HospitalInspections.org

Based on observation, document review and interviews with key personnel on January 14-16, 2014, it was determined that the governing body failed to ensure that patient medical records and other protected health information were maintained to assure the confidentiality and protection of this information.

Findings include:

1. The hospital failed to protect patients' rights of confidentiality and privacy by failing to protect patients' medical information. See Condition of Participation Patient Rights, Tag A0115, for further information.

2. The hospital failed to organize and structure medical records services to maintain the integrity, security and privacy of patient records and failed to limit access to patient records to only authorized individuals. See Condition of Participation Medical Records Services, Tag A0431, for further information.


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on record review, policy and interview with key personnel on January 16, 2014, it was determined that the facility failed to assure that policies for personnel were followed and evaluations were done annually for seven (7) of ten (10) personnel.

Findings include:

1. The facility policy, 'Wage & salary administration' indicated: "Annual performance review. Annual performance reviews will normally be conducted one year after employment and in subsequent years, on the employee's anniversary date."

2. Personnel files for staff members C, F, H, I, J, L and P all indicated that they were due for an annual evaluation during 2013. These files lacked evidence that an evaluation had been done since 2012.

3. These findings were confirmed by the Director of Human Resources on January 16, 2014 at 11:00 AM.

Based on observation, document review, and interviews with ICU/Behavioral Health Manager, Director, Health Information Management, a Hospitalist, Quality Director, and Medical/Surgical Nurse Director on January 14-16, 2014, it was determined that the facility failed to maintain administrative responsibility that assured the confidentiality and protection of the patient medical records and other medically sensitive information; failed to inform patients of their rights; and failed to assure that the facility policies were followed.

Findings include:

1. Patient Rights: Confidentiality of Records:
a. The hospital failed to ensure that both physician and nurse computer work stations were shut down when left unattended on the Medical/Surgical Unit leaving patient medical records and other medically sensitive information visible to any person in the area. Please see Tags 0146 and 0441 for additional information.

b. The hospital failed to provide an adequately secure and screened physician computer workstation area on the Medical/Surgical Unit. Please see Tags 0146 and 0441 for additional information.

c. The hospital failed to have a system to secure inpatient paper medical records, instead having an unsecured, unsupervised pull-down "box" located on the wall outside of each patient's room. These record boxes were easily opened and the enclosed medical records were readily accessible to unauthorized persons. Please see Tags 0146 and 0441 for additional information.

d. The hospital failed to secure four (4) "paper" medical records that the physician left unattended at a computer workstation in the public corridor on the Medical/Surgical Unit. Please see Tags 0146 and 0441 for additional information.

e. The hospital failed to ensure strict medical record security by allowing unauthorized individuals (with no need to access patient records) into the Medical Records Department storage room unsupervised after normal hours of operation. Please see Tags 0146 and 0441 for additional information.

2. The hospital failed to inform patients of their rights in advance of furnishing care in four (4) of thirty (30) medical records reviewed. Please see Tag A0117 for additional information.

3. The hospital failed to assure that the facility policy on complaints/grievances was followed. Please see Tags A0122 and A0123 for additional information.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on document review and interview with key personnel on January 15, 2014, it was determined that the facility failed to inform patients of their rights in advance of furnishing care. The findings follow:

1. Four (4) of thirty (30) medical records failed to contain documentation that the patients had been notified of their rights (Records N, BB, MM, and NN).

2. During an interview with the Quality Director on January 15, 2014 at approximately 11:30 AM, she explained that patient rights are contained in the "Patient and Family Guide" which is "...generally given to patients on admission, and there is a copy posted in each patient room." She noted that the nurse generally documents in the patient's medical record on admission that the "Patient and Family Guide" has been given.

Based on document review and interview with key personnel on January 15, 2014, it was determined that the facility failed to assure that the facility policy was followed for two (2) of five (5) grievance/complaints.

Findings include:

1. The facility policy, 'Complaints-resolution of patient-family', stated: "The individual will receive a written response within 7 days. If the complaint cannot be resolved in 7 days (due to the complexity of the situation), a written letter will be sent within 7 days to the individual with a time frame for resolution of the complaint. This time frame will not exceed 30 days."

2. Complaint/grievance #1 indicated that it had been received on May 9, 2013, and a letter of resolution had been sent on May 31, 2013. There was no documentation to indicate that an earlier letter was sent telling the complainant that the facility was unable to complete the investigation prior within 7 days.

3. Complaint/grievance #2 indicated that it had been received on April 5, 2013, and a letter of resolution had been sent on April 24, 2013. A letter sent on April 7, 2013, stated: "I will be back in touch with you as soon as I have finished my investigation." The letter on April 7, 2013 failed to include a time frame for resolution of the complaint.

4. The above findings were confirmed by the Quality Director on January 15, 2014 at 1:15 PM.

Based on document review and interview with key personnel on January 15, 2014, it was determined that the facility failed to assure that the facility policy on complaints/grievances was followed for one (1) of five (5) grievances/complaints.

Findings include:

1. The facility policy, 'Complaints-resolution of patient-family', stated: "The written response to the individual submitting the complaint will include: A general description of the steps taken to investigate the complaint. An explanation of Mid Coast Health Services resolution regarding the complaint."

2. Complaint/grievance #3 file indicated that this complaint/grievance had been received on June 15, 2013, and a letter of resolution was sent on June 28, 2013. The resolution stated: "the systems and communication between staff are not what they should have been," but made no mention of what actions were going to be taken toward a resolution of the complaint.

3. The above finding was confirmed by the Quality Director on January 15, 2014 at 1:15 PM.

Based on observation, document review, and interview with key personnel, on January 14-15, 2014, it was determined that the facility failed to protect the security of all patent records.

Findings include:

1. During a tour of the Medical/Surgical (M/S) inpatient unit conducted on January 14, 2014 at approximately 11:15 AM, an unattended physician computer work station, located in an alcove in a public hallway opposite patient room MS214-215, was observed with a computer monitor displaying a patient medical record (Record MM) in clear view of anyone who passed by.

a. Several minutes after the discovery of the unattended work station a Hospitalist approached the surveyors and indicated that he had been working on the patient's medical record and had "stepped away for a few minutes." The hospitalist further stated "I should have shut it down before I left." The Hospitalist asserted: "No medical records are secured and locked up at this hospital ... I have never been to a hospital where medical records are available to anyone that walks in ..."

b. A further observation of the workstation revealed four (4) "paper" patient medical records that were also unprotected (Records K, L, M, and NN).

c. Additionally, it was determined that the protected patient information displayed on the monitor was clearly visible to any person that may be in that area, as well as any occupants of a nearby patient room (room MS214-215).

d. As the tour continued, another unattended computer workstation was discovered located in an open corridor. The computer monitor had no patient information displayed; however, two (2) sheets labeled "Worklist "(3M) CDIS Daily Review Worklist" and two (2) sheets labeled "Documentation Worksheet MS-DRG" with patient identifying information , including name, DOB, Diagnosis, treatments, etc. were found unprotected on the workstation.

e. Security - Health Information Management Department Policy stated: "The health record is maintained in secure and restricted areas with access limited to those staff members who have a need for access based on either patient care needs and/or position responsibilities.... E. Health records in patient care areas are maintained in a controlled setting."

f. During an interview with the ICU/Behavioral Health Manager on January 14, 2014 at approximately 11:30 AM, he confirmed the above findings. Additionally, he revealed that the "paper" medical records for each inpatient are normally kept in an individual, unsecured, unsupervised "box" located on the wall outside of each patient's room. These boxes are easily opened and the enclosed medical records are readily accessible to unauthorized persons.

2. A second tour of the Medical/Surgical inpatient unit was conducted on January 15, 2014 at 9:00 AM. The following was noted:

a. One physician was observed leaving a M/S physician computer work station. The computer was not left open to a medical record; however, a "Call List" was left at the station (located in the corridor) with patient names, room numbers, diagnosis, vital signs, etc.

b. Another station had someone working on a computer; the contents of the screen were observable from the other side of the corridor.

c. Charts were observed in pull-down chart storage outside most occupied patient rooms.

d. On January 15 at approximately 9:30 AM, the M/S Nurse Director stated that the way we monitor access to the paper records is that if staff saw someone accessing records they would ask if they needed assistance ... also, if the physician had someone reading over their shoulder they would notice.

e. The Director of ACU/Behavior Health added: "Privacy screens were ordered for all computer screens facing corridors this morning."

3. During an interview with the Director, Health Information Management (HIM) on January 15, 2014, at approximately 12:30 PM, it was discovered that after-hour access to the Health Information Office, including the Record Storage Room, was limited to the Clinical Supervisor ...and housekeeping staff. He reported that housekeeping staff routinely empty waste baskets and vacuum the floors after all HIM staff have left the Department. When asked specifically if housekeeping would have unsupervised and unlimited access to the medical records he replied "yes". When asked if Security would question housekeeping staff observed unsupervised in the record room, he replied: "No, they are expected to clean the record room."

4. At approximately 12:40 PM on January 15, 2014, during a tour of the Medical Surgical Unit, the Director, Health Information Management (HIM) was asked how the hospital assures the security of the record stored inside of the pull-down chart storage compartments. He stated: "Someone is supposed to be at the nurses' station at all times, and they would see anyone attempting access." He was unable to state how the storage compartments around the corner from the nurses' station, (which are not in direct line of site), would be determined as secure. He agreed that inappropriate access to the record was possible. He also confirmed that the record could potentially be removed from the Hospital without detection.

5. Hospital Policy PEC010101HIM.S01 "Security - Health Information Management Department" stated: "Purpose: This policy provides guidelines for the security and safeguarding of health information against loss, destruction, tampering and unauthorized access and use," and "the Health Information Management Dept. will be locked at all times other than regularly staffed hours ... the department will be locked until a Health Information Management staff member returns ... During this time, other authorized hospital personnel will have access ...based on patient care needs and/or position responsibility."

6. On January 15, 2014, at approximately 1:00 PM, the Director of Health Information Management confirmed that unauthorized individuals, without supervision, are allowed in the record storage room. He also confirmed that the record storage compartments located on the medical-surgical nursing unit fail to prevent unauthorized access to the patient medical record.

Based on document review and interview with key personnel on January 15, 2014, it was determined that the facility failed to administer medications in accordance with physician orders.

Findings include:

1. Two (2) of five (5) Intensive Care Unit patient records contained documentation of omitted physician ordered medications.

2. Patient Record CC contained the following:
a. On January 13, 2014 at 2156 a physician order for Ativan, 2.0 mg (milligrams), PO (orally), Q6h (every six hours) was entered into the patient's medical record and was electronically signed by the physician. Pages 1 and 2 of the "M.A.R.-Temporary" further stated "X4 [times four] doses scheduled for PT [patient] with known hx [history] of seizures, hallucination, or high risk of DT's. [delirium tremens]."
b. The patient's Medication Administration Record of the Ativan 2.0 MG PO Q6h scheduled doses indicated the following:
i. 1/14/14 at 0000 "Omitted" with a reason of "Sleeping".
ii. 1/14/14 at 0600 "Omitted" with a reason of "Sleeping".
iii. 1/14/14 at 1200 "Omitted" with a reason of "Sleeping".
iv. 1/14/14 at 1800 "Given"
v. 1/15/14 at 0000 "Omitted" with a reason of "Lethargic".
vi. 1/15/14 at 0600 "Omitted" with a reason of "Sleeping".
vii. 1/15/14 at 1200 Medication discontinued.
c. The review of the Patient's medication order failed to contain any documentation indicating that this medication was to be "Omitted", or not given to the patient if the patient is "Sleeping".
d. There was no nursing documentation of physician notification of the "omitted" doses until 1/15/14. The nursing shift summary dated 1/15/14 at 0900 says "Pharmacy and Dr Bussone aware ativan still active and not being given was scheduled for 4 doses order discontinued."

3. Patient record DD contained the following:
a. On January 14, 2014 at 1606 a physician order for Gabapentin (Neurontin) CAP (capsule) 900 mg, PO, TID (three times a day) was entered into the patient's medical record and was electronically signed by the physician.
b. The Patient's Medication Administration Record of the Gabapentin (Neurontin), CAP, 900 MG, PO, TID scheduled doses indicates the following:
i. 1/14/14, 2100 dose was documented as "Omitted" with a reason of "Sleeping" at 2208
ii. 1/15/14 at 0900 "Given"
iii. 1/15/14 at 1300 "Given"
c. There was no nursing documentation of physician notification of the "omitted" dose.

d. On January 14, 2014 at 1606 a physician order for Simvastatin (Zocor) TAB (tablet), 10 mg, PO, Nightly, was entered into the patient's medical record and was electronically signed by the physician.
e. The Patient's Medication Administration Record of Simvastatin documented that the medication due 1/14/14 at 2100 was "Omitted" with a reason of "Sleeping". This was documented at 2208.
f. There was no nursing documentation of physician notification of the "omitted" dose.

g. Although the patient's Medication Administration Record for 1/14/14 at 2145 documented that the patient had been given Insulin, the medications listed above as due at 2100 were "Omitted" 23 minutes after the administration of this Insulin.

h. The review of the Patient's medication orders failed to contain any documentation indicating that these medications were to be "Omitted," or not given to the patient if the patient is "Sleeping."

4. The Medication Administration Policy PMM060101ADM.M01 states:
a. "Medications and biologicals are administered in accordance with ... the orders of the practitioner(s) responsible for the patient's care ..."
b. "...Scheduled medications shall be administered according to standardized guidelines to assure safe and timely medication therapy."
c. "...Maintenance medications that are prescribed ... every 6 hours, ... tid, ... shall be given within 60 minutes before or after their scheduled administration time."
d. "Medication administration is immediately documented in the medical record using exact medication administration times."
e. "If the medication is omitted in error ... variance report shall be filed and the prescriber notified."

5. At approximately 1400, the Unit Coordinator stated: "In my nursing judgment, I would not wake a patient to give them their meds."

Based on observation, document review, and interviews with ICU/Behavioral Health Manager, Director, Health Information Management, a Hospitalist, Quality Director, and Med/Surg Nurse Director on January 14-16, 2014, it was determined that the facility failed to maintain administrative responsibility that assured the confidentiality and protection of the patient medical records and other medically sensitive information.

Findings include:

1. The hospital failed to ensure that both physician and nurse computer work stations were shut down when left unattended on the Medical/Surgical Unit, leaving patient medical records and other medically sensitive information visible to any person in the area. See Tags A0146 and A0441 for further information.

2. The hospital failed to provide an adequately secure and screened physician computer workstation area that was located in a corridor open to the general public on the Medical/Surgical Unit. See Tags A0146 and A0441 for further information.

3. The hospital failed to have a system to secure inpatient paper medical records, instead having an unsecured, unsupervised pull-down "box" located on the wall outside of each patient's room. These record boxes were easily opened and the enclosed medical records were readily accessible to unauthorized persons. Please see Tags 0146 and 0441 for additional information.

4. The hospital failed to secure four (4) "paper" medical records that the physician left unattended at a computer workstation on the Medical/Surgical Unit. See Tags A0146 and A0441 for further information.

5. The hospital failed to ensure strict medical record security by allowing unauthorized individuals into the Medical Records Department storage room unsupervised after normal hours of operation. See Tags A0146 and A0441 for further information.


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on observation, document review, and interview with key personnel, on January 14-15, 2014, it was determined that the facility failed to protect the security of all patent records.

Findings include:

1. During a tour of the Medical/Surgical (M/S) inpatient unit conducted on January 14, 2014 at approximately 11:15 AM, an unattended physician computer work station, located in an alcove in a public hallway opposite patient room MS214-215, was observed with a computer monitor displaying a patient medical record (Record MM) in clear view of anyone who passed by.

a. Several minutes after the discovery of the unattended work station a Hospitalist approached the surveyors and indicated that he had been working on the patient's medical record and had "stepped away for a few minutes." The hospitalist further stated "I should have shut it down before I left." The Hospitalist asserted: "No medical records are secured and locked up at this hospital ... I have never been to a hospital where medical records are available to anyone that walks in ..."

b. A further observation of the workstation revealed four (4) "paper" patient medical records that were also unprotected (Records K, L, M, and NN).

c. Additionally, it was determined that the protected patient information displayed on the monitor was clearly visible to any person that may be in that area, as well as any occupants of a nearby patient room (room MS214-215).

d. As the tour continued, another unattended computer workstation was discovered located in an open corridor. The computer monitor had no patient information displayed; however, two (2) sheets labeled "Worklist "(3M) CDIS Daily Review Worklist" and two (2) sheets labeled "Documentation Worksheet MS-DRG" with patient identifying information , including name, DOB, Diagnosis, treatments, etc. were found unprotected on the workstation.

e. Security - Health Information Management Department Policy stated: "The health record is maintained in secure and restricted areas with access limited to those staff members who have a need for access based on either patient care needs and/or position responsibilities.... E. Health records in patient care areas are maintained in a controlled setting."

f. During an interview with the ICU/Behavioral Health Manager on January 14, 2014 at approximately 11:30 AM, he confirmed the above findings. Additionally, he revealed that the "paper" medical records for each inpatient are normally kept in an individual, unsecured, unsupervised "box" located on the wall outside of each patient's room. These boxes are easily opened and the enclosed medical records are readily accessible to unauthorized persons.

2. A second tour of the Medical/Surgical inpatient unit was conducted on January 15, 2014 at 9:00 AM. The following was noted:

a. One physician was observed leaving a M/S physician computer work station. The computer was not left open to a medical record; however, a "Call List" was left at the station (located in the corridor) with patient names, room numbers, diagnosis, vital signs, etc.

b. Another station had someone working on a computer; the contents of the screen were observable from the other side of the corridor.

c. Charts were observed in pull-down chart storage outside most occupied patient rooms.

d. On January 15 at approximately 9:30 AM, the M/S Nurse Director stated that the way we monitor access to the paper records is that if staff saw someone accessing records they would ask if they needed assistance ... also, if the physician had someone reading over their shoulder they would notice.

e. The Director of ACU/Behavior Health added: "Privacy screens were ordered for all computer screens facing corridors this morning."

3. During an interview with the Director, Health Information Management (HIM) on January 15, 2014, at approximately 12:30 PM, it was discovered that after-hour access to the Health Information Office, including the Record Storage Room, was limited to the Clinical Supervisor ...and housekeeping staff. He reported that housekeeping staff routinely empty waste baskets and vacuum the floors after all HIM staff have left the Department. When asked specifically if housekeeping would have unsupervised and unlimited access to the medical records he replied "yes". When asked if Security would question housekeeping staff observed unsupervised in the record room, he replied: "No, they are expected to clean the record room."

4. At approximately 12:40 PM on January 15, 2014, during a tour of the Medical Surgical Unit, the Director, Health Information Management (HIM) was asked how the hospital assures the security of the record stored inside of the pull-down chart storage compartments. He stated: "Someone is supposed to be at the nurses' station at all times, and they would see anyone attempting access." He was unable to state how the storage compartments around the corner from the nurses' station, (which are not in direct line of site), would be determined as secure. He agreed that inappropriate access to the record was possible. He also confirmed that the record could potentially be removed from the Hospital without detection.

5. Hospital Policy PEC010101HIM.S01 "Security - Health Information Management Department" stated: "Purpose: This policy provides guidelines for the security and safeguarding of health information against loss, destruction, tampering and unauthorized access and use," and "the Health Information Management Dept. will be locked at all times other than regularly staffed hours ... the department will be locked until a Health Information Management staff member returns ... During this time, other authorized hospital personnel will have access ...based on patient care needs and/or position responsibility."

6. On January 15, 2014, at approximately 1:00 PM, the Director of Health Information Management confirmed that unauthorized individuals, without supervision, are allowed in the record storage room. He also confirmed that the record storage compartments located on the medical-surgical nursing unit fail to prevent unauthorized access to the patient medical record.







32893

Based on observations and interviews with key personnel on January 15-16, 2014, it was determined that the facility failed to assure outdated, mislabeled, or otherwise unusable drugs were not available for patient use per facility policy.

Findings include:


1. Hospital Policy PIC010101ICS.P01, "Pharmacy-Infection Prevention & Control" stated: "To provide medications and pharmaceutical products that have been prepared and supplied under accepted standards for infection control."
a. Section "E. Multi Dose Vials" stated:
b. "1. Multi-dose vials will be hand dated with the beyond use date by the person opening the vial at the time the vial is initially accessed."
c. "2. Open Mulit-dose vials found undated will be immediately discarded."
d. "3. Open multi-dose ...discarded at 28 days unless otherwise specified by the manufacturer."

2. During a tour of Operating Room 3 on January 15, 2014, the anesthesia cart contained an open vial of lasix, 4 ml (milliliters), which lacked a date the vial was opened.

3. This finding was confirmed by the Nurse Director of the Operating Room on January 15, 2014 at 7:30 AM.

4. During a tour of the Wound Clinic on January 16. 2014 at approximately 12:00 PM, the following items were found:

Exam Room 1
a. Two (2) tubes Lidocaine Jelly, 2% which were opened and did not contain information including date opened, and "beyond use" date. The expiration date was also not visible.
b. One (1) Vial Lidocaine 4% Solution, which was opened and did not contain information including date opened, and "beyond use" date.
c. One (1) tube triamcinolone acetonide cream 0.1% which was opened and did not contain information including date opened, and "beyond use" date.
d. One (1) tube Mupirocin Ointment, 2% which was opened and did not contain information including date opened, and "beyond use" date.
e. One (1) tube collagenase santyl ointment 250 units, which was opened and did not contain information including date opened, and "beyond use" date.

Exam Room 2
a. One (1) Vial Lidocaine 4% Solution, which was opened and did not contain information including date opened, and "beyond use" date.
b. One (1) tube triamcinolone acetonide Cream 0.1% which was opened and did not contain information including date opened, and "beyond use" date.

Exam Room 5
a. One (1) tube collagenase santyl ointment 250 units, which was opened and did not contain information including date opened, and "beyond use" date.
b. One (1) tube Mupirocin Ointment, 2% which was opened and was labeled, however had a "beyond use" date of "9/15/13".
c. One (1) container nyamyc topical powder 100,000 units, which was opened and did not contain information including date opened, and and "beyond use" date. Additionally, the cover was not screwed on.
d. One (1) tube calmoseptine ointment, which was opened and did not contain information including date opened, and "beyond use" date.
e. One (1) tube triamcinolone acetonide Cream 0.1% which was opened and did not contain information including date opened, and "beyond use" date. Additionally, the tube had no cover and was placed inside a plastic bag.
f. One (1) Vial Lidocaine 4% Solution, which was opened and was labeled, however had a "beyond use" date of "9/9/13."

5. These findings were confirmed by the Outpatient Practice Manager on January 17, 2014 at approximately 12:15.


32893

Based on record review and interview on Janaury 15, 2014, it was deternined that patient clinical records failed to contain documentation of physician notification of medication error or adverse drug reaction in four (4) of five (5) records reviewed.

Findings include:

1. While the policy titled 'Adverse Drug Reactions and Medication Errors' required that these events be reported to the attending provider or their coverage, it did not specifically state that this notification was to be documented in the clinical record.

2. Although incident reports had been completed, Records PP, QQ, RR and SS contained no documentation of physician notification following the medication error or adverse drug reaction.

3. This finding was confirmed with the Director of Pharmacy on January 15, 2014 at approximately 11:30 AM.

Based on tours conducted throughout the hospital and interview with the Director of Facility and the Environmental Service and Food Nutrition on January 14 and 15, 2014, it was determined that the condition of the physical plant and the overall hospital environment was not developed and maintained in such a manner that the safety and well-being of patients were assured.

The findings are:

1. The dietary department had several flat surfaces that were soiled, i.e. lower shelving and dry storage shelving.

2. In the Dietary Department, the cooler that is used for storing jello products had a corroded door. In addition, clean blender jars were stored on shelves located over a dirty sink.

3. The Laboratory Department had areas of chipped paint, rusted floor areas and a soiled specimen refrigerator.

4. The Blood Bank area, located in the Laboratory Department, had dusty flat surfaces with floors that needed to be stripped and re-waxed.

5. The Pharmacy Department contained a torn chair that was repaired with a very large piece of duct tape, and not easily sanitized. In addition, floors throughout the department were soiled.

6. The Emergency Department ambulance entry had unlocked supply cabinets that housed needles. In addition, the rooms used for psychiatric emergencies had soiled accordion type doors.

7. Throughout the hospital, several patient rooms were found with dusty upper horizontal surfaces, i.e. door frames, window sills, wall sharp boxes, top of cabinets.

8. Throughout the hospital patient care areas, supply carts and crash carts were found dusty/soiled.

9. Two (2) expired Spiral Electrodes (with dates of 2009-11 and 2009-04) were observed in Maternity floor Triage Room WH 517 518.

10. Maternity Room 510 contained:
a. Wooden chair with worn and unsanitizable finish.
b. Safety grab rails in the bathroom being used as towel rods.
c. Dust over the cabinets and lights.
d. Stained and worn window sill with evidence of water damage.
e. Pullout chair mattress with a porous fabric surface which was unsanitizable.
f. One (1) Saf-T-Vac Suction Catheter was found open and unsterile.

11. Maternity - Special Care Nursery contained:
a. Dusty Baby Warmer.
b. Shelves which were dusty and had tape/adhesive residue.
c. Two (2) Glide Scope - ET tube/Stylets which were opened and unsterile.

12. The Cardiac Catheter Storage area, which contained sterile packs and supplies, also functioned as a staff locker room. Several pairs of soiled shoes, staff coats etc. were found adjacent to sterile packs used for Cardiac Catherization.

13. Public Restrooms located on main floor and at top of stairway to second floor patient units all had visible dust on the ventilation ducts.

14. The refrigerated water fountain located at the public restrooms closest to the main entrance had a visible oily soiled residue on the cooling unit ventilation grill. The climate control air intake grill located in this area was also visibly soiled.

15. These findings were confirmed by both the Infection Control Nurse and the Quality Assurance Nurse on January 14, 2014, at approximately 14:30.