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A. Based on a review of the Hospital's Quality Improvement Program, a review of the Hospital's CPIC (Clinical Performance Improvement Council) meeting minutes and staff interview, it was determined that the Hospital failed to ensure that all departments reported all quality improvement measures to the Quality Improvement Committee for analysis.

Findings include:

1. A review of the Quality Improvement Program, CPIC meeting minutes for the past year and departmental quality indicators was conducted on 04/27/10. It was indicated that the following departments did not report all measurable quality indicators to the Quality Improvement Committee for analysis: Dietary, Infection Control and Radiology. Therefore, those quality indicators that were not reported to Quality were not analyzed for improved health outcomes and prevention and reduction of medical errors.

2. During an interview conducted on 04/27/10 at 2:00 PM with the Quality Improvement Manager, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 30 (Pt #5) medical records reviewed, it was determined that the Hospital failed to ensure all drugs and biologicals were administered on the orders of a physician.

Findings include:

1. The medical record of Pt #5 was reviewed on 4/26/10. It indicated Pt #5 was admitted on 4/15/10 with a diagnosis of Small Bowel Obstruction. A physician's order, dated 4/22/10, was for the patient to receive a 500cc bolus of 0.9% saline. There was no documentation in the medical record that indicated the 500cc bolus was administered.

2. During an interview with the Quality Improvement Manager, conducted on 4/26/10 at 10:45 AM, the above finding was confirmed.

B. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure all medications were administered in a timely manner.

Findings include:

1. The Hospital policy and procedure titled, "Medication Availability and Administration" was reviewed on 4/26/10. It indicated under, "V. PROCEDURE 1.3...A. Routine medications are administered within a timeframe of 30 minutes before through 30 minutes after the scheduled administration time."

2. During a tour of the East/West medication room, conducted on 4/26/10, it was observed that a Vancomycin IV of 250ml was marked as due at 11:00 AM. It was not administered as of 11:50 AM making it 20 minutes late.

3. During an interview with the Quality Improvement Manager, conducted on 4/26/10 at 12:00 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 4 of 30 (Pt #'s 3, 18, 23, 30) medical records reviewed, the Hospital failed to ensure that all orders were dated, timed and authenticated by the ordering physician.

Findings include:

1. The Hospital policy titled, "Herrin Hospital Medical Staff Policies/Procedures" was reviewed on 04/27/10. It indicated under, "7.0 Medical Records: B., All patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided..."

2. The medical record of Pt #3 was review on 04/26/10. Documentation indicated that Pt #3 was admitted on 04/21/10 with an admitting diagnosis of Community Acquired Pneumonia. Documentation indicated that from 04/21/10 to 04/23/10, multiple physician's orders were not signed, dated or timed by the ordering physician.

3. The medical record of Pt #18 was reviewed on 04/28/10. Documentation indicated that Pt #18 was admitted on 03/11/10 with the admitting diagnoses of Pneumonia, Acute Renal Failure, Acidosis, Mental Retardation and Hypertension. Documentation indicated that from 03/16/10 to 03/20/10, multiple physician's orders were not dated and or timed by the ordering physician.

4. The medical record of Pt. #23 was reviewed on 4/28/10. Documentation indicated that Pt. #23 was admitted on 02/25/10 with the diagnoses of Cerebral Vascular Accident with Right Hemiplegia and Pressure Ulcer Lower Back. Documentation indicated that between 2/27/10 to 3/17/10 3 telephone orders had either no time of order written or incomplete dates of orders written.

5. The medical record of Pt. #30 was reviewed on 4/29/10. Documentation indicated that Pt. #30 was admitted with diagnosis of Pneumonia. Documentation indicated that 2 telephone orders written on 04/25/10 and 1 written on 4/27/10 had no date or time of physician signature.

6. During an interview conducted on 04/28/10 at 2:00 PM with the Quality Improvement Manager, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 5 of 30 (Pt #'s 11, 17, 18, 27, 28 ) medical records reviewed, that the Hospital failed to ensure that all verbal orders were authenticated within 48 hours.

Findings include:

1. The Hospital policy titled, "Herrin Hospital Medical Staff Policies/Procedures" was reviewed on 04/27/10. It indicated under, "7.1 Physician Orders: A. Timeframe: Telephone orders shall be used sparingly and authenticated within 48 hours of the order."

2. The medical record of Pt #11 was reviewed on 04/27/10. Documentation indicated that Pt #11 was admitted on 07/13/09 with the diagnoses of Bronchitis, Chronic Obstructive Pulmonary Disease and Small Cell Cancer of Right Upper Lobe. Documentation indicated that from 07/19/09 to 07/21/09, multiple telephone order were signed and dated over 48 hours from when they were written.

3. The medical record of Pt #17 was reviewed on 04/28/10. Documentation indicated that Pt #17 was admitted on 03/25/10 with the diagnoses of Urosepsis, Hypercapnic Respiratory Failure, Methicillin Resistant Staph Aureous and Bacteremia. Documentation indicated that between 03/29/10 to 04/14/10, multiple telephone orders were signed and dated over 48 hours from when they were written.

4. The medical record of Pt #18 was reviewed on 04/28/10. Documentation indicated that Pt #18 was admitted on 03/11/10 with the admitting diagnoses of Pneumonia, Acute Renal Failure, Acidosis, Mental Retardation and Hypertension. Documentation indicated that between 03/12/10 to 03/26/10, multiple telephone orders were signed and dated over 48 hours from when they were written.

5. The medical record of Pt. #27 was reviewed on 4/28/10. Documentation indicated that Pt. #27 was admitted on 02/28/10 with diagnoses of Urinary Trac Infection, Anemia and Stage I Pressure Ulcer-buttock. Documentation indicated that 2 telephone orders written on 2/28/10 were signed over 48 hours from the date written.

6. The medical record of Pt #28 was reviewed on 04/28/10. Documentation indicated that Pt #28 was admitted on 04/12/10 with the diagnoses of Pneumonia, Bronchitis and Alzheimer's Disease. Documentation indicated that on 04/12/10 and 04/13/10, multiple telephone orders were signed and dated over 48 hours from when they were written.

7. During an interview conducted on 04/28/10 at 2:00 PM with the Quality Improvement Manager, the above findings were confirmed.

A. Based on a review of hospital documents and staff interview, it was determined that the hospital failed to ensure that all medical records are completed within 30 days following discharge.

Findings include:

1. A review of the Delinquency Rate Report was completed on 4/26/10. Documentation indicated a total of 411 charts were incomplete and considered delinquent.

2. During an interview with the Quality Improvement Manager on 4/26/10 at 11:00 AM, the above finding was confirmed.

A. Based on observation and staff interview, it was determined that the hospital failed to ensure that all drugs and biologicals were maintained in a secure, locked area.

Findings include:

1. During a tour of the North Medical Nursing Unit on 4/26/10 at 11:00 AM, it was noted that several drawers in the medication cart, which was not in use, were not fully closed and therefore unlocked.

2. During an interview with the Administrative Director of Patient Care Services on 4/29/10 at 10:30 AM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that all expired/outdated drugs and biologicals were not removed from patient use areas.

Findings include:

1. The Hospital policy and procedure titled, "Outdate or Recalled Medications" was reviewed. It indicated under "II. DEFINITIONS Each drug shall have an expiration date printed on its package....Outdated medications will be removed before the expiration date listed on the medication label."

2. During a tour of the Medical/Surgical East/West medication room, conducted on 4/26/10, the following observations were made: In the Stat Heart Box a Plavix 300mg tablet expired 11/09 and a Nitroglycerin 500ml bottle was expired on 1/12/09. In the Extravasation Kit there was a Sodium Thiosulfate 50ml that expired 3/09, Sterile Water 10ml, expired 1/8/09; 0.9% Sodium Chloride 10ml, expired 1/9/09, and Solu-Cortef 2ml, expired 6/09. On the North Medical unit, 4 pre-filled syringes with normal saline were observed to be expired on 4/1/10.

3. During an interview with the Director of Pharmacy, conducted on 4/26/10 at 11:30 AM, the above findings were confirmed.

A. Based on a review of the Hospital's policy and procedure, Radiation Dosimetry Reports, and staff interview, it was determined that in 93 of 139 dosimeter badge reports, that the Hospital failed to ensure compliance with it's radiation safety badge program.

Findings include:

1. The Hospital policy and procedure titled, "Radiation Protection Policy" was reviewed on 4/27/10. It indicated under, "I. Policy ...Imaging Services has a formalized program to keep radiation exposure ALARA (As Low As Reasonably Achievable). The implementation of this program provides for a hierarchy of oversight whose ultimate aim is to reduce exposure to ionizing radiation and assure compliance with appropriate regulations." And under, "V. To comply with the requirements for safety rules and regulations for radiation exposure the following is in effect: ...(7) Proper wearing of the personnel (sic) radiation badge indicates it should be worn closest to the source of radiation..."

2. The Hospital's Radiation Dosimetry Reports were reviewed on 4/27/10. They indicated the dosimeter badges were received on 3/22/10 and the report was dated 3/29/10. Documentation indicated that 19 badges were absent (were not available for readings) and 74 that were identified as minimal exposure out of a total of 139 badges on the report.

3. During an interview with the Imaging Services Director, conducted on 4/27/10 at 2:10 PM, it was verbalized that there should have been follow up on those personnel whose badges were identified as absent. Also, it was verbalized that on those badges identified as minimal exposure, it could have been due to minimal exposure or due to personnel not wearing their dosimeter badges. It was stated that at this time there is no surveillance conducted to ensure those personnel that should wear dosimeter badges are actually wearing them.

A. Based on observation, policy and procedure, and staff interview it was determined that the Hospital failed to ensure that all foods are labeled appropriately.

Findings include:

1. During a tour of the Nursing units (west, north, and rehabilitation) on 4/26/10 at 11:00 AM, it was observed in the patient refrigerator on the west nursing unit, that 3 small unidentified containers were not labeled with a date. It was observed on all 3 units, in the patient freezers, that several containers of ice-cream and several frozen sandwhiches were not labeled with dates.

2. During a tour of the dietary department on 4/27/10 at 10:00 AM, it was observed that several food items in the refrigerators and freezers were not dated. For example, 9 containers of cottage cheese, 5 containers of potato salad, 6 packages of cheese, 3 pounds of cream cheese, several unidentified,opened packages of frozen items, and 2 boxes of hamburger patties were not dated.

3. The Hospital policy titled, "Receiving Deliveries" under "Instructions: 5. Determine whether foods will be marked with the date of arrival or the "use by" date and marked accordingly upon receipt."was reviewed on 4/27/10.

4. During an interview with the Dietary Manager on 4/27/10 at 11:00 AM, he stated that the food items should have been labeled upon receipt.

5. During an interview with Quality Improvement Manager on 4/27/10 at 1:00 PM, the above findings were confirmed.

B. Based on policy and procedure, record review, and staff interview it was determined that the Hospital failed to ensure that food tray temperatures were recorded and appropriate for patients.

Findings include:

1. The Hospital policy titled, "Meal Accuracy" under "PROCEDURE", "2. Before delivery...will check each meal for accuracy. This includes, ...temperatures are appropriate...".

2. During a record review on 4/27/10, documentation on the "Patient Trayline Temperature Log" indicated that the breakfast tray temperatures were last recorded on 3/21/10. Documentation for the lunch trays indicated that temperatures were last recorded on 4/8/10 and dinner trays were last recorded on 1/4/10.

3. During an interview with the dietary manager on 4/27/10 at 11:00 AM, he stated that food tray temperatures are to be checked daily for each meal.

4. During an interview with the Quality Improvement Manager on 4/27/10 at 1:00 PM, the above findings were confirmed.

C. Based on policy and procedure, record review and staff interview it was determined that the Hospital failed to ensure that the dietary department was included in the quality assurance program.

Findings include:

1. The Hospital policy titled, "Herrin Hospital Scope of Service Food and Nutrition Department FYE2011" under "VI. Department Performance Improvement Plan The Food and Nutrition Department will perform the following monitory and improvement activities:...".

2. During review of CPIC meeting minutes and dietary department records on 4/28/10, there was no documentation to indicate that any performance improvement monitoring had been communicated for quality assurance.

3. During an interview with the Quality Improvement Manager on 4/28/10 at 3:00 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on April 26-28, 2010, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on April 26-28, 2010, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 4/28/10.

A. Based on a review of the Hospital's Infection Control committee meeting minutes and staff interview, it was determined that the Hospital failed to ensure there were process changes following an identified problem with sterilization of surgical instruments.

Findings include:

1. The Hospital Infection Control committee meeting minutes dated 12/16/09. They indicated on page 2 of 3 "VII. Biological Testing A. Central supply There were 2 surgical loads with positive Attest. One load never left CS. In the second load 1 surgical load was used. After careful investigation, it was determined the Attests were inaccurate. The lot was destroyed....All other surgical loads had a rapid Attest included. All were negative."

2. During an interview with the Infection Control Officer, conducted on 4/27/10 at 1:45 PM, it was verbalized that surgical instruments that had a failed load indicator were used on a patient. Although the Central Supply personnel were directed to change the process to prevent this error from happening again, the Hospital was in the process of changing policy and procedures to reflect the needed changes in the process to prevent a repeat of the incident. The delay in the change of the policy was explained as due to an attempt to develop an accurate policy and procedure to reflect the process throughout the Hospital's multi-hospital system. The above findings were then confirmed.

A. Based on a review of Hospital policy and procedure, observation and staff interview, it was determined that the Hospital failed to ensure all surgical care was provided in such a manner as to prevent the possibility of cross contamination.

Findings include:

1. The Hospital policy and procedure titled, "Hand Hygiene, General, Patient Care" was reviewed on 4/26/10. It indicated under, "V. PROCEDURE 1.0 When to wash hand 1.2 When hands are obviously soiled 1.4 Before and after patient contact."

2. During the observation of the initiation of a surgical case, (on 4/26/10) it was observed that the circulating nurse and another staff member removed that patient's white (personal) socks, applied thigh high TED hose, and then placed the socks back on her feet. It was also observed that items that fell on the floor were picked up by surgical personnel, thrown into the trash, and then proceeded with surgical duties. None of the individuals observed neither washed nor disinfected their hands with a hand sanitizer immediately after caring for the patient or picking the items off the floor, but carried on with preparing the patient for the surgery.

3. During an interview with the Director of Quality Services, conducted on 4/26/10 at 1:45 PM, the above finding was confirmed.

B. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure all surgical staff adhered to the surgical dress policy.

Findings include:

1. The Hospital policy and procedure titled, "Attire, Operating Room" was reviewed on 4/26/10. It indicated under V. PROCEDURE 5.0 All personnel entering the semi-restricted and restricted areas of the surgical suite that are not wearing dedicated OR shoes wear shoe covers. 5.2 They are removed when leaving the department and replaced upon return to the department. 8.0 Personnel cover head and facial hair, including sideburns and necklines when in the semi-restricted and restricted areas of the surgical suite.... 15.0 Lab coats are worn outside of the surgery department."

2. During observation of a surgical procedure, (on 4/26/10) it was observed that the scrub tech and CRNA (certified registered nurse anesthetist) were wearing surgical skull caps which did not cover the hair at the back of the head. It was also observed on 4/28/10 that an individual was observed walking through the hallway just north of the reception area wearing surgical scrubs, bouffant hair restraint, stethoscope around his neck and shoe covers. This individual was not wearing a lab coat.

3. During an interview with the Quality Improvement Manager, conducted on 4/29/10 at 11:00 AM, the above findings were confirmed.