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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon observation the facility failed to maintain the environment to ensure the safety of patients.

Findings include:
On 7/13/10, 7/14/10, and 7/15/10 between the hours of 8:00 AM and 3:00 PM, drain lines were observed to not be provided with the required 1 inch minimum air gap in the following locations: ice machine in the clean room in the Endoscopy suite of Campus #1; ice machine in the pantry of 2nd Floor Heart Center of Campus #1, two of two food preparation sinks in the main kitchen of Campus #1; ice machine in the kitchen of Campus #2; steamer drain line in the main kitchen of the Niles campus.

On 7/13/10 at approximately 11:30 AM, the clinical sink in the soiled utility room in the Emergency Department of Campus #1 was observed with a shutoff valve on the handheld sprayer, located downstream from the atmospheric vacuum breaker (AVB).

On 7/15/10 at approximately 11:00 AM in the janitor ' s closet serving the kitchen at Campus #2, the atmospheric vacuum breaker (AVB) was observed missing the protective cap and with hardness deposits around the device. This mop sink faucet was also observed with a " wasting tee " attached, but with shut off valves on the discharge end, subjecting the built in AVB to constant pressure.

On 7/13/10, 7/14/10, and 7/15/10 between the hours of 8:00 AM and 3:00 PM, damage to the physical environment was observed in the following locations: the beverage cabinet in the Psychological unit of Campus #1; plastic laminate countertop in the isolation room of the Endoscopy suite of Campus #1; floor coving and ceiling water damage in the Morgue of Campus #1; ceiling tiles observed repaired with blue tape in the Sterile Core of Campus #1; handsink cabinet in the Dialysis Unit of Campus #1; handsink cabinet in the ICU at Campus #2; drywall damage in Physician ' s Room of Emergency Department of Campus #2; drywall damage behind the hand sink in the Medication Room of Campus #2; handsink cabinet in the Medication Room of Campus #2; drywall damage at the ambulance entrance report area at Campus #2; handsink cabinet in the lab of Campus #2, sink cabinet in the glassware washing room of the lab of Campus #2.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on July 27, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 27, 2010, for Life Safety Code.

Based on observation, interview and policy and procedure review the facility failed to ensure supplies were maintained at an acceptable level of safety and quality for patient use regarding dietary supplies and clinical supplies. Findings include:

On 7/13/10 at approximately 0845 during a tour of unit A-3 at Campus 2 one 4 ounce container of pudding was found that expired on 6/11/10 in the patient food refrigerator inside the nurses station. This finding was confirmed by staff #X.

On 7/13/10 at approximately 0900 during a tour of unit A-2 at Campus 2 one 4 ounces container of pudding was found that expired on 6/4/10 and seven 4 ounces containers of pudding were found that expired on 7/7/10 in the patient food refrigerator inside the nurses station. In addition, two bags of Lactated Ringers solution 3000ml was found in a cupboard inside the nurses station, one expired on 5/2009 and the other expired on 5/2008. This finding was confirmed by staff #X and staff #AA

On 7/13/10 at approximately 1000 an interview with food service staff #BB, #CC, and #EE and confirmed that the policies and procedures were not being followed.

On 7/13/10 at approximately 1015 during a review of the facility's policy titled "Floor Stock Distribution" under the section "Procedure 2. F." it is documented "Designated Food and Nutrition Services Department staff: Discard expired and unlabeled products from unit refrigerators."


27408

Based on observation and interview the facility failed to ensure that supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

During observation and interview on 7-15-2010 at 0950 on Campus #1 during tour of anesthesia work room it was revealed one size 7.0 endotracheal tube that was open and placed back onto shelf in clean area. In operating room #3, one endotracheal tube size 4.5 was left open and placed back into anesthesia cart.

This was confirmed by operating room manager intra-operative #ZZ.



26688

On 7/12/2010 at approximately 1620 while touring the Emergency Department at Campus 2 the following pediatric emergency kits were expired:
1) Two Red expired on 8/09
2) Two Purple expired on 10/09
3) One Yellow expired on 10/09
4) Four Blue- two expired on 8/09, one expired on 2/07, and one expired on 3/07
5) Two Green expired on 4/09

These findings were confirmed by staff #R at the time of the finding.

Based on observation, interview, and policy review the facility failed to ensure that temperature controls on a dietary refrigerator are not being properly monitored. Findings include:

On 7/13/10 at approximately 0900 during a tour of unit A-2 at Campus 2 the "Food Refrigerator Temperature Log" on the patient food refrigerator located inside the nurses station dated July had been documented on 2 (7/3 and 7/8) of 13 days in the month of July. This finding was confirmed by staff #X.

On 7/13/10 at approximately 1000 an interview with staff #BB, #CC, and #EE confirmed that the policies and procedures were not being followed.

On 7/13/10 at approximately 1015 during a review of the facility's policy titled "Floor Stock Distribution" under the section "Procedure 5." it is documented "Nutrition Services is responsible for daily temperature monitoring of the unit refrigerator(s) and freezer(s) on a posted temperature sheet, unless otherwise indicated."