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Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to obtain orders for the use of restraints for one of four restraints medical records reviewed (MR7).

Findings include:

A review conducted on March 4, 2010, of facility administrative policy "Restraints and Seclusion Guidelines", last reviewed November 2009 revealed: "... POLICY: 2. Restraints for Medical Surgical- ...f. Restraints may be terminated prior to the ordered interval, if release criteria are met per assessment of an RN. If a patient was recently released from restraint and exhibits behavior that can only be handled by the re-application of restraints, a new order is required. Staff cannot discontinue an order and then restart it under the same order because that would constitute a PRN order."

1) A review conducted on March 4, 2010, of MR7 revealed that restraints were used for this patient. The medical record did not contain a physician order for each episode of restraint usage.

An interview conducted on June 11, 2009, at 10:00 AM with EMP2 confirmed that there was not a physician order for each episode of restraint usage in MR7.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that the condition of the patient in restraints was monitored according to the established facility policy for one of four restraint medical records reviewed. (MR5)

Findings include:

A review conducted on March 4, 2010 of facility administrative policy "Restraints and Seclusion Guidelines", last reviewed November 2009, revealed " ... The Nursing Staff: 1. Directly observes patient status. A. every one (1) hour if patient is in vest, soft limb, or Geri-chair ...2. Directly observes patient and check, and meets identified patients needs related to hydration, elimination, nutrition, activity, comfort, room temperature, at least every two(2) hours ... "

1) A review conducted on March 4, 2010, of MR5 revealed a physician order written on December 19, 2009, for soft wrist restraints. Review of the nursing documentation revealed the patient was assessed at 16:43, 19:31, 21:32, 00:00, 03:48, and 06:00 while in restraints.

2) An interview conducted on March 4, 2010, with EMP2 confirmed there was no documented evidence that nursing staff directly observed the patient every one hour.

Based on a review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that the medical record contained documentation of the patient's change in condition for two of four medical records reviewed (MR5 and MR7).

Findings include:

A review conducted on March 4, 2010 of facility administrative policy "Restraints and Seclusion Guidelines", last reviewed November 2009, revealed "...Policy...Documentation: 1. The RN will document the initial behavior and alternatives tried and failed and the rationale for termination of restraints on the Restraint/Seclusion Flow Sheet ... 3. Information relative to temporary, short-term(less than one (1) hour) restraint may be entered in the nurse's notes/progress records ..."

1) A review conducted on March 4, 2010, of MR5 revealed that there was a physician order of soft wrist restraints written on December 18, 2009, at 11:00AM. Further review of MR5 revealed the restraints were not used. The medical record had no documentation of a change in the patient's condition that indicated the restraints were not needed.
An interview conducted on March 4, 2010, with EMP2 confirmed the soft wrist restraints were not applied and that there was no documentation of change in the patient's condition that indicated no restraints were needed.
2) A review conducted on March 4, 2010 of MR7 revealed that there was a physician's order for soft wrist restraints and four side rails written on November 21, 2009, at 9:40AM. Further review revealed the side rails were not used. The medical record had no documentation of a change in the patient's condition that indicated the side rails were not needed.
An interview conducted on March 4, 2010, with EMP2 confirmed the side rails were not used and that there was no documentation of change in the patient's condition that indicated the side rails were not needed.

Based on observation and interview with staff (EM), it was determined the facility failed to discard remaining unit dose medication and failed to date multiple dose vials when opened.

Findings include:
A review of facility policy "Infection Control Standards of Pharmacy Department" last reviewed February 2009, revealed "No multiple dose vials will be used after 28 days.
1) A tour conducted on March 2, 2010, at 1:45 PM of Littlestown Professional Center revealed two multi-dose vials of Dexamethasone (an anti-inflammatory) which were opened and not dated.
An interview on March 2, 2010, at 1:45 PM with EMP4 confirmed the multi-dose vials were opened and not dated when opened.
2) A tour conducted on March 3, 2010, of the Obstetrical unit revealed the sub sterile area contained two anesthesia carts. One anesthesia cart contained an opened single dose vial of Sensorcaine (long-acting local anesthetic) that was dated and timed with "3/2 at 9:40." The other anesthesia cart contained an opened single dose vial of normal saline.
An interview conducted on March 3, 2010 at 10:50 AM with EMP3 confirmed the anesthesia carts had opened single dose vials of Sensorcaine and Normal Saline that should have been discarded.

Based on review of facility documents, medical records (MR) and interview with staff (EMP) it was determined that the facility failed to report medication errors immediately to the attending physician for three of four medical records (MR) reviewed. (MR1, MR2, and MR3)

Findings include:

A review conducted on March 4, 2010, of facility policy" Procedure for Medication Error" last revised March 2008, revealed "Procedure...2. The prescribing physician is notified immediately of the error for and corrective measure to be taken in patient care or safety by nursing, pharmacy, or department where error occurred..."

1) A review on March 4, 2010, of facility "Incident Reports" revealed that reports were completed related to medication errors for MR1, MR2, and MR3 .

2) A review of MR1, MR2, and MR3 revealed no documented evidence that the physician was notified of the medication errors.

3) Interview with EMP14 on March 4, 2010, at 1:00PM, confirmed there was no documented evidence that the medication errors were reported to the physician.

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to report drug diversions of controlled substances in accordance with applicable State laws.

Findings include:

1) Review of facility documents revealed the facility investigated two diversions of controlled drugs. Further review revealed that none of the diversions were reported to the Commonwealth of Pennsylvania Bureau of Drug Control of the Office of Attorney General.

4) Interview with EMP5 and EMP1 on March 4, 20010, at 1:25 PM confirmed the facility had two separate drug diversions and did not report the diversions to the Commonwealth of Pennsylvania Bureau of Drug Control of the Office of Attorney General.

Based on Life Safety Code Validation survey, the Condition for Physical Environment is not met based on the results of the Department of Safety Inspection survey completed on March 2 and 3, 2010. See the Life Safety Code survey 2567 for the deficiencies.

Based on review of facility policy, observation and interview with staff (EMP), it was determined that the facility failed to ensure that the facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality throughout the hospital.

Findings include:

A review on March 4, 2010, of facility policy "Environmental Health & Safety Program" (no date of last review) revealed, "It is the policy of Hanover Hospital to conduct regular surveys of all areas of the organization to determine whether the current activities used to manage the environment of care are effective. ...Engineering...Doors in need of repair...Infection Control ... Improper storage in refrigerator ...Food in refrigerator dated (patient only). ...Improper storage of food... Expired Meds/materials. ... Improper storage of items ... Inadequate separation of clean and soiled supplies.

A tour conducted on March 4, 2010, of the rehabilitation unit revealed a refrigerator that
contained an undated plastic container of nine eggs.

Each rehab patient room had a gait belt that hung on a hook. The gait belt, when hung on
the hook dragged on the floor.

The clean utility room had a physical therapy (PT) cart with an open bottom shelf that
contained patient supplies.

An interview conducted on March 4, 2010, at 11:00 AM with EMP6 confirmed the
refrigerator contained an undated plastic container with nine eggs. The interview with EMP6
also confirmed that each patient room had a gait belt that when hung on the hook would
drag on the floor and that the bottom shelf of the PT cart was not solid and contained patient
supplies.

2) A tour conducted on March 2, 2010, of the emergency department revealed a patient refrigerator that contained a sandwich that was labeled "Mon." The day of the tour was Tuesday.

Emergency room 1 had cart that contained 16 expired blood tubes. The dates of expiration ranged from January 2008 to August 2008.

An interview conducted on March 2, 2010, at 2:45 PM with EMP7 confirmed the patient sandwich should have been discarded and the expiration date for the sandwich was Monday. The interview with EMP7 also confirmed the emergency room cart had 16 expired blood tubes with dates that ranged from January 2008 to August 2008.

3) A tour conducted on March 3, 2010, of the pediatric unit revealed the pediatric emergency cart contained two blood tubes that expired December 2009.

The lower half of the entrance door to the toy room had an approximately four inch area that was gouged and splintered.

An interview conducted on March 3, 2010, at 11:30 AM with EMP8 confirmed the pediatric emergency cart contained two blood tubes that expired December 2009. The interview with EMP8 also confirmed the toy room door had a four inch area that was gouged and splintered.

4) A tour of the obstetrical unit conducted on March 3, 2010, revealed the sub sterile operating room that contained two red biohazard containers of dirty syringes, a bucket of water with a mop in the bucket and mop heads on the counter.

A tour of the obstetrical unit on March 3, 2010, revealed an unlocked soiled utility room that contained biohazard material. The soiled utility room was not capable of locking and was not in view of the nurses' station.

An interview conducted on March 3, 2010, at 10:30 AM with EMP9 confirmed the sub sterile operating room contained two red biohazard containers of dirty syringes, a bucket of water with a mop in the bucket and mop heads on the counter. An interview with EMP9 confirmed the soiled utility room was not capable of locking and was not in view of the nurse's station.

5) A tour of the cardiac catheterization unit revealed accucheck control solutions that were dated "6/09."

An interview conducted on March 4, 2010, at 11:00 AM with Emp10 confirmed the accucheck controls had expired and should have been discarded 3 months after opening.

6) A tour on March 4, 2010, at 11:00 AM revealed a fracture hip table in a storage room in the operating room suite. The table had an approximate 2" by 1" tear on the edge exposing the underlying padding.

An interview conducted on March 4, 2010, at 11:00 AM with EMP11 confirmed that the padding was exposed.

7) A tour on March 2, 2010, at 10:00 AM of the Dietary Department revealed several bottom shelves in walk-in refrigerators and freezers and storage racks that did not contain a solid bottom. The bottom shelves contained various refrigerated and frozen foods. The storage racks contained clean pots and pans.

An interview on March 2, 2010, at 10:00 AM with EMP12 confirmed the bottom shelves contained various foods and pots/pans, and did not have solid bottoms.

8) A tour on March 2, 2010, at 10:15 AM of the Dietary Department revealed multiple large canned food items in a storage rack. None of the cans were dated when received.

A review of facility policy "Food Storage" last revised June 2009, revealed, "All food will be labeled with the date that the item was received in Food and Nutrition services department.

An interview on March 2, 2010, at 10:15 AM with EMP12 confirmed the canned food items were not dated when received.

9) A tour on March 2, 2010, at 1:40 PM of the Littlestown Professional Center revealed a soiled linen cart which contained bags of soiled linen stored in the clean utility room.

An interview conducted on March 2, 2010, at 1:40 with EMP4 confirmed the soiled linen cart was stored in the clean utility room.

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that medical records of sufficient content to ensure continuity of care accompanied the patient at the time of transfer to another facility for two of two cardiac catheterization transfer medical records reviewed. (MR10 and MR11).

Findings include:

A review conducted on March 4, 2010, of the facility's policy "Transferring Patients to other facilities," revised November 19, 2008, revealed, "...2. The transferring hospital provides the receiving facility with appropriate medical records (or copies thereof) of the examination and treatment effected at the transferring hospital. ..."

1) A review conducted on March 4, 2010, of MR10 and MR11 revealed that the patients were transferred to another hospital. There was no documented evidence that medical records were sent with the patients at the time of transfer.

2) An interview conducted on March 4, 2010, at 1:15 PM with EMP13 confirmed that there was no documentation in MR10 and MR11 to indicate that medical records accompanied the patients at the time of transfer.

Based on facility documentation and interview with staff (EMP), it was determined the surgical services department failed to maintain a roster of practitioners specifying the surgical privileges of each practitioner.

Findings include:

1) A review on March 4, 2010, at 10:45 AM of the surgical services privileges revealed the privileges were dated from 2005 to 2006. The surgical services department did not maintain a current list of approved privileges for each practitioner.

2) An interview conducted on March 4, 2010, at 10:45 AM with EMP11 confirmed the surgical privileges for each physician were not up to date.