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A. Based on document review, observation and interview it was determined for 1 of 2 (humalog) opened insulin vials, the Hospital failed to ensure the expiration date was placed on the vial.

Findings include:

1. The Hospital policy titled, "Vials (revised 10/16)" was reviewed on 1/10/18. The policy required, "Multidose vials are discarded: ... b. twenty eight days after opened."

2. During a tour of the 4 North Nursing unit on 1/9/18 at 9:30 AM the following was observed:
-At 10:15 AM, two vials of insulin in the Pyxis (medication dispensing system) were observed in a drawer. One vial was empty. The other vial was open and had a label that was illegible. Two random nurses in the nurses station were asked to identify the date. Neither nurse could read the date or verbalize how long an opened vial could be "kept before discarding."

3. During an interview on 1/10/18 at 9:45 AM, E#8 (Nurse Manager) stated, "Vials are good for 28 days after opening." E#8 was unable to identify the date on the opened insulin vial.



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B. Based on observation, document review, and interview, it was determined for 2 of 2 Accucheck machines (used to check blood sugar) on the 5 East unit, the Hospital failed to ensure that the glucose control solutions used for quality control testing were dated as required. This potentially affected the five diabetic patients on the unit using the accucheck machines.

Findings include:

1. On 1/9/18 at approximately 10:00 AM, an observational tour of the 5 East unit was conducted. During the tour, it was observed that the glucose control solutions for the two Accucheck machines were not dated.

2. On 1/10/18 at approximately 11:00 AM, the Hospital's policy titled "Glucose by Accucheck Inform Meter - POCT procedure" (reviewed 9/17) was reviewed and required, "... Quality Control Testing: Control tests are performed once per 24 hours... Glucose control solutions must be stored at room temperature... The date the vial is opened should be written on the vial label... Spot checks are done for undated... QC material..."

3. On 1/9/18 at approximately 10:00 AM, findings were discussed with E #2. E #2 (Registered Nurse) stated that the control solutions were used by staff to conduct quality control testing for the Accucheck machines. E #2 added that the control solutions should have been dated.

Based on document review and interview, it was determined that for 5 of 12 (Pt. #1, #4, #6, #8, and #9) clinical records reviewed for care plan, the Hospital failed to ensure the Plan of Care included isolation as part of patient's problems.

Findings include:

1. On 1/9/18, the Hospital's policy titled "Nursing Plan of Care" (revised 9/17) was reviewed and required, "... The Nursing Plan of Care ... corresponds to each of patient's unique needs... The Nursing Plan of Care... Includes identification of a nursing problem list based off of the patient's primary medical diagnosis...5. Update of Nursing Plan of Care: a. Document the nursing problem list on the care plan intervention..."

2. The clinical record of Pt. #1 was reviewed on 1/9/18. Pt. #1 was a 46 year old male admitted to the 4 north nursing unit on 12/19/17 with the diagnosis of pancreatitis. Pt. #1 was placed on contact isolation on 12/20/17. The plan of care lacked documentation of the isolation as of 1/9/18.

3. The clinical record of Pt #6 was reviewed on 1/9/18 at approximately 10:15 AM. Pt #6 was a 53 year old male who was admitted on 1/8/18 with a diagnosis of sepsis. Pt #6's clinical record contained documentation that Pt #6 was on Contact Precautions. Pt #6's patient care plan dated 1/8/18 failed to include isolation.

4. The clinical record of Pt #4 was reviewed on 1/9/18 at approximately 10:30 AM. Pt #4 was a 2 month old male admitted on 1/7/18 to the Pediatric Unit with diagnoses of weakness, not tolerating feedings well and Respiratory Syncytial Virus (RSV) infection. Pt #4 was placed on contact and droplet isolation precautions on 1/7/18. Pt #4's Plan of Care, dated 1/7/18, did not include Isolation Precautions.

5. On 1/9/18 at approximately 11:00 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 92 year old male admitted on 1/4/18 with a diagnosis of community acquired pneumonia. Pt. #8's clinical record included a physician's order for droplet precaution isolation dated 1/5/18. As of survey date 1/9/17, Pt. #8's plan of care was not updated to include droplet precaution as part of Pt. #8's problems.

6. On 1/9/18 at approximately 11:15 AM, the clinical record of Pt. #9 was reviewed. Pt. # 9 was an 87 year old male admitted on 1/5/18 with a diagnosis of tracheotomy complication. Pt. #9's clinical record included a physician's order for contact isolation dated 1/6/18. As of survey date 1/9/17, Pt. #9's plan of care was not updated to include contact isolation as part of Pt. #9's problems.

7. During an interview on 1/9/18 at 10:45 AM, E#8 (Nurse Manager) stated, "Isolation should be included on the plan of care."

8. The Manager of the Intensive Care Unit and Immediate Care Unit (E #12) stated during an interview on 1/9/18 at approximately 11:00 AM that the care plan had not been updated to include all the patient's problems

Based on document review and interview, it was determined that the Facility failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. The Facility's policy titled, "Delinquent Medical Records (reviewed 8/17)" required, " ... A medical record is considered to be delinquent if items remain incomplete 30 days after discharge or if an operative report is not dictated/completed within 24 hours of the surgical procedure..."

2. The Facility letter dated 1/11/18 from the Director of Medical Records (E #22) noted "The number of delinquent medical records as of today is 1,130."

3. On 1/11/18 at approximately 11:00 AM, an interview was conducted with the Director of Medical Records (E # 22). E #22 stated that there were 1,130 delinquent medical records as of 1/11/18. E #22 stated that medical records are considered delinquent after 30 days.

Based on document review, observation and interview, it was determined that for 5 of 5 quarts of whipping cream and 1 bag of frozen vegetables, the Hospital failed to ensure items were labeled with expiration date after opening or removing from original container. This potentially affected all patients consuming the product.

Findings include:

1. The Hospital policy titled, "Food and Supply Storage Procedures (revised 8/17)" was reviewed on 1/11/18. The policy required, "Cover, label and date unused portions and open packages. ... Products are good through the close of business on the date noted on the label."

2. During a tour of the Food and Nutrition department on 1/11/18 at 10:45 AM, the following was observed:
At 11:00 AM, the frozen food freezer contained an open bag of frozen vegetables lacking an expiration date.
At 11:10 AM, the dairy refrigerator contained 5 - 1 quart containers of whipping cream, removed form the original box, without an expiration date.

3. During an interview on 1/11/18 at 11:15 AM, E#21 (Director of Patient Food & Nutrition) stated, "There should be an expiration date on the individual items."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Sample Validation Survey conducted on January 9 - 11, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Sample Validation Survey conducted on January 9 - 11, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on document review and interview, it was determined that for 1 of 1 nourishment refrigerator and 1 of 1 crash cart on the 4 north Nursing unit, the Hospital failed to ensure daily checks of required equipment were completed. This potentially affected all 18 patients on the unit.

Findings include:

1. On 1/9/18 at 10:40 AM, the Refrigerator or Freezer Temperature Log - 120.7 was reviewed. The refrigerator log lacked documentation of temperature checks on 12/16/17, 12/17/17, 12/19/17 - 12/21/17,12/24/17, 12/25/17 and 1/2/18 - 1/5/18.

2. On 1/9/18 at 10:45 AM, the Code Blue Supply and Crash Cart Daily Checklist was reviewed. The code blue supply and crash cart checklist lacked documentation on 12/24/17, 12/25/17, 12/30/17 and 12/31/17.

3. On 1/9/18 at 2:00 PM, the Hospital policy titled, "Infection Control Policies for Clinical Areas", (reviewed 4/17) was reviewed. The policy included, "Clinical Area Routines and Equipment Care...patient food refrigerators are checked at least once a day when workstation is open; to be sure temperature is maintained between 32 - 40 degrees F (Fahrenheit) for refrigerators and -10 - -0.4 for freezers."

4. On 1/9/18 at 2:00 PM, the Hospital policy titled, "Code Blue Cart Replacement and Stock Assurance", (revised 9/17) was reviewed. The policy included, " ...the defibrillator, expiration sticker and code blue cart seal are checked on days of department operation by department personnel and recorded on the code blue supplies checklist ..."

5. During an interview on 1/9/18 at approximately 10:40 AM, E#8 (Unit Manager), stated, " ...the secretaries are assigned to check the refrigerator temperatures daily ..." E#8 (Unit Manager), stated that the code blue carts should be checked daily by staff.





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B. Based on document review, observational tour and interview, it was determined that the Hospital failed to ensure an oxygen tank was stored safely in Cardiology Exam Room #2 of Radiology, potentially affecting approximately 12 patient cases completed each month in Cardiology Intervention.

Findings include:

1. On 1/11/18 at 1:30 PM, policy titled, "Medical Gas System," revised July 2017, was reviewed and required, "Portable oxygen cylinders... B. Oxygen 'E' cylinders are stored in separate carts in a secure area of Central Transportation. Cylinders are kept in individual holders until needed on a nursing unit... F. Oxygen 'E' cylinders are used as required by Respiratory Therapy and Nursing units as needed." The policy failed to mention a means to secure oxygen tanks when in use on the units in order to prevent them from falling and potentially exploding.

2. On 1/9/18 between 1:00 PM and 2:00 PM, an observational tour was conducted in the Radiology and Nuclear Medicine areas. At 1:25 PM, an oxygen tank containing oxygen was found unsecured behind the door of Cardiology Exam Room 2, located in Radiology.

3. On 1/9/18 at 1:25 PM, an interview was conducted with the Director of Radiology (E# 25). E# 25 stated this was a Cardiology Exam Room and that the oxygen tank should be in a stand.

Based on document review, observation and interview, it was determined that for 1 of 1 Registered Nurses (RN) (E #14) performing a bedside Accucheck, the Hospital failed to ensure the Accucheck monitor was not contaminated.

Findings include:

1. The Hospital policy entitled, "Glucose by Accucheck Inform II Meter - POCT (point of care testing) Procedure," (revision 1/16) required, "Patient Testing...Personal protection equipment as required for universal blood collection precautions...9. Remove a test strip from the vial....16. Remove the test strip from the meter...19. Clean and disinfect the meter using a cleaning cloth...Results..1. If a 'Strip Defect error' message appears on the display...Perform a control using a new test strip..."

2. On 1/9/18 at approximately 12:30 PM, a bedside Accucheck procedure was observed. During the procedure, the E #14 opened the Accucheck box and laid the monitor on the patient's bed. She was observed performing a finger stick and obtaining a blood specimen. E #14 stated that she did not obtain enough blood and proceeded to take another test strip and finger lancet from the Accucheck box, without removing her gloves and washing her hands. After performing the tests a second time, E #14 placed the monitor into the box without cleaning.

3. During an interview on 1/9/18 at approximately 12:35 PM, the Manager of the Intensive Care Unit and Immediate Care Unit (E #12) stated that the monitor box should not have been taken into the patient's room.

A. Based on document review, observation and interview it was determined that for tube feeding bottles on the 4 North nursing, the Hospital failed to ensure clean supplies were separated from dirty.

Findings include:

1. The Hospital policy titled, "Infection Control (reviewed 4/17) " was reviewed on 1/9/18. The policy required, "There are separate areas for clean and dirty storage."

2. During a tour of the 4 North unit on 1/9/18 at 9:30 AM the following was observed:
-At 10:30 AM, an unused bottle of tube feeding for patient use was stored in a cabinet with a dirty flower vase and dirty personal staff dishes.

3. During an interview on 1/9/18 at 10:45 AM, E#8 (Nurse Manager) stated, "The tube feeding should be stored in its own cabinet."

B. Based on document review, observation and interview it was determined that for 1 of 2 (E#7) staff cleaning OR (operating room) #5, the Hospital failed to ensure cleaning was performed in the proper order to prevent cross contamination.

Findings include:

1. The Hospital policy titled, "Sanitation OR (revised 9/14)" was reviewed on 1/10/18. The policy required, "Surgical teams assigned to the OR and/or housekeeping personnel damp dusts all OR furniture, surgical lights, ... from top to bottom ..."

2. During an observational tour of OR #5 at 9:55 AM, E#7 (Surgical Services Aide) disinfected the OR cart and then disinfected the surgical light directly above the already disinfected surgical cart.

3. During an interview on 1/10/18 at 10:00 AM, the Charge Nurse (E#5) stated, "The light should have been cleaned before the cart."


C. Based on observation, interview and document review, it was determineted that for 1 of 1 Food Service Technician (E #18) observed during food preparation, the Hospital failed to ensure hand hygiene was conducted.

Findings Include:

1. On 1/11/18 at approximately 10:50 AM, in the Food and Nutrition Department, E#18 (Food Service Technician) was observed plating food in the food tray line. E#18 was observed with gloved hands, to touch the handle of a food storage heater to open the heater and removed brown meat patties and placed them on patient plates. E#18 returned to the food tray line and picked up lettuce and tomatoes and placed them on the brown meat patties with the same gloved hands. E#18 did not change gloves or perform hand hygiene after moving from dirty to clean during food handling.

2 During an interview on 1/11/18 at approximately 11:05 AM, E#21 (Director of Patient Food and Nutrition) stated, " ... (E#18) should have used tongs to pick up the lettuce and tomatoes and should have changed her gloves ..."

3. On 1/11/18 at 12:45 PM, the Hospital policy titled, "Food Handling Guide" (reviewed 8/17) was reviewed. The policy included, " ...Cross Contamination Precautions ... single use disposable gloves are worn when preparing foods that will not be cooked again (ready-to-eat foods) and while serving. ... Gloves are changed between tasks. ... Hands are washed after gloves are removed ..."



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D.. Based on observation, interview and document review, it was determined that staff (1 CT technician, 1 Certified Nurse Anesthesist, and 1 Anesthesiologist) on Radiology Department, observed providing patient care, the Hospital failed to ensure that hand hygiene was performed as required.

Findings include:


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1. On 1/9/18 from 1:00 PM to 2:00 PM, an observational tour was conducted in the Radiology and Nuclear Medicine areas. At 1:40 PM, in the CT (computerized tomography) room, Pt. #13 was being prepared for a chest CT. A CT Technician (E #3), wearing gloves, infused contrast solution into Pt. #13's intravenous line, removed the gloves, but did not disinfect his hands. E #3 returned to the control room panel to operate the CT scan.

2. On 1/9/18 at 1:45 PM, an interview was conducted with E #3. E #3 stated that he should have washed his hands after removing the gloves.

3. On 1/10/18 from 9:30 AM to 11:30 AM, an observational tour was conducted in the Operative Area (OR). At 11:20 AM, in OR Suite #1, a Certified Registered Nurse Anesthetists (E #11), wearing gloves, intubated Pt. #16, removed the gloves, did not disinfect her hands, donned new gloves, and placed tape on Pt. #16's eye lids.

4. On 1/10/18 at 11:22 AM, in OR Suite #1, an Anesthesiologist (MD #2), wearing gloves, adjusted Pt. #16's blanket, took off the gloves, did not disinfect his hands, did not donn new gloves, picked up a cord from the floor, turned the OR table, and touched Pt. #16's breathing tube.

5. On 1/10/18 at 11:30 AM, an interview was conducted with the OR Manager (E #9). E #9 stated that staff should disinfect their hands after removing gloves.

6. On 1/12/18 the policy entitled, "Hand Hygiene" (rev. 7/16) was reviewed and required, "All hospital personnel properly clean their hands to prevent the spread of infections. This includes all health care workers who have direct or indirect contact with patients, medical devices or equipment...Gloves use is not a substitute for hand cleaning. Hand hygiene should be performed after glove removal..."

E. Based on document review, observational tour and interview, it was determined that for 1 of 1 Scrub Technician (E #20), the Facility failed to ensure that staff did not extend exposed/uncovered arms over the sterile field.

Findings include:

1. On 1/11/18 at 1:00 PM, Facility policy #08-661-44 titled, "Aseptic Technique," revised March 2017, was reviewed. The policy included: "3. Persons in nonsterile attire [should]: ... b. Avoid reaching over or touching the sterile field ..."

2. On 1/11/18 between 9:15 AM and 10:00 AM, an observational tour was done of the Outpatient Center for Ambulatory Surgery. At approximately 9:40 AM, a Scrub Technician (E# 20) was preparing sterile supplies for a procedure in Operating Room 2. E #20 wore a short sleeve scrub top exposing her bare arms. E# 20 donned a sterile glove on her left hand. E #20 then reached into the sterile field with her left hand to set up sterile supplies during which her uncovered/bare arm crossed over the sterile field approximately eight times.

3. On 1/11/18 at 10:00 AM, an interview was conducted with Lead Nurse Anesthetist (E #24). E# 24 stated that bare arms (non-sterile) should not reach over the sterile field and that wearing a sterile gown could have been a way to prevent this from happening.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #24 and Pt. #25) patients discharged home with home care services, The Hospital failed to ensure that the patients were provided a list of options of available home care services.

Findings include:

1. On 1/11/18, the Hospital's policy titled, "Referral to Community Resources" (revised 7/16) was reviewed and required, "...Social Work provides patients and families with referrals to community agencies... The Social Worker offers options to patients and families... and documents accordingly in Meditech (patient's electronic medical record).

2. On 1/11/18 at approximately 11:00 AM, the clinical record of Pt. # 24 was reviewed. Pt. #24 was a 72 year old male admitted on 12/19 17 with a diagnosis of congestive heart failure. Pt. # 24 was discharged on 12/26/17 with a physician's order for home care services. The clinical record lacked documentation of a list of options for home care agencies being provided to the patient.

3. On 1/11/18 at approximately 11:15 AM, the clinical record of Pt. #25 was reviewed. Pt. #25 was a 92 year old female admitted on 10/27/17 with a diagnosis of hypertensive emergency. Pt. #25 was discharged with a physician's order dated 10/31/17 for home care services. The clinical record lacked documentation of a list of options for home care agencies being provided to the patient.

4. On 1/11/18 at approximately 11:45 AM, findings were discussed with E #27 (Clinical Director of Case Management and Social Work) and E #28 (Lead Social Work). E #27 and E #28 stated that there was no documentation that a list of options for home care services were provided to the patients. E #27 stated, "It is our practice that we discuss with patients available options for home health services."

A. Based on document review, observation, and interview, it was determined that for 2 of 2 ancillary personnel, E #14 (Operating Room Orderly) and E #15 (Anesthesia Technician), the Hospital failed to ensure all facial hair was covered, as required.

Findings include:

1. The Hospital policy entitled, "Dress Attire," (date 3/3/17) required, "Procedure...3. a...don single-use hat or hood. b. Assure that the hat or hood completely confines the hair. All possible head and facial hair including sideburns and neckline are covered in the semi-restricted and restricted areas...9. Required Attire: a.Restricted Areas: includes O.R.s, inner and outer core. ...Surgical cap or hood..."

2. During an observational tour of the Hospital's Surgical Department on 1/10/18 between 9:15 AM and 10:00 AM, the following was observed:
-At 9:15 AM, an Operating Room Orderly (E #14) was observed in the outer core with his beard uncovered and an Anesthesia Technician (E #15) was observed coming from the Anesthesia Workroom with his beard uncovered.

3. The Director of Surgical Services (E #16) stated during an interview on 1/10/18 that the beards were uncovered.


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B. Based on document review, observation and interview it was determined that 3 of 4 (E#4, E#5 and E#6) staff observed in the inner core, the Hospital failed to ensure staff wore the required surgical attire.

Findings include:

1. The Hospital policy titled, "Dress Attire (3/17)" was reviewed on 1/10/18. The policy required, "Jewelry including earrings, ... that cannot be contained or confined within the surgical attire should not be worn. ... Masks: ... Secure mask over nose and mouth to prevent venting. ... Required Attire: Restricted Areas: Includes O. R.s (operating rooms) 1 - 9, inner and outer core ... Masks should be worn in the presence of open sterile supplies and in the inner core at all times."

2. During a tour of the OR inner core on 1/10/18 at 9:30 AM, the following was observed:
-At 10:00 AM, E#6 (Anesthesiologist) entered the inner core holding a mask and then tied the mask while walking down the isle to OR room #5.
-At 10:10 AM, E#4 (Materials Management Technician) was at a counter with the bottom of the mask untied.
-At 10:15 AM, E#5 (Charge Nurse) was walking towards OR room #5 while tying the upper and lower ties of the mask.

3. During an interview on 1/10/18 at 10:15 AM, E#5 stated, "No one should enter the inner core of the OR without a mask properly secured."


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4. On 1/10/18 from 9:30 AM to 11:30 AM, an observational tour was conducted in the Operative Area (OR). At 10:35 AM, in OR Suite #1, where sterile instruments and supplies were open, a Circulating Registered Nurse (E #10) entered OR Suite #1 tying on her face mask and wearing earrings.

5. On 1/10/18 at 10:45 AM, a third year Podiatry Resident (MD #1), entered OR Suite #1 tying on her mask.

6. On 1/10/18 at 11:00 AM, a Certified Registered Nurse Anesthetist (E #11), in OR Suite #1, was wearing earrings.

7. On 1/10/18 at 11:30 AM, an interview was conducted with the OR Manager (E #9). E #9 stated that staff should have their mask tied and should removed jewelry before entering the restricted area.