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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on June 29, 2015, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation, document review, and interview, it was determined for 3 of 3 food thermometers in the dietary department, the facility failed to ensure food safety by developing and utilizing policy/program to track food thermometer calibration/preventive maintence. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. During a observational tour of the dietary department, conducted on 6/2/15 at 8:30 AM, three stem type food thermometers available for staff use was noted.

2. The policy titled "Calibrating a Thermometer" (no revised/reviewed date) was reviewed 6/2/15 at approximately 2:00 PM. Policy required "There are two ways to check the accuracy of a food thermometer...ice water and the other uses boiling water."

3. The document titled "Center for Disease Control and Prevention: Food Preparation and Service (October 2003)" was reviewed on 6/4/14 at 11:00 AM. Document required, "Stem type product thermometer: a thermometer with a dial that reveals temperature by one to two degrees. The shaft on the thermometer can enter the product to ascertain temperature...stem type thermometer been used to monitor the proper internal cooking temperature... All stages must be monitored to prevent forborne illness...An effective preventive maintence and calibration program ensures that equipment that could impact food safety the way it should, and does not present food safety hazards."

4. During an interview with the Manager of Dietary Department (E #11) on 6/2/15 at 8:45 AM, E #11 stated, "We calibrate the food thermometers every month, but we don't keep track or document those readings. We don't have a policy on preventive maintences or calibration of food thermometers."

A. Based on observation, document review, and interview the Hospital failed in 1 of 2 radiology department x-ray rooms to ensure cleaning supplies were securely stored. This has the potential to affect all patients receiving radiology services at the hospital.

1. On 6/2/15 at approximately 9:00 AM an observational tour was conducted in the radiology department. X-ray room #2 contained an opened one gallon container of equipment disinfectant in an unlocked floor level cabinet.

2. On 6/2/15 at approximately 1:45 PM, the document titled, "Material Safety Data Sheet" for the above mentioned disinfectant, (issued 11/14/07) was reviewed. The document required "Toxic if swallowed. Irritating to eyes, skin, and respiratory tract...if ingested seek medical attention immediately."

3. During an interview with the Manager of Radiology (E #10) conducted 6/2/15 at 9:15 AM, E #10 stated, "Patients are left unattended in the exam rooms and there was nothing preventing a patient from accessing the cleaning chemicals."

A. Based on observation, document review, and interview the Hospital failed in 2 of 2 medical clinic exam rooms to ensure patient care areas were clean and sanitary. This has the potential to affect all patients receiving care at the hospital.

1. On 6/2/15 at approximately 11:00 AM an observational tour was conducted in the medical clinic. Cabinet under the sinks in exam rooms #1 and #2 had a film of black substance on entire surfaces, which could be removed by a disinfected wipe.

2. On 6/2/15 at approximately 2:45 PM, the policy titled, "Housekeeping " (no revised/reviewed date) was reviewed. The document required "wipe off and disinfect all counter tops and sinks...dust and wipe down all furniture and equipment. "

3. During an interview with the Chief Nursing Officer (E #1) conducted 6/2/15 at 11:15 AM, E #1 stated, "The areas under the sinks are dirty and need cleaned. "

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on June 29, 2015, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined the Hospital failed to ensure yearly performance evaluations were completed for 2 of 9 ( E # 18, E #19) personnel records reviewed.

Findings include:

1. On 6/3/15 at approximately 11:00 AM, the Respiratory Therapist ' s (E #18) personnel file was reviewed. E #18 lacked a performance evaluation since 7/2013.

2. On 6/3/15 at approximately 11:15 AM, the Speech Therapist ' s (E #19) personnel file was reviewed. E #19 lacked a performance evaluation since 9/2013.

3. On 6/3/15 at approximately 3:00 PM, the policy titled, "Employee Hand Book " was reviewed. The policy required "Performance Evaluation: Performance evaluations will be completed...All employees will receive an annual performance evaluation. "

4. During an interview with the Medical Records Executive Assistant (E #14) conducted 6/3/15 at 11:30 AM, E #14 stated, "We do not have current annual performance evaluations for E #18 and E #19. "

Based on observation, document review, and interview, it was determined in the laboratory department, the Hospital failed to ensure outdated biologicals were not available for patient use. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. On 6/2/15 at approximately 7:45 AM an observational tour was conducted in the laboratory department. One 16 ounce bottle of glycerin with an open date of 2/8/06 had an expiration date of 10/10.

2. On 6/2/15 at approximately 3:15 PM, the policy titled, "Pharmacy-Beyond Use Date " ( revised 3/13) was reviewed. The policy required "Expired medications will be removed from patient supply and disposed of per protocol for expired medications. "

3. During an interview with the Manager of Laboratory Department (E #12) conducted 6/2/15 at 8:15 AM, E #12 stated, "Expired medication should have been removed and disposed. "

A. Based on observation, document review, and interview, it was determined for 2 of 5 (x-ray room #1, ultrasound room) procedure rooms in the radiology department and for 1 of 2 phlebotomy stations in the laboratory department, the Hospital failed to ensure potentially contaminated equipment was disinfected. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. On 6/2/15 at approximately 7:45 AM an observational tour was conducted in the laboratory department. One phlebotomy station (lab draw cart) contained two 2 inch by 2 inch red stains on the side of the phlebotomy station, which could be removed with a disinfectant wipe.

2. On 6/2/15 at approximately 9:00 AM an observational tour was conducted in the radiology department. X-ray room #1 contained a wheelchair with cracked material on both arms. Ultrasound room contained a bedside table tray in the sonogram room with brown red stains in the table tray, which could be removed with a disinfectant wipe, and a patient gurney with tape residue on the side rails.

3. On 6/2/15 at approximately 12:15 PM, the policy titled, "Housekeeping " (no revised/reviewed date) was reviewed. The document required "wipe off and disinfect all counter tops and sinks...dust and wipe down all furniture and equipment. "

4. On 6/2/15 at approximately 1:00 PM, the policy titled, "Infection Control-Radiology Department" (reviewed/ 1/16/96) was reviewed. The policy required "All x-ray equipment is washed regularly with bleach and water solution...All equipment used is thoroughly cleaned after patient is removed."

5. During an interview with the Manager of Laboratory Department (E #12) conducted 6/2/15 at 8:15 AM, E #12 stated, "The areas on the phlebotomy station should be clean of any stains. "


6. During an interview with the Manager of Radiology Department (E #10) conducted on 6/2/15 5 at 9:15 AM, E #10 stated, "We don't use the wheelchair for patients most of the time. We transport protective aprons in it. There is no way to thoroughly disinfect the wheelchair arms due to the cracks in the material or the side rails due to the tape residue." E #10 agreed the bedside table had removable stains in the tray.

A. Based on document review and interview, it was determined for 1 of 20 patient (Pt #16), the Hospital failed to ensure the plan of care (POC) included goals specific to patient care needs. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. The policy titled "Care Planning" (revised 12/18/03) was reviewed on 6/3/15 at approximately 1:00 PM . The policy required, "The Plan of Care shall be individualized, based on the diagnosis and patient assessment...The Plan of Care shall be updated daily, with revisions reflecting the reassessment of needs of the patient. "

2. The clinical record of Pt. #16 was reviewed on 6/3/15 at approximately 9:30 AM. Pt. #16 was admitted on 4/15/15 with a diagnosis of shortness of breath. According to the clinical record, Pt. #16 had a high risk for falls (fall risk score of 45. High risk =45 or above). On 4/17/15 at 10:00 AM, Pt #16 fell. The plan of care had no specific goals related to fall and safety risks.

3. During an interview with the Director of Quality (E #3) on 6/3/15 at 10:30 AM, E #3, stated there were, "no POC specific goals or interventions for Pt# 16's fall and safety risks. "