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Based on observation, staff interview, documentation review and policy and procedure review, the hospital's Chief Executive Officer (CEO) failed to ensure the hospital environment was maintained for the safety of patients on three (3) of three (3) days of survey.


Findings Include:


Cross Refer to A0700 for the CEO's failure to ensure the hospital environment was maintained for the safety of patients.

Based on observation, staff interview, and policy review, the facility failed to ensure that Patient #4 received the correct dosage of six (6) of six (6) medications administered during a Medication (Med) Pass.


Findings Include:


Observation of the Medication Nurse during Med Pass on 09/28/16 at 10:05 a.m. revealed Patient #4 did not receive the correct dosage of six (6) of six (6) medications delivered per her PEG tube. The nurse crushed the medications separately in Tablet Crusher Pouches. When the medication nurse attempted to transfer the medications from the pouches, some of the medication adhered to the pouches and were not given to the patient. The medications were: Levofloxacin 250 milligrams (mg); Atorastin Calcium 10 mg; Aspirin 325 mg; Famotidine 20 mg; Amlodipine Besylate 5 mg; and Metroprolol Tartrate 50 mg.


During an interview on 09/29/16 at 2:00 p.m. the medication nurse indicated agreement with these findings.


Review of the facility's "Medication and Orders for Treatment" policy revealed: "...a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care profession, patient, or consumer. Such events may be related to professional practice, health care products, procedure, and systems which included dispensing and wrong dose preparation..."

Based on observation, staff interview, job description review, review of manufacturer guidelines, and policy and procedure review, the facility failed to ensure the hospital environment was maintained for the safety of patients during three (3) of three (3) days of survey.


Findings Include:


Observation of the Cat Scan (CT) Room on 09/27/16 at 3:34 p.m. revealed both entrance doors were unlocked and accessible from the main hallway. Patient care supplies, intravenous (IV) supplies and contrast were stored inside the room. No staff member was inside the CT room at the time of observation.


Observation of the Dirty Surgical Equipment room on 09/27/16 at 3:40 p.m. revealed the entrance door was unlocked and accessible from the main hallway. A sign taped to the door read "Enter this door to leave dirty contaminated instruments". A wall sign beside the door read "Decontamination Staff Only". During the observation the Surgery Patient Care Manager stated that the equipment decontamination room door was left unlocked so the Emergency Room staff could get to patient care supplies in the sterile supply room.


Observation of the Sterile Surgical Equipment room on 09/27/16 at 3:42 p.m. revealed the door was unlocked and accessible from the main hallway. A sign on the door read "Please Keep Door Closed; Only Surgery Staff and Patient Care Supervisors Allowed In Sterile Supply Department". A wall sign read "Sterile Supply".


Observation of the Surgical Suite on 09/27/16 at 3:44 p.m. revealed the entrance door to the Surgical Suite was unlocked during procedure hours and accessible from the main hallway. A sign on door read "Surgery Authorized Personnel Only". During the observation the Surgery Patient Care Manager stated that the department was open three (3) days a week, Monday, Tuesday and Wednesday when procedures were scheduled. She also stated, "The Sterile Supply and Surgical Suite doors are locked when the staff are finished working each day."


Observation of the Laboratory Department on 09/27/16 at 3:50 p.m. revealed that the entrance door was unlocked and accessible from the main hallway. A sign on the door read "Laboratory Authorized Personnel Only. Please continue to the door next to Respiratory and ring the doorbell."


During an interview on 09/27/16 at 3:52 p.m. the Administrator confirmed all observations and stated, "The facility doors have been like this for years."


Observation of the Acute/Swing Bed Floor on 9/28/16 from 9:40 a.m. to 11:33 a.m. revealed:
Room #2003 had a one (1) to two (2) inch break in the wall paper and plaster behind the patient bed.
Room #2045 was used for Swing bed Activities. The room had no door sign indicating this was an Activity Room.
Room #2047 had a broken ceiling tile.
The "Storage Room" had an unsecured oxygen cylinder stored in room.
The Doctors Lounge door was unlocked and accessible from the main hallway.
The Housekeeping room had no door signage
On the second floor there were two (2) sets of double doors that separated the hospital medical surgical floor from a physician's clinic which was located on the second floor of the hospital. There was no observable security measure on the doors restricting entrance to or from the hospital.


Observation of the Radiology Department on 09/28/16 from 10:15 a.m. to 10:45 a.m. revealed:
The Mammography Film Storage Room had three (3) ceiling tiles with brown colored stains and/or broken ceiling tiles. The movable filing cabinets housing the films were located within 18 inches of the sprinkler heads;
The Ultrasound room had a broken ceiling tile;
The Storage Room had no sign on the door;
The Nuclear "Hot Lab" had no sign on the door;
The Patient Dressing room door had no sign; and
The stairwell door located in the Radiology Treatment area was unlocked making this area accessible from the stairwell.
During these observations the Radiology Director stated that visitors had in the past entered the Radiology Department when patients were receiving treatment.


Observation of the Nuclear Treatment area, made with the Radiology Director on 09/28/16 at 10:55 a.m., revealed the door was unlocked and accessible from the main hallway. The sign on the door stated "Authorized Personnel Only". The Stress Test room was located across the hall from the Nuclear Test room. A door leading to the Surgical Suite was unlocked and accessible upon entrance to the Nuclear Treatment area. The Radiology Director confirmed these observations.



Observation of the CT room on 09/28/16 at 11:05 a.m. revealed patient care supplies and equipment continued to be stored inside the room. A 500ml primed saline bag, dated 09/28/16, was observed hanging on a pole with the tubing left exposed in the air. When the Radiology Director was asked what the saline bag was used for and why it was left hanging there she stated, "It is used as a saline flush with the CT injector equipment. We (the facility) were instructed by the manufacturer that we could use the same saline bag for multiple patients for up to 12 hours, so we have been doing this."

Review of the manufacturer guidelines for saline bags, revised: 06/2014, revealed: "...Description: Sodium Chloride Injection, USP solutions are sterile ...The solutions contain no bacteriostat, antimicrobial agent or added buffer and each is intended only as a single-dose injection. When smaller doses are required the unused portion should be discarded ...".

Review of the manufacturer guidelines for the CT Injector, dated: 11/2014, revealed: " ...Photo depicts the use of a single dose saline bag ...".

Review of the facility's "CT Injector" policy, revealed no directions on the use of saline bags. There was no effective date on the policy.

Review of the facility's "Dual Head Injector (CT Injector)" policy, dated: 09/28/16, revealed: "A new saline bag ...and connector kit must be utilized for each patient receiving IV contrast ...Remove saline ...".




Observation of the Respiratory Department on 09/28/16 at 11:18 a.m. revealed there was no sign on the General Respiratory Supply door. During this observation the Respiratory Director stated that all supplies were disposable except for the Christmas Tree Adapters (oxygen connectors).

Review of the manufacturer guidelines for oxygen connectors, per email response dated 09/28/16, revealed: "...Subject: Email Per Your Request Christmas Tree Adaptor (Oxygen Connector) ...We (Customer Service) confirmed with the manufacturer that item...(oxygen connector) is disposable so a one-time use only ...and that this item it not reusable ...".

Review of the facility's "Respiratory Care Services Oxygen Connector" policy, revealed: "A. ...oxygen connectors are a single use patient item. They will be removed from the oxygen flowmeter, at the time of discharge ...B. New ...oxygen connectors will be placed on the oxygen connector, when oxygen is applied to a patient ...".



Observation of the Materials Management Department Supply Storage room on 09/28/16 at 11:28 a.m. revealed the door to the loading dock was left unlocked and accessible from outside the building. No staff member was present at the time of observation.


Observation on 09/28/16 at 3:20 p.m., made with the Administrator, revealed that the Exit double doors, located on the first floor by Administration, were unlocked. The Administrator confirmed the double doors were unlocked and stated that they were left open from 8:00 a.m. to 10:00 p.m. each day.


Review of the facility's "Surgery Patient Care Manager" Job Description, dated: 09/24/14, revealed: "Job Summary: The Nurse Manager is accountable and responsible for managing and guiding all the activities of the unit including, but not limited to, the staff, environment, patients ...".


Review of the facility's "Director of Nurses" Job Description, dated: 10/01/14, revealed: "Job Summary: The DON is accountable and responsible, under the direct supervision of the Administrator, for the overall coordination and direction of all nursing activities ...".


Review of the facility's "General Maintenance Mechanic" Job Description, dated: 10/10/11, revealed: "Job Summary: Constructs and maintains structural woodwork ...repairs broken furniture ...and other items..replacing ...maintaining proper operation of all doors and door closures ...cleaning and performing repairs to electrical fixtures. Replaces ...ceiling tile. Performs related duties as needed ....".


Review of the facility's "Surgery Manual", reviewed: 07/28/16, revealed: " ...Section: Central Sterile ... 2. Asepsis principles: ...C. Sterile items will be stored in a controlled environment, in all areas, to maintain optimum conditions to assure sterility of all items ... 3. Dress Code: A. Central Sterile is a controlled environment. Only authorized personnel, therefore, may enter the area for processing instruments and supplies ... L. Visitors, outside service or maintenance personnel, or anyone not in a staff capacity who enter the department must adhere to the following: 1) Wear a scrub suit, cover gown, or disposable jumpsuit, shoe covers and cap, while in the restricted area of Central Sterile Processing ... 5. Traffic Control in CSP (Central Sterile Supply): A. Central Sterile is divided into 2 main side; 1) Decontamination 2) Sterile Processing and Supply. B. Both sides of CSP and Sterile Supply are considered a controlled environment. Only authorized staff in appropriate attire will be allowed in these areas ... 11. Doors to the department and decontamination will remain closed at all times ... Section: Pre-Operative and Surgical Services ...Traffic Control: Purpose - The purpose of this policy is to identify the ...restricted areas of the OR (Operating Room) suite. Policy - The surgical suite is divided into three areas: ...2. Semi-restricted. 3. Restricted. These areas must be monitored and maintained to avoid contamination of the area. Procedure: ... 2. Semi-restricted areas include storage areas for clean and sterile supplies, PACU, and Surgery desk ... Proper surgical attire including clean scrub attire, caps to completely cover head will be worn. 3. Restricted areas include the operating rooms and scrub sink areas ...Traffic will be limited in these areas. 4. Traffic in the OR will be monitored by the OR staff. 5. Surgery is identified by doors which are clearly marked. Only authorized personnel will be permitted. 6. All traffic within the OR Suite is kept to a minimum."


During Exit Conference on 09/29/16 at 3:00 p.m. these findings were discussed. No further documentation was submitted for review.

Based on observation, staff interview, job description review, review of manufacturer guidelines, and policy and procedure review, the facility failed to ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of all patients.


Findings Include:


Cross Refer to A0700 for the facility's failure to ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner to ensure the safety and well being of all patients.

Based on observation, staff interview, job description review, review of manufacturer guidelines, and policy and procedure review, the facility failed to ensure patient care supplies and/or equipment was stored in a manner to ensure safety from theft, damage and/or contamination during three (3) of three (3) days of survey.


Findings Include:


Cross Refer to A0700 for the facility's failure to ensure patient care supplies and/or equipment used for patient treatment in the Cat Scan (CT) room, Surgical Sterile Supply room, Surgical Decontamination Equipment room and Materials Management was maintained and safe from theft, damage and/or contamination.

Based on observation, staff interview, job description review, review of manufacturer guidelines, and policy and procedure review, the facility:
1. failed to ensure respiratory staff and/or clinical staff followed manufacturer guidelines for patient care when using oxygen connectors on three (3) of three (3) days of survey; and
2. failed to ensure radiology clinical staff followed manufacturer guidelines when using saline bags in the Cat Scan (CT) room on one (1) of three (3) days of survey.


Findings Include:


Observation of the Cat Scan (CT) room, made with the Director of Nurses (DON) on 09/28/16 at 11:05 a.m., revealed patient care supplies and equipment were stored inside the room. A 500ml (milliliter) primed saline bag, dated 09/28/16, was observed hanging on a pole with the tubing left exposed in the air. When the Radiology Director was asked what the saline bag was used for and why it was left hanging there she stated, "It is used as a saline flush with the CT injector equipment. We (the facility) were instructed by the manufacturer that we could use the same saline bag for multiple patients for up to 12 hours, so we have been doing this." The DON confirmed these observations.

Review of the manufacturer guidelines for saline bags, revised: 06/2014, revealed: "...Description: Sodium Chloride Injection, USP solutions are sterile ...The solutions contain no bacteriostat, antimicrobial agent or added buffer and each is intended only as a single-dose injection. When smaller doses are required the unused portion should be discarded ...".

Review of the manufacturer guidelines for the CT Injector, dated: 11/2014, revealed: " ...Photo depicts the use of a single dose saline bag ...".

Review of the facility's "CT Injector" policy, revealed no directions on the use of saline bags. There was no effective date on the policy.

Review of the facility's "Dual Head Injector (CT Injector)" policy, dated: 09/28/16, revealed: "A new saline bag ...and connector kit must be utilized for each patient receiving IV contrast ...Remove saline ...".



During observations in the Respiratory Department, on 09/28/16 at 11:18 a.m., the Respiratory Director stated that all supplies were disposable except for the Christmas Tree Adaptors (Oxygen Connectors).

Review of the manufacturer guidelines for oxygen connectors, per email response dated 09/28/16, revealed: "...Subject: Email Per Your Request Christmas Tree Adaptor (Oxygen Connector) ...We (Customer Service) confirmed with the manufacturer that item...(oxygen connector) is disposable so a one-time use only ...and that this item it not reusable ...".

Review of the facility's "Respiratory Care Services Oxygen Connector)" policy, revealed: "A ...oxygen connectors are a single use patient item. They will be removed from the oxygen flowmeter, at the time of discharge ...B. New ...oxygen connectors will be placed on the oxygen connector, when oxygen is applied to a patient ...".



Review of the facility's "Radiology Director" Job Description, approved on 10/10/14, revealed: "Job Summary: Directly ...responsible for the overall direction ...supervision, instruction ...of professional and supportive staff ...Additionally responsible for the monitoring of all patient care programs, policies and procedures ...to ensure quality patient care ...".


Review of the facility's "Respiratory Therapy Director" Job Description, approved on 10/19/15, revealed: "Job Summary: Plans, organizes ...directs staff; controls department operation ...and activities. Insures quality patient care in maintained ...provide the care needed as described in the department's policies and procedures ...".



No further facility documentation was submitted for review during Exit Conference on 09/29/16 at 3:00 p.m.

Based on observation, staff interview, job description review, review of manufacturer guidelines, and policy and procedure review, the facility failed to ensure the control of infections during three (3) of three (3) days of survey.


Findings Include:

Cross Refer A0747 for the facility's failure to ensure respiratory, radiology and/or clinical staff followed manufacturer guidelines for patient care when using oxygen connectors and/or patient care guidelines when using saline bags in the CT (Cat Scan) room.

Based on activity calendar review, staff interview, and policy and procedure review, the facility failed to have an ongoing program of activities.


Findings Include:


Review of copies of the facility's activity calendars revealed "Family Time" was the only recorded activity for the weekends from January-September of 2016.

During an interview with the Activity Coordinator on 09/27/16 at 2:50 p.m. she stated that weekend activities consist of family visitation.

Review of the facility's "Activity Policy No. 2" revealed, "A program of activities shall be planned for each day of the week."