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Based on review of clinical records and interview with staff, it was determined that the facility failed to provide complete medical records consistent with the facility's policies and procedures.

Findings were:

Review of the medical record of patient # 3, admission date 10/31/2013, revealed that the Pre and Post-operative progress notes were not completed to include the history and physical portion of the document. The physician signed, dated and timed the document without completing the portions of the document which indicate if the history and physical exam was up to date or if it required any changes.

Review of the medical record of patient # 7 revealed that the Post-anesthesia evaluation for the record dated 10/27/2013 was not completed by the anesthesiologist. The Post-anesthesia evaluation consists of: 1- Respiratory status review. 2- Cardiovascular status review. 3- Mental status review. 4- Pertinent observations of temperature, pain control, nausea and vomiting, and fluid status. This surveyor observed that all these fields were left blank.

Review of facility policy regarding medical records stated the following on page 14, item 6: A post-anesthesia evaluation is completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.

In an interview, the Chief Nursing Officer concurred that the records were incomplete.

Based on tour of surgical suite and surgical storage areas on 11/04/2013, it was determined that the facility failed to enforce its infection control policy regarding guidelines for attire in Semi-Restricted and Restricted Surgical Areas. Futhermore, the facility failed to follow best practices regarding safe storage af surgical devices and proper cleaning of surgical suites.

Findings were:

1. Environmental Tour conducted on 11/04/2013 at approximately 10:15 AM revealed the following: Three operating rooms (OR) were inspected which included OR # 1 with an ongoing surgical procedure. During the inspection of OR # 2, this surveyor observed that a vial of Neostigmine Methyl sulfate had been open and not dated to state when it would expire. An inspection of the crash cart in the OR # 2 revealed a lab tube with an expiration date of 10/2013. Tour of OR # 3 revealed two small medical supply debris on the floor just adjacent to the operating room table. This surveyor asked if the rooms were ready to receive a patient and the OR director responded confirming that the rooms had been cleaned and were ready for the use.

During a tour of the surgical area's supply room, this surveyor observed two guide wire devices used in surgical procedures were inappropriately stored. The devices were touching the storage room's floor.

2. During inspection of OR #1 during a surgical procedure, it was observed that staff did not wear shoe covers during the procedure when blood could be observed in several sections of the OR floor. When interviewed, the OR Director stated that the facility did not require staff to wear shoe covers in the OR suite. Review of policy titled: Delineating Guidelines for Attire in Semi-Restricted and Restricted Surgical Areas; Category: Infection Control; Effective date: 9/2010, revealed the following (not all inclusive):
? Surgical attire, which includes scrub clothes, surgical gowns, hair coverings, protective eyewear, and other protective barriers, are worn to provide a barrier to contamination that may pass from personnel to patient and/or patient to personnel.
? Protective barriers shall be available to reduce the risk of exposure to potentially infectious materials. These include, but are not limited to, gloves, masks, protective eyewear, and shoe covers.
? Additional protective attire such as liquid resistant aprons, gowns, and shoe covers should be worn when there is exposure to large volumes of blood, body fluids or potentially infectious material.
Staff could be observed walking within the surgical suite and stepping on potentially infectious body fluids without wearing shoe coverings.
These finding were confirmed by the Operating Room Director during the tour of the surgical suite.