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Based on record review and interview, a registered nurse (RN) did not supervise and evaluate 1 of 5 current inpatients (Patient #5), in that a nurse (Personnel #29) administered medications without following the frequency ordered by the physician on 01/24/14.

Findings included:

Patient #5 was admitted on 01/24/14 after a surgical procedure: left knee arthroscopy, irrigation, and debridement. On 01/24/14 at 5:40 PM, Patient #5 was given "Percocet" 2 tablets by mouth for pain. On 01/24/14 at 7:57 PM, Personnel #29 administered "Percocet" 2 tablets by mouth for pain. "Percocet" was given 2 hours and 17 minutes after the last dose. Per physician's order the next dose should have been at 9:40 PM.

A telephone physician's order dated 01/24/12 reflected "Percocet 1-2 PO Q 4 hours PRN pain."

A review by the pharmacist (Personnel #12) on 01/27/14 reflected "Medication...Incident Report...A dose of Percocet (2 tablets) were given at 5:40 PM (on 01/24/14) and then the next dose (2 tablets) was given at 7:57 PM (on 01/24/14) only 2 hours and 17 minutes between doses and not the 4 hours as directed" by the physician.

In an interview on 01/27/14 and 01/28/14 at 4:13 PM and 9:00 AM respectively, Personnel #12 (Pharmacist) was informed of the above findings. Personnel #12 confirmed the findings and stated the incident was considered as an "adverse drug reaction."

In an interview on 01/28/14 at approximately 2:30 PM, the Chief Nursing Officer (Personnel #3) was informed of the above findings. Personnel #3 was asked if she was aware that a nurse did not follow the directed frequency of the "Percocet" order. Personnel #3 replied the pharmacist reported this error to her.

Policy: "Patient Safety Plan" reviewed on 08/2013 required "Purpose: A. The purpose of the organizational Patient Safety...is to improve patient safety and reduce risk to patients through an environment that encourages...6. Organizational learning about medical/health care errors...B. Methodology...2. All departments within the organization ...are responsible to report safety occurrences and potential occurrences to the Risk Manager (RM) within 24 hours of occurrence..."

Based on record review and interview, the facility failed to ensure that the nursing care plan was kept current, citing 1 of 5 current inpatients (Patient #5) who had a change of condition on 01/25/14. Patient #5 was found unresponsive on 01/25/14 at 1:50 AM.

Findings included:

Patient #5 was admitted on 01/24/14 after a surgical procedure: left knee arthroscopy, irrigation, and debridement. On 01/25/14 at 1:50 AM, Patient #5 was found to have shallow breathing and "turning dusky...failed attempts to arouse patient even with a sternum rub several times..." Per physician's order, a total of 0.6 mgs of "Narcan" was administered. The nursing care plan was not updated to reflect the patient's change of condition.

In an interview on 01/28/14, Personnel #1 (Inpatient Director/Quality Manager) was informed of the above findings. Personnel #1 confirmed the findings.

Policy: "Nursing Plan of Care" reviewed on 08/2013 required "4. Evaluation - The nursing plan of care shall be reviewed ...The problems, goals, priorities, and interventions shall be revised or documented again as needed..."

Based on interview and record review 3 of 4 House Nursing Supervisors (Personnel #8, #27 and #28) did not have a current required Pediatric Advanced Life Support (PALS) certification as described in their job description.

Findings included:

Review of Personnel #8, #27 and #28's employee file revealed their signed job description of House Supervisor included a required PALS certification. Personnel #8 and Personnel #28 did not have any documentation of having a PALS certification. Personnel #27 had a PALS certification with an expired date of 03/2013.

During an interview on 1/29/14 at 11:20 AM with Personnel #1 she confirmed Personnel #8, #27 and #28 did not have current PALS certification. Personnel #1 stated pediatric and adult patients received care in the hospital and the hospital's ED (emergency department).

Based on observation, interview and record review, the facility failed to ensure that unauthorized individuals cannot gain access to or alter patient records in that 3 of 5 inpatient's medical records were left unsecured and unattended at the nursing desk on 01/27/14, citing Patient #1, #2, and #5.

Findings included::

During a tour on 01/27/14 at 1:25 PM on the inpatient floor, two surveyors observed 3 inpatient records (Patient #1, #2, and #5) were left unsecured and unattended at the nursing desk. A female client walked by the nursing desk and stated she wanted a drug screen, and asked for directions to the laboratory. No hospital staff was available to answer the question.

In an interview on 01/27/14 at 1:40 PM, Personnel #8, House Supervisor was informed of the above observation. Personnel #8 confirmed the observation.

The facility's policy "Secure Filing of Medical Records" last revised 8/23/12 required "Medical records shall not be left unattended in areas accessible to unauthorized individuals".

Based on observation, interview and record review the facility failed to ensure 2 of 2 glucometers located in the preoperative/post-anesthesia care unit (PACU) and at the nurses' station/in-patient department had current biomedical inspection.

Findings included:

Observation on 1/28/14 at 9:55 AM at the nurse's desk in the Pre-OP/PACU (pre-operative/post anesthesia care unit) revealed the Hemocue Glucose glucometer did not have a biomedical sticker. Personnel #14 confirmed there was not a biomedical sticker on the glucometer.

During an interview on 1/28/14 at 11:10 AM with Personnel #17 he stated he had no documentation confirming the Pre-OP/PACU glucometer had been checked by the contracted biomedical company. Personnel #17 called the biomedical company and confirmed there was no documentation that the glucometer had been checked.

Observation on 1/28/14 during the afternoon of the nurses station in the in-patient department revealed the Hemocue Glucose glucometer had a biomedical inspection sticker with an expired date of 11/2013. Personnel #8 confirmed the glucometer's expired date.

The hospital's Medical Equipment Management Plan policy and procedure dated 12/2012 reflected, "...The Biomedical Engineering Technician assures that scheduled testing of all non-life support equipment is performed in a timely manner..."

Based on interview and record review the facility failed to ensure temperature and humidity levels were kept within safe parameters for 4 out of 4 operating rooms (OR #1, #2, #3, and #4).

Findings included:

Review of the hospital's surgical January, 2014 Temperature and Humidity log for operating rooms (ORs) 1-4 revealed room temperatures should be maintained between 65 F-73 F (F-Fahrenheit); and room humidity levels should be maintained between 30%-60%.

The temperature and humidity levels were tested 19 days during January, 2014. The following reflect the readings in ORs 1-4.
OR 1: Temperatures were not maintained between 65 F-73 F for 17 days. Humidity levels were not maintained between 30%-60% for 14 days.
OR 2: Temperatures were not maintained within the parameters for 16 days. Humidity levels were not maintained between the parameters for 14 days.
OR 3: Temperatures were not maintained within the parameters for 18 days. Humidity levels were not maintained between parameters for 16 days.
OR 4: Temperatures were not maintained within the parameters for 19 days. Humidity levels were not maintained between parameters for 14 days.

During an interview with Personnel #14 on 1/28/14 at 10:15 AM she confirmed the temperature and humidity levels were not always maintained in the ORs. Personnel #14 stated the surgeons often requested the temperatures in the ORs to be lowered. Personnel #14 stated she had reported the lower humidity levels in the ORs to the maintenance department.

During an interview with Personnel #17 on 1/28/14 at 11:10 AM he stated when the OR room temperatures are kept colder (outside the parameters) the humidity levels would be lower. Personnel #17 stated he had known about the humidity levels not staying within the suggested parameters for "around 2 weeks." Personnel #17 stated one of the facility humidifiers didn't always work properly and he needed to call the repair company and have them come to the hospital and repair it.

The hospital's Operating Rooms Temperature, Humidity and Ventilation Policy and Procedure dated 11/2010 reflected, "...Keep the relative humidity at 30 to 60 percent... Temperature of the operating room will be maintained at 68 to 73 degrees F..."

Based on observation, record review, and interview, the facility failed to implement and enforce an infection control policy in that, 3 of 3 health care providers (Personnel # 23, #24, and #25) were observed to wear masks outside the restricted area (surgical suite) on 01/29/14.

Findings included:

During a tour in one of the hospital's outpatient departments (HOPD) on 01/29/14 at 8:51 AM, the surveyor observed Personnel #23 transferring a gurney from the surgical suite to the preoperative area. Personnel #23 was wearing a surgical mask. At 9:01 AM, Personnel #23 was observed again wearing a surgical mask in the preoperative area. At 8:56 AM, Personnel #24 was observed in a patient's bay in the preoperative area wearing a surgical mask. At 9:25 AM, Personnel #25 was observed wearing a surgical mask and was walking through the preoperative office in the presence of Personnel #26 (Director of the HOPD) and the two (2) surveyors.

In an interview on 01/29/14 at 9:30 AM, Personnel #26 was informed of the above findings and confirmed the findings. Personnel #26 stated the facility follows the guidelines of AORN (Association of periOperative Registered Nurses).

Perioperative Standards and Recommended Practices, 2012 edition under "...Surgical Attire" page 66 reflected "VI.c. "Surgical masks should be discarded after each procedure."

Policy: "Procedure for Donning and Removing a Mask" revised on 08/2012 did not include when to discard the used mask.

Based on observation and interview the facility failed to ensure 1 of 2 surgical services (the free standing outpatient surgery center) maintained a roster with a list of surgeons and their delineated surgical privileges.

Findings included:

On 1/29/14 at 9:30 AM during a tour of the hospital's outpatient surgery center a surgical roster was not observed.

During an interview with Personnel #26 on 1/29/14 at 9:50 AM he confirmed there was no surgical roster containing the names of the practicing surgeons with their delineation of surgical privileges.

During an interview on 1/29/14 at 11:40 AM with Personnel #1 she stated the hospital did not have a policy for a surgical roster that contained the names of the practicing surgeons with their delineated surgical privileges.