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Based on review of Hospital documents and staff interview, it was determined that in 1 of 4 (Pt #11) clinical records reviewed on the 3rd floor nursing units (3 East and 3 North), the Hospital failed to ensure all patients receive a complete nursing assessment.

Findings include:

1. The clinical record of Pt #11 included that Pt #11 was a 29 year old female admitted on 11/12/12 with a diagnosis of Bronchitis. Pt #11 had a Left Upper Arm Fistula for dialysis access on admission. The nursing admission assessment dated 11/13/12 at 1:20 AM lacked an assessment of Pt #11's Left Upper Arm Fistula.

2. Hospital policy entitled , "Documentation of Nursing Care," (effective 8/10) required, "Attachment I: In-patient Admission...4. The Admission Assessment includes: c. Physical Assessment 1. This includes a physical assessment organized by body system."

3. The Unit Manager of the 3 East Unit stated during an interview on 11/13/12 at approximately 2:00 PM that Pt #11 did not have her fistula assessed.

Based on review of Hospital documents and staff interview, it was determined that for 1 of 3 (Pt #8) clinical records reviewed on the 3 East Medical/Surgical Unit, the Hospital failed to ensure all medications were administered according to physicians' orders.

Findings include:

1. The clinical record of Pt #8 included that Pt #8 was a 22 year old female admitted on 11/11/12 with a diagnosis of Sickle Cell Anemia. The clinical record contained a physician's order dated 11/11/12 that required that Pt #8 be medicated with Dilaudid 2 mg IVP (intravenous push) every 3 hours prn (as needed) for pain rated between 7 - 10 on a scale of 1 - 10. Nursing documentation dated 11/12/12 at 10:10 AM and at 11:48 PM included that Pt #8 received Dilaudid 2 mg IVP for pain rated at a 6.

2. Hospital policy entitled, "IV and IV Push Medications, Administration of," (effective date 02/12) required, "Policy Statements: A. Administration of IV and IVP medications shall be initiated by order of a physician with FHN Memorial Hospital privileges."

3. The Manager of the 3 East Unit stated during an interview on 11/13/12 at approximately 11:30 AM that the patient received IVP pain medication for a pain level below the prescribed requirement of 7 - 10.

Based on review of Hospital documents and staff interview, it was determined that the Hospital failed to ensure all clinical records are completed, as required.

Findings include:

1. On 11/14/12 at approximately 1:45 PM the Hospital presented an attestation letter that indicated that as of November 14,2012, the Hospital had 306 delinquent (incomplete)records, greater than 30 days post discharge.

2. The Director of Health Information Management stated during an interview on 11/14/12 at approximately 2:00 PM, that there are 306 delinquent records.

Based on review of Hospital documents, observational tour, and staff interview, it was determined that for 3 of 6 surgical and procedure rooms (Rms. 2, 4, & 6) and the soiled instrument room, the Hospital failed to ensure the Operating Room (OR) and equipment was maintained, in order to reduce the potential of surgical site infections. This potentially affected 15 of 15 patients having surgical procedures on 11/14/12.

Findings include

1. Hospital policy, revised February 2003, titled "Patient Outcome: Standards of Perioperative Care" required, "The Surgical Department of FHN Memorial Hospital will follow A.O.R.N. 'Standards of Perioperative Care'".

2. Association of periOperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices 2012 Edition was reviewed and required, "Recommendation I: The patient should be provided a clean, safe environment... Exogenous sources for pathogens that may cause a surgical site infection (SSI) include... the operating room environment... The risk of infection from pathogenic organisms on environment surfaces... [may] be transferred to many surfaces..."

3. Hospital policy, effective September 2010, titled, "Cleaning and Decontamination of Reusable Surgical Instruments and Patient Care Equipment" required "... Manual cleaning... must be done as a pre-cleaning step for instruments with lumens..."

4. On 11/14/12 between 6:40 AM and 7:45 AM, an observational tour was conducted in the OR and the following was found:

- Room 2, in the ready for use Anesthesia Cart, 3 opened sterile packages contained 3 Yankauer suction tubes, creating the potential for contamination of the instruments.

- Room 4, in the ready for use Anesthesia Cart, 2 opened sterile packages contained 2 Yankauer suction tubes.

- Room 4, the ceiling light above the surgical bed contained rust, creating the potential for contamination to the surgical site.

- Room 6, the wall contained multiple tears, which could not be properly disinfected during cleaning.

- The soiled instrument room, included 4 of 20 dirty/fragmented wire brushes used to clean cataract instruments and lumens prior to flash sterilization, creating the potential to introduce contaminants into the instruments during cleaning.

5. An interview was conducted with the OR Manager on 11/14/12 at approximately 7:00 AM. The OR Manager stated that the OR follows AORN standards and recommended practices. Yankauer suction tubes should not be left open in the anesthesia cart.

A. Based on review of Hospital documents, observation and staff interview, it was determined that for 6 of 9 employees ( E #1, 2, 3, 5, 6, and 7) observed in OR room #3, the Hospital failed to ensure adherence to the OR dress code.

Findings include:

1. Hospital policy entitled, "Infection Control - Dress Code Within Operating Room," (effective 03/09) required, "Method of Implementation. A. Only persons wearing appropriate scrub clothes with caps and appropriate shoe/shoe covers will be allowed in the semi-restricted and restricted areas of the Surgical Suite... F. Scrub Clothes... 5. Shoes should have enclosed toes...G. Masks. 1. A disposable mask, covering mouth and nose is required...4. Masks will be tied properly when worn. H. Caps. 1. Hair must be covered at all times..."

2. On 11/14/12 between 7:00 AM and 8:00 AM, the following observations were identified in OR #3:
- the CRNA (E #7) entered the room with approximately 1 and one half inches of hair exposed from the back of his head cover;
- the house keeper (E #6) entered the room tying her mask;
- the Circulating Nurse (E #5) entered the room tying her mask;
- the Anesthesiologist (E #1) entered the room with approximately 1 inch of hair exposed from the back of her head cover, tying her mask, and with open toed shoes;
- Staff nurse (E #2) entered the room tying her mask;
- the PA (E #3) entered the room tying his mask and with beard exposed from the side of his face mask.

3. The findings were discussed with the OR Manager during an interview on 11/14/12 at approximately 8:30 AM.

B. Based on review of Hospital documents, observation and staff interview, it was determined that in 1 of 2 (OR #3) OR suites observed, the Hospital failed to ensure morning cleaning was completed prior to room preparation.

Findings include:

1. The Hospital's cleaning service policy entitled, "Surgical/Invasive Areas and Delivery Rooms - Start of Day," (Chapter 8, dated 10/31/12) required, "All horizontal surfaces in the OR (e.g. ...surgical lights...) should be damp dusted before the first scheduled surgical procedure of the day."

2. On 11/14/12 at approximately 7:00 AM, during an observational tour of OR #3, it was observed the surgical table was prepared with a clean drape and surgical packs were in the room. The Housekeeper (E #6) was observed lowering the surgical lights, above the prepared surgical table, and proceeded to clean the lights.

3. The findings were discussed with the OR Manager during an interview on 11/14/12 at approximately 8:30 AM. Prior to proceeding with the scheduled surgical procedure, the table was cleaned, prepped and new surgical supplies were brought into the room for usage.