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A. Based on request for CAH policy, observation, and staff interview, it was determined that in 1 of 7 (Room 4A) Emergency Department (ED) rooms, the CAH failed to ensure that all supplies available for patient care use were not outdated.

Findings include:

1. On survey date 1/11/10 at approximately 9:15 AM a tour was conducted in the Hospital's ED. During the tour the following patient care supplies were identified as expired and therefore unavailable for use: Foley catheters size 6, five (5) expired 4/2010, four (4) expired 6/2010 and one (1) nasopharyngeal airway size 22 expired 12/2009.

2. The CAH's policy regarding outdated patient care supplies for the ED was requested on 1/11/11 at approximately 11:00 AM. As of 2:15 PM on 1/11/11 the policy was unavailable for review.

3. The findings were verified with by the Director of Emergency Services on 1/11/11 at approximately 9:30 AM. On 1/12/11 at approximately 8:45 AM the Chief Medical Officer stated that Hospital does not have a policy regarding outdated patient care supplies for the Emergency Department.

A. Based on observation, review of dietary sanitizer requirements, and staff interview, it was determined that the CAH failed to ensure all mixtures of sanitizers in dietary met the minimum requirements.

Findings include:

1. During a tour of the dietary department, conducted on 1/10/11 at 1:15 PM, it was observed there were dipsticks to measure the concentration of sanitizer in the three compartment sink. There was no documentation that indicated the dipsticks were used to ensure the proper concentration was achieved when new water was mixed.

2. The directions for the sanitizer (Quat-San Plus) on the container indicated that the proper concentration is 200 PPM (parts per million). There was no documentation that indicated the dipsticks were used to ensure the proper concentration of sanitizer.

3. During an interview with the Dietary Manager, conducted on 1/10/11 at 1:20 PM, the above finding was confirmed.

A. Based on a review of policy and procedure, review of radiation dosimetry reports, and staff interview, it was determined that for three of three quarters for year 2010, (5 of 45 for the quarterly report dated 4/21/20, 8 of 52 for the quarterly report dated 8/26/10, and 25 of 54 for the quarterly report dated 12/7/10), the CAH failed to ensure all staff utilized dosimetry badges properly.

Findings include:

1. The CAH policy and procedure titled, "PERSONNEL MONITORING BADGES" was reviewed on 1/10/11 at approximately 2:00 PM. The policy required, "... C. All personnel issued badges are required to wear the body and/or ring badges during all working hours."

2. The radiation dosimetry reports dated 4/21/10, 3/26/10, and 12/7/10 were reviewed. They indicated that of a total of 151 dosimetry badge readings 38 were marked as "absent" or "unused" (5 of 45 for the quarterly report dated 4/21/20, 8 of 52 for the quarterly report dated 8/26/10, and 25 of 54 for the quarterly report dated 12/7/10).

3. During an interview with the Radiology Manager, conducted on 1/10/11 at 2:00 PM, the above findings were confirmed. It was also verbalized that those dosimeter badges marked as "absent" were lost and therefore, could not be turned in for readings.

A. Based on review of review of Medical Staff Rules and Regulations, attestation letter, and staff interview, it was determined that the CAH failed to ensure all Medical Records were completed within 20 days as required by Hospital by-laws.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations, reviewed on survey date 1/11/11 at approximately 10:00 AM, required, "..XI. Medical Records:..O. Suspensions, 2. Any medical record shall be considered delinquent when it has been incomplete for more than 20 days.."

2. On survey date 1/11/11 at approximately 1:30 PM, the Health Management Department Manager presented an attestation letter dated 1/11/11, that indicated the CAH has 23 medical records delinquent past 20 days.

3. The findings were verified with the Chief Medical Officer during an interview on 1/11/11 at approximately 1:45 PM.