Findings include:

On 2/9/10 at approximately 12:10 pm during record review, it was determined that 48 of 58 medical records were found to be incomplete regarding discharge summaries, emergency treatment notes, operative reports, history and physicals that were pending dictations and/or signatures. Interview with the Health Information Director confirmed the medical record omissions.

During tour of 5 East on 02/08/2010 at 12:12 PM, the tub room for bathing burn patients contained an opened 500ml bottle of Normal Saline and written on the label was "Epi "and dated 12/12. No other information was available. During interview with the 5th flour Manager at time of tour, she confirmed the findings. Review of DMC policy no:2 PC 1201 titled "Infection Control: Patient Care Services" reads under Medication Supplies 2. Sterile water or normal saline used for care at the bedside must be disposed of by 24 hours after opening. In addition policy no: 2 MED 500 EMR titled "Medication Orders, Administration and Documentation" reads under 5. In procedural areas, if a medication is transfered from its original container into another container (i.e.' from a vial to a syringe, from a syringe to a basin on the sterile field), the secondary container must be labeled with medication name and dose.


28267

Based on observation, interview and record review, the facility failed to ensure that outdated medications were not available for patient use. Findings include:

During tour of the General Pediatric Clinic (GPC) on 02/09/2010 at 11:40 AM with the RN Coordinator, the medication room refrigerator contained 1-vial of Tuberculin vaccine opened 11/09/2009 and 1-bottle of Poliovirus vaccine that was opened and not dated. The vaccine refrigerator contained 15 boxes of Flumist vaccine that had expired 01/15/2010. During interview with the RN Clinic Coordinator at the time of tour, she confirmed the findings.

Review of DMC policy no: 2 MED 113 titled "Multidose Vials and Multi-Use Medication Packaging Available in Patient Care Areas" reads under Provisions:
1) "A. 2. All vials must be dated upon opening and/or when dispensed by pharmacy."
2) "A.4. Multidose vials of medication for intramuscular, subcutaneous, or intradermal injections are to be disposed of within 28 days or according to the manufacture' recommendation, whichever is less."
3) "A.5. Vaccines are to be discarded according to the manufacture expiration date on the vial unless obviously contaminated."

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 on observation, the facility failed to maintain the hospital environment to assure the safety of patients.

Findings include:
On 2/9/10 during a tour of the hospital, the following damage was observed: plastic laminate countertop damage in the Pharmacy, plastic laminate damage in the Immunology Lab, floor coving damage in the corridor outside of the Pharmacy.
On 2/10/10 during a tour of the hospital, the ice machine in the pre/post operative area was observed to not have an approved air gap for the sewage drain line.
On 2/10/10, the janitor closet in the pre/post operative area was observed to have a chemical dispensing system improperly attached to the mop sink faucet with a built in atmospheric vacuum breaker.
On 2/10/10, the HVAC system installed in the Sterile Core between Operating Rooms #2 and #3 was observed to not have the duct properly sealed to the ceiling.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on February 8-11, 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 February 11, 2010, for Life Safety Code.

In the 5 east medication room were 6-Kattostate dressings that were outdated 2/2008. During interview with the 5th flour Manager at time of tour, she confirmed the findings.


28267

Based on observation and interview, the facility failed to ensure that supplies are maintained at an acceptable level. Findings include:

During tour of the Allergy/Immunology/Rheumatology Clinic on 02/09/10 at 10:30 AM, the lab area contained 6 blue top tubes used for blood specimens that outdated on 11/2009 and a box of approximately 50 Hemocult slides expired 7/09. Findings were confirmed by the Allergy/Immunology/Rheumatology Clinic Manager.

During a tour of the Pre-op area on 02/11/2009 at 11:10 AM, the drawer containing tubes used for blood draw specimens, there were 3 serum seperator tubes that were outdated (2-11/09 and 1-6/09). Findings were confirmed by Interm Manager Sameday Surgery and Recovery.




28273

Based on observation and interview the facility failed to provide a sanitary environment. Findings include:

On 2/8/10 between 10:00 am and 1:30 pm while touring the facility with the Emergency Department Medical Director as guide the following was observed:

4 East-Neonatal Units

A large drawer at the nursing work station between rooms Room 408 A and 408 B contained open, empty, and uncapped syringes sized, 0.5 cc, 1cc, 3cc, 5cc, 30cc, and 60 cc placed in compartments from bulk supply that are used for oral medications. This was confirmed by the Clinical Manager for 4 East.
During the observation RN # 1, stated that the drawers are accessed with bare hands, refilled from a bulk supply from a large plastic bag with bare hands and that the uncapped syringes are used for oral medications on the neonatal patients. A couple of pieces of material that was not a syringe was located in the 3 cc uncapped syringe compartment, she stated that no other material is to be located inside the compartments.

Room 406 A and 406 B had paper and materials on floor, which was more concentrated near the trash receptacle in the patient care area. In addition, a large drawer at the nursing work station between rooms there were open, empty, and uncapped syringes sized, 0.5 cc, 1cc, 3cc, 5cc, 30cc, and 60 cc placed in compartments from bulk supply that are used for oral medications. This was confirmed by the Clinical Manager for 4 East.

Emergency Department

Noted on top of every Pyxis station (medication delivery area) on a flat surface are 3 clear containers that hold open, empty, and uncapped syringes. Each container has a specific size syringe, 3cc, 5cc, and 10cc. In the Starfish pod on top of the pyxis machine the container that held the 10cc uncapped syringes was cracked and held together with tape. In the Turtle pod on top of the pyxis machine in the container that held the 3cc uncapped syringes had caps and a pencil at the bottom of the container. The observation was confirmed by the Emergency Department Clinical Manager. The ED Clinical Manager stated that the syringes located in the containers are used for oral medications for the patients.


28273

During tour of the General Pediatric Clinic on 02/09/2010 at 11:45 AM, a refrigerator containing vaccines was observed to have 5 food items; 2 items in the freezer section (a container of strawberries, a container of pineapple) and 3 items in the refrigerator door (2 containers of sealed yogurt, and a styrofoam cut with tan liquid) inside of it.

Policy no: 3 CHM ADM 008 titled " Food and Beverage Consumption" under Provisions that apply to employees states: "4. Food and beverages must be stored in designated employee refrigerators and never with specimens or medications."

Based on observation, it was determined that the facility failed to develop a system for controlling infections and communicable diseases of patients and personnel.

Findings include:
On 2/9/10 and 2/10/10, by observation, surfaces throughout the facility were observed with an accumulation of dust. The surfaces included sloped tops on cabinets throughout the facility, tops of equipment throughout the facility, a fan in the dishroom of the kitchen, and underneath shelving in several storage rooms throughout.

On 2/10/10 by observation, the storage room across from the "Visteon Playroom" is contained in a mechanical room with exposed ductwork, which is not easily cleanable. Dust and debris accumulation was also observed on high surfaces in this area.

Based on record review and interview the facility failed to ensure that the "Gift of Life(GOL)Notification/Declaration of Death" document was completed in 7 out of 14 closed medical records, by hospital staff in regards to improving the identification of potential donors (Patients #13, #14, #15, #16, #17, #20, # and #38). Findings include:

Patient #13's chart, the GOL document was not completed by the physician. Date of death was 10-05-09.

Patient #14's chart, the GOL document was not completed by the nurse. Date of death was 08-05-09.

Patient #15's chart, the GOL document was not found in the closed medical record. Date of death was 05-12-09.

Patient #16's chart, the GOL document was not completed by the physician. Date of death was 11-24-09.

Patient #17's chart,the GOL document was not completed by the nurse. Date of death was 09-19-09.

Patient #20's chart,the GOL document was not completed by the nurse. Date of death was 08-16-09

Patient #38's chart, the GOL document was not found in the closed medical record. Date of death was 10-05-09.

Interview with the Director of Transplantation and the Director of the Emergency Department on 2/09/10 at 9:10am, they confirmed that the records were incomplete.