HospitalInspections.org

Based on observations as referenced in the Life Safety Report of Survey completed 05/11/2012, the hospital failed to have an effective governing body responsible for the functions of the hospital.

The findings include:

1. The hospital failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross-refer to 482.41 Physical Environment - Condition Tag A0700.

Based on the facility's "Dialysis Sheet-R.O. (Reverse Osmosis) Water Treatment System" log review, medical record review, staff interview and facility policy review, the facility failed to provide a safe environment for hemodialysis patients by failing to ensure that total chlorine testing of the hemodialysis treatment water had times documented that testing was completed prior to patients initiating treatment and again prior to the beginning of each patient shift; failing to ensure that automatically regenerated water softener timers were checked at the beginning of each hemodialysis treatment day to prevent regeneration cycle during patient hemodialysis treatments; and failing to ensure physician orders for patient hemodialysis blood flow rates (BFR) were obtained prior to hemodialysis treatments in 3 of 5 sampled hemodialysis patients (Patients #44, 45, 51).

Findings include:

1. Review on 05/08/2012 of the facility's "Dialysis Sheet-R.O. (Reverse Osmosis) Water Treatment System" log from 10/31/2011 through 05/08/2012 revealed that the facility's dialysis staff failed to document times of total chlorine testing performed to ensure safe hemodialysis treatment water. The review revealed documentation from the log as "Shift #1 Chlorine Check-Post #1 Carbon Tank" with the results of testing documented. No time was found on the entire log from 10/31/2011 through 05/08/2012 that indicated when the total chlorine testing was actually performed by the staff.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administrative staff revealed no times were documented for hemodialysis water testing of total chlorine. The interview revealed that the staff only documented the results at the sections of shifts without times. The interview revealed that they could not verify a specific time of the chlorine testing and if the tests were conducted before the beginning of patient shifts based on the lack of documentation. The interview revealed "We know we do the testing, but the documentation of times is not present."

Review of the facility's policy and procedures for the facility's Hemodialysis Unit revealed no policy to address the specifics of the total chlorine testing guidelines during the survey.

2. Review on 05/08/2012 of the facility's "Dialysis Sheet-R.O. (Reverse Osmosis) Water Treatment System" log from 10/31/2011 through 03/25/2012 revealed that the facility's dialysis staff failed to document daily timer checks to ensure that automatically regenerated water softener timers were checked at the beginning of each hemodialysis treatment day to prevent regeneration cycle during patient hemodialysis treatments. The review revealed that the timers were documented as checked on a weekly basis from 10/31/2012 through 03/25/2012. Review from 03/26/2012 through 05/08/2012 revealed that the facility staff began checking the timers on a daily basis before patient treatments.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administrative staff revealed no daily checks of the timers were completed on the log from 10/31/2011 through 03/25/2012. The interview revealed that the facility realized that they were not compliant with the documentation and changed the practice on the checks of timers for daily checks beginning 03/26/2012. The interview confirmed the findings.

3. A) An open medical record review on 05/08/2012 for patient #44 revealed that the patient was a 46 year old male admitted to the facility for hemodialysis treatments on 04/30/2012. Review of the physician orders for hemodialysis treatment dated 05/01/2012 at 0041 revealed that no specific blood flow rate (BFR) was ordered for the patient's hemodialysis treatment. Documentation revealed "Blood flow, use outpatient clinic order." No documentation was found where the patient was ordered a specific BFR his hemodialysis treatment.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administration revealed that the nurses should ensure that a blood flow rate is ordered specific for patients and their hemodialysis treatments. "Physicians should give a number for BFR."

B) An open medical record review on 05/08/2012 for patient #45 revealed that the patient was a 29 year old male admitted to the facility for hemodialysis treatments on 05/03/2012. Review of the physician orders for hemodialysis treatment dated 05/04/2012 at 1125 revealed that no specific blood flow rate (BFR) was ordered for the patient's hemodialysis treatment. Documentation revealed "BFR Max." No documentation was found where the patient was ordered a specific BFR his hemodialysis treatment.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administration revealed that the nurses should ensure that a blood flow rate is ordered specific for patients and their hemodialysis treatments. "Physicians should give a number for BFR."

C) A closed medical record review on 05/10/2012 for patient #51 revealed that the patient was a 31 year old male admitted to the facility for hemodialysis treatments on 04/22/2012 through 05/09/2012. Review of the physician orders for hemodialysis treatment dated 04/24/2012 at 1315 revealed that no specific blood flow rate (BFR) was ordered for the patient's hemodialysis treatment. Documentation revealed "BFR Max." No documentation was found where the patient was ordered a specific BFR his hemodialysis treatment.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administration revealed that the nurses should ensure that a blood flow rate is ordered specific for patients and their hemodialysis treatments. "Physicians should give a number for BFR."

Based on policy and procedure review, closed medical record review and staff interview the Emergency Department (ED) staff failed to identify a chemical restraint in 1 of 1 patients receiving a chemical restraint (#53).

The findings include:

Review of the hospital policy "Restraint Use for Adults and Children" revised and effective 02/12 revealed "IV. DEFINITIONS Chemical Restraint a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

2. Closed medical record review of patient #53 revealed a 39 year old presenting to the hospital A's ED on 5/6/2012 with a chief complaint of "acutely psychotic suffering from hallucinations and paranoid delusions" Record review revealed documentation by the physician "he believes there was a device implanted in him which will cause him to be electrocuted if anyone touches him...over the course of the interview the patient becomes increasingly agitated and outwardly hostile". Record review at 2022 revealed "patient is very paranoid, thinks he has a device implanted in him that will kill him if someone touches him. patient is exhibiting extreme flight of ideas, pacing around room, patient is very angry and paranoid. Record review revealed at 2040 the patient's assessment was "abnormal" and the patient's behavior was "aggressive, agitated, anxious, apprehensive, complaining, defensive, hallucinates, hysterical and restless." Record review revealed nursing documentation at 2040 "patient is very anxious pacing, patient very paranoid." Record review revealed the patient was administered Geodon (antipsychotic) 20 mg intramuscularly (IM) at 2155. Record review revealed at 2300 "patient resting with eyes closed on bed." Record review revealed on 5/7/2012 at 1140 the patient's behavior was documented "aggressive, agitated, defensive, demanding, hallucinates, hostile, hysterical, inappropriate, irrational, irritable...Walking around yelling, trying to leave, cursing at staff". Record review revealed the patient was administered Geodon 20 mg IM at 1140. Record review revealed one physician's order not dated or timed for Geodon 20 mg IM.

Interview with administrative ED staff and Medical Officer on 5/10/2012 at 1515 revealed the Geodon administered IM was not recognized as a chemical restraint.

Based on observations, hospital documentation reviews and staff interviews the hospital failed to have an effective process/system in place ensuring environmental safety within the Behavioral Health Unit.

The findings include:

Observations during tour of the A unit behavioral unit on 5/9/2012 at 0930 revealed metal springs attaching the metal support for the mattress to the frame of the bed (holding the mattress support in place). Observation revealed the springs were not secured to the frame of the bed or to the support for the mattress. Interview during tour with the administrative behavioral staff revealed A unit is the only unit that has the beds with springs. The interview revealed the beds on the two other units, B and C have beds that are secured without metal attachments.

Review of hospital documentation revealed a "Post Risk Assessment Work Plan" for the Behavioral Health Unit dated June 2007. Further review of documentation presented revealed "Environmental Tour Reports" dated January 13, 2008, June 5, 2008, December 23, 2008, June 5, 2009, December 4, 2009 and June 30, 2010. Review of the reports did not reveal documentation of of risk assessments for safety on the behavioral health unit.

Interview on 5/10/2012 at 1030 with the hospital Director of Paten Satiety revealed the beds had been replaced on B and C unit due to the springs being seen as a risk for safety and the beds on A unit had not been replaced. The interview revealed staff had conducted walk through of the behavioral health units but there was no documentation of the walk through. The interview revealed a patient would not be allowed to keep a spring as noted on the beds if the patient brought it in from home. The interview revealed it would be removed from the patient's possession since it could cause harm to the patient and others. Continued interview at 1415 revealed the documentation presented was more of environmental rounds and not rounds assessing for safety in the units.

Based on medical record review and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to obtain and clarify a specific dialysis prescription order from a physician for 2 of 5 sampled hemodialysis patient records (Patient #51, 44), and failing to follow physician orders of a change in the dialysis prescription for 1 of 5 sampled hemodialysis patient records (Patient #43).

Findings include:

1. A closed medical record review 05/10/2012 for patient #51 revealed that the patient was admitted to the facility (Campus A) on 04/22/2012 through 05/09/2012 with diagnosis of "Hyperkalemia." Review revealed that the patient was on hemodialysis treatments at the hospital. Review of a telephone obtained physician order dated 04/28/2012 at 1120 from facility registered nurse #1 revealed the order as "HD (Hemodialysis) may be done on 04/29/2012. Use same order of 04/28/2012." No specific dialysis prescription order for the patient's 04/29/2012 hemodialysis treatment was found in the patient's medical record.

An interview 05/10/2012 at 1200 with the facility's nursing administration staff revealed that blanket orders should not be written and specific orders should be obtained by staff. The interview also revealed no policy existed at the facility to address blanket orders for hemodialysis care at the facility.

2. An open medical record review on 05/08/2012 for patient #44 revealed that the patient was a 46 year old male admitted to the facility (Campus A) for hemodialysis treatments on 04/30/2012. Review of the physician orders for hemodialysis treatment dated 05/01/2012 at 0041 revealed that no specific blood flow rate (BFR) was ordered for the patient's hemodialysis treatment. Documentation revealed "Blood flow, use outpatient clinic order." No documentation was found where the patient was ordered a specific BFR his hemodialysis treatment.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administration staff revealed that the nurses should ensure that a blood flow rate is ordered specific for patients and their hemodialysis treatments. "Physicians should give a number for BFR."

3. An open medical record review on 05/08/2012 for patient #43 revealed that the patient was 45 year old female admitted to the facility (Campus A) for hemodialysis treatments on 04/19/2012. Review of the physician orders dated 04/24/2012 (no time) revealed a change in the patient's dialysis prescription as "Change to 3 K (potassium) bath dialysate." Review of the patient's hemodialysis treatment documentation sheets on 04/24/2012, 04/26/2012, 04/28/2012, 05/01/2012, 05/03/2012, 05/05/2012, and 05/08/2012 (total of seven (7) hemodialysis treatments) revealed the patient received hemodialysis treatment with a 2 K (potassium) bath instead of the ordered 3 K bath. No documentation was found in the medical record where the patient received the physician ordered 3 K bath during her hemodialysis treatments after 04/24/2012.

An interview on 05/08/2012 at 1400 with the facility's hemodialysis administration staff revealed that the nursing staff should follow physician orders and the patient's dialysate bath should have been changed as ordered to 3 K (potassium).

Based on policy and procedure review, open and closed medical record reviews and staff interviews the nursing staff failed to obtain a physician's order to administer medications in 1 of 1 patients ordered the nitroglycerin protocol (#52) and 1 of 1 patients receiving chemical restraints (53) and failed to document injection sites for 5 of 36 sampled inpatients (#46, #47, #48, #21, and #24).

The findings include:

Review of policy "Medication Ad ministration" revised and effective 05/10 revealed "All medications must be ordered by a prescriber or a XXX (name of hospital) medical staff...and are to be written on the prescriber's ordered sheet."

Interview on 05/08/2012 at 1415 with the Administrator of Adult Inpatient Services revealed nursing staff should rotate sites of subcutaneous injections. Interview revealed nursing staff must document the site of injection to ensure the site was rotated with each subsequent injection.

1. Open medical record review of patient #52 revealed a 58 year old presenting to campus B's Emergency Department (ED) on 5/9/2012 at 0957. Record review revealed the patient's primary complaint was Chest Pain with central chest tightness. record review revealed the patient received Nitroglycerin (dilates blood vessels in the heart) 1 pill under the tongue at 1014 for chest pain rated at 5 out of 10 on a 10 point scale with 10 being the worst pain. Record review revealed the patient was administered a second dose of Nitroglycerin at 1210 for pain rated 3 out of 10. Record review revealed no physician's order for Nitroglycerin to be administered. Record review revealed no documentation of nitroglycerin protocol.

Interview with ED Director on 5/9/2012 at 1445 revealed the hospital changed it's chest pain/nitroglycerin protocol. The interview revealed the change had occurred around January 2012. The interview revealed with the current protocol the physician must order Nitroglycerin because it had been removed from the protocol. The interview revealed there must be a physician's order for any protocol used.

Interview with the ED nurse manager on 5/9/2012 at 1445 revealed the patient received the Nitroglycerin based on the Nitroglycerin protocol and the physician had ordered the nitroglycerin protocol. The interview revealed the manager was not aware the physician must order the nitroglycerin to be given with the current protocol. The interview revealed there was no documentation of a physician's order for the two doses of Nitroglycerin administered and there was no documentation of a physicians order for a protocol during the time of administration in the ED.

2. Closed medical record review of patient #53 revealed a 39 year old presenting to the hospital A's DED on 5/6/2012 with a chief complaint of "acutely psychotic suffering from hallucinations and paranoid delusions" Record review revealed documentation by the physician "he believe there was a device implanted in him which will cause him to be electrocuted if anyone touches him...over the course of the interview the patient becomes increasingly agitated and outwardly hostile". Record review revealed at 2040 the patient's assessment was "abnormal" and the patient's behavior was "aggressive, agitated, anxious, apprehensive, complaining, defensive, hallucinates, hysterical and restless." Record review revealed nursing documentation at 2040 "patient is very anxious pacing, patient very paranoid." Record review revealed the patient was administered Geodon (antipsychotic) 20 mg intramuscularly (IM) at 2155. Record review revealed on 5/7/2012 at 1140 the patient's behavior was documented "aggressive, agitated, defensive, demanding, hallucinates, hostile, hysterical, inappropriate, irrational, irritable...Walking around yelling, trying to leave, cursing at staff". Record review revealed the patient was administered Geodon 20 mg IM at 1140. Record review revealed one physician' order not dated or timed for Geodon 20 mg IM.

Interview with administrative ED staff on 5/10/2012 at 1515 revealed there was no date or time for the order for Geodon noted in the medical record. The interview revealed based on the documentation there was not a complete physicians's order to administer Geodon for one dose given and no physician's order for the other dose given.



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3. Open medical record review on 05/08/2012 at 1515 for Patient #46 revealed a 39 year-old female that was admitted to the hospital's Campus A on 04/29/2012 with respiratory distress and salicylate overdose. Record review revealed a physician's order dated 04/29/2012 at 1000 to administer Heparin (anticoagulant medication) 5000 Units (u) by subcutaneous injection (SQ) every 8 hours. Review of the Medication Administration Record (MAR) revealed the patient was given Heparin 5000 u SQ every 8 hours from 2237 on 04/29/2012 through 0630 on 05/08/2012 (26 doses). Record review revealed no documentation of the site of Heparin injection on: 04/29/2012 at 2237; 04/30/2012 at 1300; 05/01/2012 at 1322 and 2206; 05/02/2012 at 0521 and 2135; 05/03/2012 at 0512, 1442, and 2152; 05/04/2012 at 0558, 1305, and 2242; 05/05/2012 at 0503, 1432, and 2127; 05/06/2012 at 0502 and 2120; 05/07/2012 at 1317 and 2207; and 05/08/2012 at 0630 (20 of 26 doses).

Interview on 05/08/2012 at 1515 with the Nursing Coordinator on the Neurosciences Unit during record review confirmed there was no available documentation of injection sites for the doses of Heparin administered subcutaneously to the patient on 04/29/2012 at 2237; 04/30/2012 at 1300; 05/01/2012 at 1322 and 2206; 05/02/2012 at 0521 and 2135; 05/03/2012 at 0512, 1442, and 2152; 05/04/2012 at 0558, 1305, and 2242; 05/05/2012 at 0503, 1432, and 2127; 05/06/2012 at 0502 and 2120; 05/07/2012 at 1317 and 2207; and 05/08/2012 at 0630 (20 of 26 doses).

4. Open medical record review on 05/09/2012 at 1000 for Patient #47 revealed a 35 year-old female that was admitted to the hospital's Campus A on 04/17/2012 with nausea, vomiting, diarrhea, and dehydration. Record review revealed a physician's order dated 04/30/2012 at 1350 to administer Lovenox (anticoagulant medication) 40 milligrams (mg) by subcutaneous injection (SQ) every day. Review of the Medication Administration Record (MAR) revealed the patient was given Lovenox 40 mg SQ every day from 04/30/2012 through 05/08/2012 (9 doses). Record review revealed no documentation of the site of Lovenox injection on 05/01/2012, 05/02/2012, and 05/07/2012 (3 of 9 doses).

Interview on 05/10/2012 at 0900 with the Chief Nurse Executive revealed, "Injection sites are not consistently being documented." Interview confirmed there was no available documentation of injection sites for the doses of Lovenox administered subcutaneously to the patient on 05/01/2012, 05/02/2012, and 05/07/2012 (3 of 9 doses).

5. Open medical record review on 05/09/2012 at 1000 for Patient #48 revealed a 34 year-old female that was admitted to the hospital's Campus A on 05/08/2012 with chest pain. Record review revealed a physician's order dated 05/08/2012 at 1840 to administer Heparin (anticoagulant medication) 5000 Units (u) by subcutaneous injection (SQ) every 8 hours. Review of the Medication Administration Record (MAR) revealed the patient was given Heparin 5000 u SQ on 05/08/2012 at 2308 and on 05/09/2012 at 0938. Record review revealed no documentation of the site of Heparin injection on 05/08/2012 at 2308 (1 of 2 doses).

Interview on 05/10/2012 at 0900 with the Chief Nurse Executive revealed, "Injection sites are not consistently being documented." Interview confirmed there was no available documentation of the injection site for the dose of Heparin administered subcutaneously to the patient on 05/08/2012 at 2308 (1 of 2 doses).

6. Closed medical record review for Patient #21 revealed a 75 year-old female that was admitted to the hospital's Campus B on 02/23/2012 with right hip fracture. Record review revealed on 02/24/2012 the patient underwent a surgical open reduction and internal fixation of the right hip. Record review revealed a physician's order dated 02/24/2012 to administer Lovenox (anticoagulant medication) 40 milligrams (mg) by subcutaneous injection (SQ) every day, beginning on the first post-operative day. Review of the Medication Administration Record (MAR) revealed the patient was given Lovenox 40 mg SQ every day from 02/25/2012 through 02/28/2012 (4 doses). Record review revealed no documentation of the site of Lovenox injection on 02/25/2012, 02/26/2012, 02/27/2012, and 02/28/2012 (4 of 4 doses).

Interview on 05/10/2012 at 0900 with the Chief Nurse Executive revealed, "Injection sites are not consistently being documented." Interview confirmed there was no available documentation of injection sites for the doses of Lovenox administered subcutaneously to the patient on 02/25/2012, 02/26/2012, 02/27/2012, and 02/28/2012 (4 of 4 doses).

7. Closed medical record review for Patient #24 revealed a 39 year-old female that was admitted to the hospital's Campus A on 03/20/2012 with bilateral pulmonary emboli and pneumonia. Record review revealed a physician's order dated 03/30/2012 to administer Lovenox (anticoagulant medication) 80 milligrams (mg) by subcutaneous injection (SQ) every 12 hours. Review of the Medication Administration Record (MAR) revealed the patient was given Lovenox 80 mg SQ every 12 hours from 2052 on 03/30/2012 through 1814 on 04/02/2012 (7 doses). Record review revealed no documentation of the site of Lovenox injection on 03/31/2012 at 0852, 04/01/2012 at 0858, and on 04/02/2012 at 0929 and 1814 (4 of 7 doses).

Interview on 05/10/2012 at 0900 with the Chief Nurse Executive revealed, "Injection sites are not consistently being documented." Interview confirmed there was no available documentation of injection sites for the doses of Lovenox administered subcutaneously to the patient on 03/31/2012 at 0852, 04/01/2012 at 0858, and on 04/02/2012 at 0929 and 1814 (4 of 7 doses).

Based on policy, medical record review, and staff interview, the hospital's nursing staff failed to monitor vital signs during a blood transfusion per policy for 1 of 5 sampled patients that received blood transfusions (#24).

The findings include:

Review of current hospital policy entitled "Blood Transfusion - Whole Blood and Packed Red Blood Cells" dated 02/2012 revealed, "I. PURPOSE....To promote the safe administration of whole blood and packed red blood cells....IV. Procedure A. Administration of Blood Products...Assess the vital signs (temperature, pulse, respirations, and blood pressure) as follows: 1) 15 minutes after start of infusion (test dose) 2) every 1 hour during transfusion 3) At end of transfusion...."

Closed medical record review for Patient #24 revealed a 39 year-old female that was admitted to the hospital's Campus A on 03/20/2012 with bilateral pulmonary emboli and pneumonia. Record review revealed the patient was treated and subsequently discharged to home on 04/02/2012. Record review revealed a transfusion of Packed Red Blood Cells was started per physician's orders on 03/20/2012 at 2346. Record review revealed the patient's temperature was 99.8F (elevated)at the time the transfusion was started. Record review revealed documentation the patient's temperature was 100.5F on 03/21/2012 at 0001 and 102.4F at 0119. Record review revealed the nurse stopped the blood transfusion at 0121 and reported a possible transfusion reaction to the physician and lab. Review of the pathologist's notes on the "Investigation of Suspected Hemolytic Transfusion Reaction" form dated 03/21/2012 revealed, "Febrile reaction, probably not related to transfusion." Further record review revealed the patient's temperature gradually decreased and was noted to be 98.7F (normal) at 0700 on 03/21/2012. Record review revealed a physician's order dated 03/21/2012 at 0740 to transfuse 2 units of Packed Red Blood Cells (PRBC). Record review revealed transfusion of the first unit of PRBC began on 03/21/2012 at 0745 and ended at 1100. Record review revealed documentation the patient's temperature was assessed at the following times during the transfusion: 0800 (98.9F), 0848 (99.4F), and 1000 (99.9F). Record review revealed no documentation the patient's temperature was reassessed when the transfusion ended at 1100. Record review revealed transfusion of the second unit of PRBC began on 03/21/2012 at 1115 and ended at 1450. Record review revealed the next documentation the patient's temperature was assessed was at 1200 (100.7F), one hour after the first transfusion ended and 45 minutes after the second transfusion began. Record review revealed no documentation the patient's temperature was assessed again during the second transfusion. Record review revealed the next documentation the patient's temperature was assessed was at 1505 (102.3F) (3 hours and 5 minutes after the patient's temperature was noted to be increased by 1.8 degrees Fahrenheit during blood transfusion).

Interview on 05/08/2012 at 1415 with the Administrator of Adult Inpatient Services revealed vital signs should be monitored by nursing staff during each blood transfusion "every 15 minutes times 4, then every hour during transfusion". Interview revealed assessment of the patient's temperature should be included with each set of vital signs during blood transfusion. Interview revealed, "Increased temperature is the first indicator of transfusion reaction, besides shortness of breath." Interview confirmed there was no available documentation nursing staff monitored the patient's temperature per policy during the blood transfusions on 03/21/2012.

Based on policy review, observation during tour, and staff interview, the hospital failed to ensure that unauthorized individuals did not have access to medical records by failing to limit access to the Health Information Management (HIM) Department to HIM staff.

The findings include:

Review of current hospital policy entitled "Security of the Medical Record" dated 03/2012 revealed, "I. PURPOSE....Medical Records are the property of the medical center and are to be safeguarded against loss, destruction, tampering, and unauthorized access and users. The Health Information Management Department and Information Services Department, as well as hospital leadership, will strive to ensure that medical records and other information will be maintained in secure and restricted area with access limited to those staff members who have need for access based on either patient care needs and/or position responsibilities...."

Observation on 05/10/2012 at 1000 during tour of the HIM Department revealed the department was located in an offsite office building. Observation revealed the office building also housed the following hospital departments: Information Technology, Human Resources, Fiscal Services (includes Accounts Payable, Payroll, Budget, and Financial Reporting), Reimbursement, Purchasing, and Patient Financial Services. Observation revealed the entrance into the office building was not locked. Observation revealed the upper floors, including the second floor where the HIM Department was located, was accessible by a badge-access operated elevator. Observation revealed the Information Technology Department was on one side of the second floor and the HIM Department was on the other side. Observation of the HIM Department revealed the two large glass doors at the entrance into the Department. Observation revealed the glass doors were fully opened, allowing easy entry into the Department. Observation within the HIM Department revealed an open work area in the center of the Department (not enclosed by doors or walls). Observation revealed several patients' medical records on a shelf in the open work area. No HIM staff members were in the open work area at the time of observation.

Interview on 05/10/2012 at 1000 during tour with the Director of HIM revealed open work area was the "prepping area". Interview revealed medical records stay out in the prepping area until they are scanned into the computer, usually within 24 hours of arriving to the Department. Interview revealed after the records are scanned, they are then locked in storage room in the Department for a short time, until they are transported to the offsite storage facility. Interview revealed the glass doors at the entrance into the HIM Department stayed opened all day and were closed, but not locked, at night. Interview revealed HIM staff were within the Department 24 hours a day, 7 days per week. Interview revealed depending on where within the Department the staff were located they might or might not see a person enter the Department. Further interview revealed approximately 300 hospital employees worked in the office building. Interview revealed approximately 100 of those were HIM staff and approximately 200 were staff that worked in one of the other departments within the building (Information Technology, Human Resources, Fiscal Services [includes Accounts Payable, Payroll, Budget, and Financial Reporting], Reimbursement, Purchasing, and Patient Financial Services). Interview revealed the entrance to the office building remained open 1700, at which time it was locked. Interview revealed all hospital employees whose office was located in the office building had a badge that would open the door at the entrance to the office building. Interview revealed same badges accessed the elevators to the upper floors, including the second floor where the HIM Department was located. Interview revealed, "Only HIM staff should have access to medical records." Interview confirmed any employee in the office building (approximately 200 of which were not HIM staff) could enter the HIM department and would have access to medical records.

Based on facility policy review, medical record review, and staff interview the facility failed to ensure PRN (as needed) medication orders included a specific indication for use in 1 of 51 sampled patient records (Patient #30).

Findings include:

Review on 05/09/2012 of the facility's policy "Practitioner Prescribing/Ordering Practices" (Revised 10/2011) revealed "D. On Call and PRN Medications: On call and PRN medication orders must include indications for giving does not give the caregiver enough direction to know whether or not a medication should be administered. For medications that may have multiple uses (ie, diphenhydramine, acetaminophen (Tylenol), and promethazine), the prescriber shall identify the specific indication for which the medication is to be administered."

An open medical record review 05/09/2012 for patient #30 revealed that the patient was an 88 year old male admitted to the facility (Campus A) on 05/04/2012 with a diagnosis of "Severe Hypoglycemia." Review of the physician orders dated 05/05/2012 at 2310 revealed the order as "Tylenol 650 milligrams by mouth every 4 hours PRN (as needed)" without any indication of use in the prescribed order. The review revealed that the order was written as a read back telephone order by a registered nurse taken over the telephone from the assigned physician.

An interview on 05/09/2012 at 1030 with a facility's pharmacist #1 revealed all PRN medication orders should have indications for use in the order. The interview confirmed the findings.

Based on policy and procedure review, observations and interview, facility staff failed to ensure medications were secured in 2 of 3 observed anesthesia carts.

Findings include:

Review of "Standards for Medication Control" policy revised January 2012 revealed "1. All hospital personnel shall strictly adhere to all security measures that apply to medications and medication devices. All medications are secured to prevent diversion and possible adulteration by patients, visitors, and hospital employees. To meet standards for security, all medications and their devices must be either under lock and key or be in constant view of authorized personnel...."

1. Observation during tour of the operating room suite on 05/08/2012 at 1430 revealed an anesthesia cart in Endoscopy Room #1 that was not secured. Observation revealed no staff were present in Endo Room #1 and the anesthesia cart was not in view of staff at the time of the observation. Observation revealed vials of anesthesia medications and pre-filled labeled syringes were located in the first and second drawer of the unsecured anesthesia cart.

Interview with operating room (OR) administrative staff during tour confirmed the anesthesia cart was unsecured and not under observation of OR personnel. Interview revealed the anesthesia carts have an automatic locking mechanism that engages (locks) after five minutes of inactivity. The staff member stated the anesthesia carts should be secured when not in use or under observation.



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2. Observation during tour of the labor and delivery area on 05/08/2012 at 1040 revealed an anesthesia cart in C-Section OR (operating room) #1 that was not secured. Observation revealed no staff were present in OR #1 and the anesthesia cart was not in view of staff at the time of the observation. Observation revealed vials of anesthesia medications and pre-filled labeled syringes were located in the first and second drawer of the unsecured anesthesia cart.

Interview with administrative staff during tour confirmed the anesthesia cart was unsecured and not under observation of OR personnel. Interview revealed the anesthesia carts have an automatic locking mechanism that engages (locks) after five minutes of inactivity. The staff member stated the anesthesia carts should be secured when not in use or under observation.

Based on policy and procedure review, observation and staff interviews. the Hospital's dietary staff failed to ensure a clean and sanitary environment for the safe handling of food and equipment use in the dietary services area.

Findings include:

Hospital dietary policy ,"Refrigerator/Freezer Temperature Logs," revised 04/12 revealed ...2. Record temperatures using thermometer on inside of unit and the ambient air temperature.

Review of a "Weekly Detail Cleaning List" shows Clean all fans in the kitchen, Detail clean Hotboxes, remove sheet pans and replace, Detail Clean Line A Plate Warmer, Detail Clean Line B Plate Warmer.

During the dietary tour on 5/8/2012 starting at 09:45 am it was noted that exhaust fans and air circulating fans in the dish washing area, the bake shop walk-in cooler, the ice machine fans x 2, the dairy cooler fans and walk-in cooler fans were dusty/dirty. No documentation was available to show when the fans were last cleaned. There was ice build up on the ice cream freezer, ice around the doors of the walk-in freezer #1, where the door had been left open and the temperature reading from the temperature log over the past 8 days ranged from 10 - 12 degrees F. Also a freezer in the Kona Coast Cafe and walk-in freezer at Hospital B location had ice build up.

A four container cover was not in place, leaving the container open when not in use. Hot Box Plate warmer #2 and #3 were dirty and no documentation was available to show when they were last cleaned.
The ice machine in the main kitchen had a large scoop that would not fit in the appropriate holder when not in use was located laying on top of the ice machine.

There were no inside thermometers in Freezer/Cooler in an ice cream cooler as well as no temperature documentation. Also no thermometers on the Line A "Air Curtain #1, the Top Reach In Cooler #1, Line B Air Curtain #2. In the Light House Cafe no in-side thermometer was in the Freezer and the ice cream Freezer with no temperature documentation.

Out dated products i.e. Classic Syrup (coffee flavoring) was noted. One bottle with an expiration date of 2 Dec, 2011, (5 months ago) and 2 with an expiration date of 21 April 2012 (14 days ago).

In the Kona Coast Cafe open products i.e. pudding, blueberry filling, apricot glaze and vanilla icing were not dated as to when the product was opened.

At the Surgical Kiosk, the refrigeration logs showed temperatures ranging from 45 to 48 degrees F, with no explanations and or corrections being made. Milk was found to be at 45.1 and 46 degrees F, and cream cheese was found to be at 47 degrees F. These products were removed from service.

Based on observations as referenced in the Life Safety Report of Survey completed May 11, 2012, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

The hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.

Based on observations as referenced in the Life Safety Report of survey completed May 11, 2012, the hospital staff failed to ensure the safety and well-being of patients, staff, and visitors by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building - 01
1. Main Hospital, Service Level, Main Electrical room accessible from the covered breezeway outside the kitchen storage area had holes and or penetrations that were not seal in order to meet the required rating of the area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

2. Main Hospital, Service Level, IS mezzanine area, There are holes in the fire proofing covering the beams in the IS mezzanine area that were not properly repaired in order to maintain the required rating on the beams.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

3. Main Hospital, 1st floor, soiled utility room at CCU, the soiled utility room door at that location did not latch when tested.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

4. Main Hospital, Service Level, Clean Respiratory Therapy, The corridor door from the clean respiratory therapy room required two motions of the hand to unlock and open.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

5. Main Hospital, Service Level, Kitchen Area, The catering closet located next to the dry storage room had kick down stop on the door preventing the door from closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

6. Main Hospital, Service Level, Kitchen Area, The door to the chemical closet did close latch and seal.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

7. Main Hospital, 7th floor, chase in the visitors elevator lobby, the rated chase door in that area did not close and latch when opened during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0020.

8. Main Hospital, Service Level, IS-UPS Room, there are holes in the ceiling where conduit penetrate the ceiling that were not properly sealed in order to maintain the required rating of the area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

9. Main Hospital, 1st floor, ED Radiology suite, the first floor emergency department radiology suite had two doors with magnetic hold open devices that were not tied to the fire alarm system. Both doors had the listed closure arm removed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0027.

10. Main Hospital, 1st floor, outpatient services area, the soiled utility room door for the West area didn't not latch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

11. Main Hospital, 1st floor Mechanical Room Cath Lab, there are unsealed penetrations in the rated corridor wall area around the duct penetration at back top left section of the wall.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

12. Main Hospital, Service Level, Kitchen Area, the dry storage room in the kitchen did not close latch and seal.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

13. Main Hospital, 1st floor, classrooms/old operating rooms/storage, the small storage in the old operating rooms/classrooms was not smoke tight; the door to the area had been removed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

14. Main Hospital, 1st floor, main concourse gift shop, there was not positive latching to the gift shop door on the main concourse exit corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

15. Main Hospital, Service Level, Kitchen Area, the chemical closet located in the kitchen will need to be one hour and sprinkler. The area is considered a high hazard area due to chemicals and flammable fuels stored in the room.



16. Main Hospital, 1st floor, ED Behavioral Health suite, the emergency department behavioral health suite currently exits into another suite.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

17. Main Hospital, 1st floor, ED main entrance, the break away doors to the 1st floor emergency department main entrance did not have signage to indicate which doors break away.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

18. Main Hospital, 1st floor, near the mail lobby, the exit egress doors at this location leading to the inpatient unit does not have an on/off emergency door release switch at the double doors at the required exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

19. Main Hospital, 1st floor, Staff Bathroom at the CCU, the staff bathroom required two motions of the hand to exit that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

20. Main Hospital, 1st floor, CCU 4 sets of double door on the egress corridor; the staff must verify the door release mechanism operation at these locations. This area does not have all the items for control access nor North Carolina Special Locking.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

21. Main Hospital, Service Level, the means of egress from the AHEC exit and Service Level Concourse exit into the courtyard is not clearly marked that will direct individuals to safety.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

22. Main Hospital, 1st floor, Cross Corridor doors at the CVIC area, these control access doors did not release as required, but exiting from the space was not impeded as the hardware on the door allowed exiting into the corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

23. Main Hospital, Service Level, IS mezzanine area, the means of egress from the IS mezzanine area to the corridor does not have adequate lighting that would prevent the area from being left in darkness

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0045.

24. Main Hospital, Service Level, Bio-Med Mezzanine, the bio-med mezzanine area did not have lights connected to emergency power that would prevent the area from being left in darkness.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0045.

25. Main Hospital, Mezzanine kitchen level, the exit directional signage from this area is incomplete to the egress corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

26. Main Hospital, EVS corridor, the East EVS exit egress corridor exit directional signage leading East to the public way was incomplete.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

27. Main Hospital, Service Level, IS Mezzanine Exit and directional signage is incomplete from the mezzanine to the corridor exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

28. Main Hospital, 1st floor, the Kona Kitchen area, the exit directional signs in this space is incomplete to the exit egress corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

29. Main Hospital, 1st floor, ICU entrance corridor adjacent to the emergency department near the Kona Kitchen area has exit directional signage that is blocked and is not clearly visible in the path of egress.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

30. Main Hospital, 1st floor, Radiology suite, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0052.

31. Main Hospital, 1st floor, Emergency Department for the women's clinic, this area is covered by the fire alarm system for the hospital but failed to give an audible sound or chime when the fire alarm system was activated.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0052.

32. Main Hospital, Service Level, Kitchen, there were three ceiling mounted smoke detectors in the kitchen that had the sensing device cover preventing proper operation.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0054.

33. Main Hospital, Sprinkler heads were found in the facility were of the intermediate temperature rating of 200 degree F in place of the ordinary temperature rating of 155 degree F. Intermediate temperature heads were found in the following areas. The facility must provide documentation from the sprinkler designer noting the use of this particular rated sprinkler heads for this particular area.

Main Hospital, 6th floor mechanical, electrical room and date closet located in the center conference room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

34. Main Hospital, Service Level Concourse sprinkler heads are located above conduits and HVAC ductwork, this particular areas has sprinkler heads are being blocked not be an object on the side of the head but by the ductwork below the sprinkler heads.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

35. Main Hospital, Service Level Concourse, does not have adequate sprinkler coverage. The existing sprinkler heads are located above the existing conduit and ductwork and not providing complete coverage of the corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

36. Main Hospital, 1st floor, ED, old electrical room/telecom room, there was not a sprinkler head in the telecom room located in the emergency department.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

37. Main Hospital, document review, sprinkler system, library, the document review of the fire marshal's report dated July 27, 2011 from the main hospital indicated that there were sprinkler heads obstructed by book shelves. Staff indicated that the facility currently working on the issue. The facility must confirm the sprinkler coverage in the library provides adequate coverage by the sprinkler designer.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

38. Main Hospital, Service level laundry and drying area, the sprinkler head near dryer # 2 is blocked by ductwork just above the light fixture in that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

39. Rooms and/or areas were not provided with sprinkler coverage;
a. Main Hospital, Breezeway located outside leading from the courtyard and kitchen supply storage area.

b. Main Hospital, Service Level - Kitchen, walk-in cooler and freezes in the kitchen.

c. Main Hospital, Service Level - Kitchen, Electrical Room.

d. Main Hospital, Service Level Main Electrical room accessible from the covered breezeway outside the kitchen storage area.

e. Main Hospital, Service Level - Kitchen, Catering Closet next to kitchen electrical room.

f. Main Hospital, Service Level - Pharmacy, walk-in cooler in the Pharmacy.

g. Main Hospital, Service Level - Kitchen, the Electrical closet located next to the pulper extractor.

h. Main Hospital, Service Level - Concourse, Electrical rooms NS001, NS002, NS003.

i. Main Hospital, Service Level - Pharmacy, there is an alcove located to the right of the walk-in refrigerator that is not properly covered by sprinkler coverage.

j. Main Hospital, Service Level - Pharmacy, the FAP data chase outside pharmacy.

k. Main Hospital, Service Level - IS-UPS Room, The IS-UPS room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

40. Main Hospital, Sprinkler hot box for the fire pump, the tamper alarm failed to give a signal at the main fire control station that one of the four valves was in the closed position.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0061.

41. Main Hospital, Basement, the distribution dry sprinkler system, the dry part of the sprinkler system has a high and low pressure valve that is not currently electrically supervised. The pressure operated flow switch valve up stream is not electrically supervised.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0061.

42. Main Hospital, 1st floor, Radiology suite, this area did not have an emergency air handler shut down switch installed for the air hander for that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

43. Main Hospital, 1st floor, MICU, STICU and SVICU, there are items stored in the corridor that are neither used or moved including beds, blood pressure machines, intravenous bag poles.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

44. Main Hospital, Service Level, Kitchen Area, the catering closet corridor door located near the electrical room was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

45. Main Hospital, Service Level, the IS EUS closet corridor door did not open 180 degrees and restricted the width of the by more than 7 inches when left open. This particular door opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

46. Main Hospital, Service Level Concourse, patient bed and other equipment was stored in the exit corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

47. Main Hospital, 1st floor, ED Trauma Bay suite, the means of egress, which includes two doors in a single exit discharge path, from the emergency department trauma bay suite, were blocked with storage.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

48. Main Hospital, 9th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

49. Main Hospital, 4th floor Clean Linen room, the facility had a mixture of full and empty oxygen cylinders in the full location in that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

50. Main Hospital, Mezzanine kitchen level, the facility had contractor welding cylinders not individually chained in that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

51. Main Hospital, oxygen storage farm, not all of the oxygen cylinders are individually chained. Not all of the Cylinders are not protected from rusting as they are sitting on the concrete pad. The cylinder valves are not protected from extremes from weather.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

52. Main Hospital, Service level Patient Transport, in the oxygen storage area in the patient transport area oxygen was found mixed and not labeled full and empty.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

Building 02
53. Women's and Children's, 2nd floor, patient doors on the corridor, the patient doors at this location have two leafs where the left leaf does not have positive latching. The left leaf if not attached to the door frame does not allow the right leaf to latch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

54. Main Hospital, 6th floor, North End Soiled Utility Room, the access door to the vertical chase did not close and latch and seal when tested. (Door required considerable force to close.)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0020.

55. Women's and Children's, 2nd floor, equipment storage between 228 and 236, the equipment door at that location did not have a door closure installed at that hazardous location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

56. Women's and Children's, 2nd floor, "A" wing on/off emergency release switch at the nurses station, The staff was not familiar with the release switch for the North Carolina Special Locking at this location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

57. Women's and Children's, Pediatrics "C" wing exit egress door, the on/off emergency release switch at the egress door was not a simple switch and did relock the door after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

58. Women's and Children's, 3rd floor elevator lobby, the two required exit doors at this location did not release with activation of and automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

59. Women's and Children's, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the facility required exit doors at the stairwells did not release with activation of an automatic fire alarm activation.

NOTE: this particular deficiency was corrected before the end of the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

60. Women's and Children's, 3rd floor exit egress stairwells, during the testing of the Hugs® Infant Protection System, the emergency door on/off switch was not a simple switch and did relock the door after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

61. Women's and Children's, 1st floor, triage area nurses station, there was no on/off emergency release switch a regularly manned station for the exit egress double doors at the entrance to the triage area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

62. Women's and Children's, 1st floor, triage area, the on/off emergency switch at the exit egress double door for the triage area was not a simple switch and did relock the door after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

63. Women's and Children's, Labor and Delivery area nurses station, there was no on/off emergency release switch a regularly manned station for the exit egress door or that location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

64. Women's and Children's, 2nd floor, "A" wing exit egress door. The North Carolina Special Locking system at this location does not have an on/off emergency release switch at the door location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

65. Women's and Children's, 3rd floor, Corridor # 2, the soiled tray holding room across from room 326 has a door that opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

66. Women's and Children's, 2nd floor, pediatrics electrical room, the double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

67. Women's and Children's, 2nd floor, electrical room near exam rooms 1 and 2, the double doors at that location open into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

68. Women's and Children's, 3rd floor, small cabinets on the egress corridor, the cabinet's right leaf door swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 12" into the corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

69. Women's and Children's, 3rd floor, ABC wings, there were unattended blood pressure machines plugged into the egress corridor on the A, B and C wings not in use.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

70. Women's and Children's, Ground floor, the storage room across from the procedure room at NICU, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall no has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

71. Women's and Children's, 1st floor, Med. Gas storage, the first floor medical gas storage room has several cylinders that are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

Building 03
72. Cape Fear Hospital, Basement, door to room B-08, the door at that location was wedged open preventing the door from being closed and latched.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

73. Cape Fear Hospital, 3rd floor, Board Room & Lecture Room, there was not positive latching to the corridor doors to the board room and the lecture room on third floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

74. Cape Fear Hospital, 1st Floor, corridor side of the switch board brake room, there were unsealed penetrations in the rated walls on the corridor side of the switch board brake room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

75. Cape Fear Hospital, bed and wheel chair repair room, there are unsealed penetrations in the rated walls on the corridor side at that location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

76. Cape Fear Hospital, 3rd floor, exit egress stairwell at the Pyxis/Storage room East wing, the stairwell door does not have a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

77. Cape Fear Hospital, Basement, soiled linen room B-05, the door to this room did not close latch and seal when tested.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

78. Cape Fear Hospital, required exit for Bigford area, the required exit at this area did not have a solid non slick surface other than grass or soil from that exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

79. Cape Fear Hospital, 2nd floor, four room alcove in the respiratory area, the doors for the rooms in this area had dead bolts installed and resulted in two motions of the hand for egress for these rooms.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

80. Cape Fear Hospital, 1st floor, ICU, the first floor ICU suite, this area less than 5,000 square feet, has identified a second exit with signage through the adjacent suite, this exit does not meet exit egress requirements as this exit had special locking arrangements installed but was not a simple switch and did relock the door after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

81. Cape Fear Hospital, 3rd floor, storage room, the third floor storage room at the entrance of the unit had more than one range of motion to exit the door.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

82. Cape Fear Hospital, 1st floor, Vendor/Contractor rooms, the vendor/contractor rooms are areas that are padlocked preventing egress from these rooms. Hospital staff does not carry keys for these areas.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

83. Cape Fear Hospital, 1st floor, cafeteria doors leading to the exit corridor, these two doors had dead bolts installed and results in more that one motion of the had to exit from that cafeteria location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

84. Cape Fear Hospital, 1st floor, cafeteria exit corridor, the North Carolina Special locking system for the egress corridor exit did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

85. Cape Fear Hospital, 1st floor, employees entrance, the North Carolina Special locking system for this location did not have an on/off emergency switch at the door. The switch was momentary and would relock after several seconds.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

86. Cape Fear Hospital, basement, exit egress near room B-14, the exit directional signage for that location is incomplete.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

87. Cape Fear Hospital, 1st floor, Pre admission testing side exit, the exit directional sign at that location leads to an outside walkway with no exit directional sign at the end of that walkway.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

88. The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking , and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

a. Cape Fear Hospital, 1st floor, radiology storage, confirm the sprinkler coverage in the first floor radiology storage room provides adequate coverage. This room was converted from an old dressing room with walls extending to the ceiling for each of the three dressing bays. The currently only one sprinkler head is in the space and is located in the back of the room.

b. Cape Fear Hospital, 3rd floor, water treatment room, the sprinkler head in this space is being blocked by the light fixture in that space.

c. Cape Fear Hospital, 3rd floor, the small MRI Electrical room, there was no sprinkler system coverage in the MRI electrical room. This room is not 2 hr Fire Rated Construction.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

89. Cape Fear Hospital, basement, sprinkler tamper alarm location LIN34, The sprinkler tamper alarm at that location failed to give a signal at the fire alarm control panel when tested.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0061.

90. Cape Fear Hospital, document review, smoke dampers, the documentation review of the smoke dampers for this building indicated that there were 9 out of 70 ducts within the smoke wall that did not have smoke dampers as required.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

91. Cape Fear Hospital, 2nd floor, water treatment room, the double doors for the water treatment room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

92. Cape Fear Hospital, 1st floor, surgery suite at the soiled linen location , the door to the surgery side of soiled linen did not have positive latching.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0075.

93. Cape Fear Hospital, oxygen storage farm, the oxygen cylinders are not individually chained. The Cylinders are not protected from rusting as they are sitting on the concrete pad. The cylinder valves are not protected from extremes from weather.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

94. Cape Fear Hospital, 2nd floor, O2 storage room, the second floor oxygen storage had partial tanks mixed with full tanks.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

95. Cape Fear Hospital, 1st floor, surgery suite, soiled linen room, the ABHR (Alcohol Base Hand Rub) in this room was located directly above an ignition source the light switch for that room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211.

Building 04
96. Behavioral Health, administration area, the attic access door at administration did not return to the closed position after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

97. Behavioral Health, the A/B Unit regularly manned station; this area does not have an emergency shut down switch for the air handler unit that services that area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

98. Behavioral Health, generator annunciator, the audible signal for the generator annunciator did not indicate that the generator was running after conducting the loaded generator test at the facility.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0144.

Building 05
99. Rehabilitation Hospital, 2nd floor, storage room doctors office, the storage room for the doctor's office across from the rehabilitation counselors' office had a dead bolt installed and resulted in more that one motion of the had to exit from that location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

100. Rehabilitation Hospital, 2nd floor, EMT FACP Room, Sprinkler head in that space is blocked.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

101. Rehabilitation Hospital, 2nd floor, Electrical Room, Sprinkler head in that space is blocked.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

102. Rehabilitation Hospital, 2nd floor, near bathroom W9, there are splatters of paint on the sprinkler head bulb near bathroom W9.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

103. Rehabilitation Hospital, 1st floor, electrical room, the door for this room opens into the egress corridor without opening 180 degrees flat to the corridor wall nor has a door closure installed to keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

104. Rehabilitation Hospital, 2nd floor, restorative range, the restorative rang in the independent living area was not locked out to prevent the range from being accidentally turned on.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0147.

Building 06
105. Medical Mall, the regularly manned station for this facility; this area does not have an emergency shut down switch for the air handler unit that services the hospital based provider area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

Building 07
106. H&D at Military Cutoff, corridor wall at back entrance, there are unsealed penetrations in the rated wall above the ceiling tile at the back wall to the back entrance of the hospital based provider space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

107. H&D Military Cutoff, Soiled Linen room, the door at the soiled linen room does not have a door closer installed to keep this hazardous are closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

Building 08
108. Cardiac Imaging, the hospital based provider space; the hospital based provider space is not separated from other tenants in the building as required.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

Building 09
109. The facility is utilizing special locking arrangements (Delayed egress and North Carolina Special Locking, and controlled access). The facility currently has areas in buildings number 1, 3, and 9 that are not fully sprinklered nor provide smoke detection (fully automated, supervised fire suppression or fully automated, supervised fire detection system) tied into the hospital main Fire Alarm Control Panel (FACP) as required when utilizing special locking arrangements. Some areas not covered are listed below. Provider to check all spaces for verification and for submittal of Plan of Correction.

a. Zimmer Cancer Center, Microbiology area, there is no sprinkler coverage in the walk-in cooler as required.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

110. Zimmer Cancer Center, Penthouse, the duct detector for air handler number 1 did not have and access door installed in order to view the sampling tubes at that location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

111. Zimmer Cancer Center, lab area, the carbon dioxide large cylinders in the lab are not individually chained to prevent cylinders from moving in the case that the current chain around them is removed.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

112. Zimmer Cancer Center, Control Room, Generator annunciator, the generator annunciator did not give an indication that th

Based on facility policy review, observation of care, and staff interview, the facility's infection control officer failed to maintain a hospital-wide program for the prevention and control of potential infections by failing to ensure that hemodialysis staff wore appropriate PPE (personal protective equipment) during a patient hemodialysis treatment where potential for contamination with blood/body fluids existed.

Findings include:

Review on 05/07/2012 of the facility's policy "Infection Control Precautions in the Hemodialysis Unit" (revised 08/2008) revealed "I. Purpose..To provide guidelines that reduce opportunities for transmission of infectious agents from patient to patient, staff to patient by contaminated equipment, supplies, environmental surfaces or hands of personnel. III. General Standards for Infection Control 8. Staff will wear appropriate PPE (impervious gown, face shield, mask, and gloves) during any procedure where there may be a potential for contamination with bloody/body fluids. This includes but is not limited to: initiation and termination of dialysis, access cannulation, checking sites, drawing blood from blood lines and/or administering medications into bloodlines."

Observation of care on 05/07/2012 at 1440 in the facility's hemodialysis unit (Campus A) revealed a hemodialysis registered nurse inside of a patient's hemodialysis station with a gown, face shield and gloves on. The observation revealed the nurse touching the patient's (considered contaminated) hemodialysis face screen for documentation, then grabbing a bio-hazard labeled specimen bag from the patient's station. The observation of the registered nurse revealed her impervious gown sleeves were rolled up her forearms on both arms while inside of the patient's hemodialysis station and holding the biohazard specimen bag.

An interview during the observation at 1450 with the hemodialysis administration staff revealed the staff member should have her gown sleeves covering her arms. The interview revealed the hemodialysis machine is considered contaminated. The interview also revealed that anytime specimen bags are touched, PPE should be worn appropriately. The interview confirmed the findings.

Based on Medical Staff Bylaws review, medical record review, and staff interview, the hospital failed to ensure the completion of an operative report immediately following surgery for 3 of 12 surgical records reviewed (#21, #15 and #12).

The findings include:

Review of current Medical Staff Bylaws dated 04/26/2011 revealed, "...Operative/Procedure Notes A. for inpatient/major invasive procedures: The operative note should be fully described by the operating physician in a standardized format and should include: Date of surgery, Preoperative diagnosis(es), Post operative diagnosis(es), Name of surgical procedure(s), Name of primary surgeon and assistant(s), Identity of anesthesia technique, Operative findings, Specimens removed (if not implied by the name of the case), Estimated blood loss, (and) Description of any intra-operative complications and resultant action taken....D. For-Post Operative/Procedure Progress note(s): The operative procedure progress note should be described by the operating physician and should include: Name of physician performing procedure and assistant(s), Name of technical procedure used, Description of findings, Estimated blood loss, Specimen(s) removed (if not [implied] by the name of the case), (and) Postoperative diagnosis...."

1. Closed medical record review for Patient #21 revealed a 75 year-old female that was admitted to the hospital's Campus B on 02/23/2012 with right hip fracture. Record review revealed on 02/24/2012 the patient underwent a surgical open reduction and internal fixation of the right hip. Record review revealed the surgery ended on 02/24/2012 at 1609. Record review revealed documentation of a handwritten post-operative noted dated 02/24/2012 (no time) and signed by the surgeon. Review of the handwritten post-operative note revealed documentation of preoperative diagnosis, postoperative diagnosis, procedure name, surgeon's name, and type of anesthesia administered. Review of the note revealed no documentation of a description of findings, estimated blood loss, or specimen(s) removed. Further record review revealed documentation of an operative report dictated by the surgeon on 03/26/2012 at 0747 (31 days after surgery). Record review revealed no documented evidence a physician's post-operative report was completed and available in the record immediately following the patient's surgery.

Interview on 05/09/2012 at 1430 with the Nurse Manager of the 3rd floor post-operative nursing unit at Campus B revealed the surgeon should write a post-operative note immediately following surgery and place it in the medical record. Interview revealed there was a template that contained all of the required components of a post-operative note that was usually used by the surgeon for the post-operative note. Further interview revealed the post-operative note must be timed to show it was completed immediately after surgery. Interview confirmed the hand-written post-operative note for the patient was not timed and there was no documented evidence the note was completed immediately following surgery. Interview confirmed the post-operative note did not include all required components of a post-operative note, including no documentation of a description of findings, estimated blood loss, or specimen(s) removed. Further interview confirmed the first available documentation of a complete post-operative report was on 03/26/2012, when the surgeon dictated an operative report 31 days after surgery.



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2. Closed medical record review for Patient #15 revealed a 69 year-old female that was admitted as an outpatient to the hospital's Campus B on 04/12/2012 for an arthroscopy of the left shoulder (surgical procedure). Record review revealed the surgery ended on 04/02/2012 at 0805. Record review revealed a pre-printed "Post Operative Progress Notes" template that included the required components of a post-operative note. Review revealed this section of the note stated "See Op Note" and was not dated, timed or signed by the physician. Further record review revealed a dictated operative report was transcribed and available on 04/02/2012 at 1030 (2 hours and 25 minutes after the surgery ended).
Record review revealed no documented evidence a physician's post-operative report was completed and available in the record immediately following the patient's surgery.

Interview on 05/09/2012 at 1400 with Operating Room nursing administration staff at Campus B revealed the surgeon should write a post-operative note immediately following surgery and place it in the medical record. Interview revealed there was a template that contained all of the required components of a post-operative note that was usually used by the surgeon for the post-operative note. Further interview revealed the post-operative note must be timed to show it was completed immediately after surgery. Interview confirmed the hand-written post-operative note for the patient referenced a dictated post-operative note that was not transcribed and available immediately following surgery. Further interview confirmed the first available documentation of a complete post-operative report was on 04/02/2012 at 1030 (2 hours and 25 minutes after the surgery ended).

3. Closed medical record review for Patient #12 revealed a 23 year-old female that was admitted to the hospital's Campus A on 04/03/2012 for abdominal pain with nausea and vomiting. Record review revealed the patient had a laparoscopic cholecystectomy and laproscopic appendectomy (surgical procedure) completed on 04/07/2012. Record review revealed the surgery ended at 1559. Record review revealed a handwritten operative note dated 04/07/2012, not timed that failed to include the anesthesia type, specimens removed and description of complications. Further record review revealed a dictated operative report was transcribed and available on 04/07/2012 at 1654 (55 minutes after the surgery ended).
Record review revealed no documented evidence a physician's post-operative report was completed and available in the record immediately following the patient's surgery.

Interview on 05/09/2012 at 1030 with Operating Room nursing administration staff at Campus A revealed the surgeon should write a post-operative note immediately following surgery and place it in the medical record. Interview revealed there was a template that contained all of the required components of a post-operative note that was usually used by the surgeon for the post-operative note. Further interview revealed the post-operative note must be timed to show it was completed immediately after surgery. Interview confirmed the hand-written post-operative note for the patient was not timed and failed to include the anesthesia type, specimens removed and complications. Further interview confirmed the first available documentation of a complete post-operative report was on 04/07/2012 at 1654 (55 minutes after the surgery ended).