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Based on observation, interview with staff, and record review the facility is not constructed, arranged, and maintained to ensure access to and safety of patients. See ID Prefix tag C221 for findings.

Based on observation, interview with staff, and record review the facility is not constructed, arranged, and maintained to ensure access to and safety of patients.
Findings:
(1) The building is constructed with masonry load bearing walls and a roof structure of unprotected steel beams and bar joists and does not have roof framing protected with materials capable of one-hour fire resistance rating or is not fully protected with a fire sprinkler system. See ID prefix tag K 012 survey event BT0V21
(2) Doors do not have a means suitable for keeping the door closed. See ID prefix tag K 018 survey event BT0V21
(3) Written records of fire drills are not maintained as required by NFPA 72, 19.7.1.2. See ID prefix tag K 050 survey event BT0V21
(4) Written records for testing the fire alarm system are not maintained accordance with NFPA 70 and 72, 0.6.1.4. See ID prefix tag K 052 survey event BT0V21
(5) The partial sprinkler system for certain hazardous areas is not maintained in accordance with NFPA 25. See ID prefix tag K 056 survey event BT0V21
(6) Written records of testing the emergency generator are not maintained as required by NFPA 99, NFPA 110, and LSC 3.4.1. See ID prefix tag K 144 survey event BT0V21

Based on review of the infection control meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active infection control program for identifying, reporting, and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Findings:

1. The personnel file, for the person identified as the ICO, did not contain evidence the individual had training or experience in infection control.

2. On 05/04/2010 at 1540, the person identified as the ICO stated she took the position because no one else would do so. She told the surveyor that she did not have any experience or training in infection control or in setting up an infection control program.

3. Review of infection control meeting minutes for the past year did not contain evidence patient and staff infections and been reviewed with an analysis to determine whether changes in hospital practices were needed.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authenticated. This occurred in eight of eight records (Records #9, 10, 12, 13, 14, 16, 17, and 18) reviewed for completed entries.

Findings:

1. Record #9 - admission 03/28/2010 through 04/04/2010:
a. Dictated Emergency Room Record, History and Physical, Progress notes, Discharge Summary, Surgery Consult and Operative Reports did not contain the date and time the physicians signed/authenticated the dictated documents.

b. Eleven of fifteen orders by the physicians did not contain the time the order was written.

c. Thirteen of thirteen verbal/telephone orders did not contain the date and time the physician signed the orders.


2. Record #10 - admission 03/30/2010 through 03/31/2010:
a. The dictated History and Physician, Progress note, and Discharge Summary did not contain the date and time the physician signed/authenticated the dictated documents.

b. The admission order on 03/30/2010 and the discharge order on 03/31/2010 did not contain the time the physician wrote the order.

c. The telephone order on 03/31/2010 at 0300 did not contain the date and time the physician signed the order.


3. Record #12 - admission 04/03/2010 through 04/05/2010:
a. The dictated History and Physical and Discharge Summary did not contain the date and time the physicians signed/authenticated the dictated documents.

b. The admission order on 04/03/2010, and additional order on 04/03/2010 and the discharge order on 04/05/2010 did not contain the time the physician wrote the order.

c. A telephone order on 04/03/2010 did not contain the time the nurse took the order from the physician and did not contain the date and time the physician signed the telephone order.


4. Record #13 - Day Surgery 04/28/2010:
a. Two telephone orders did not contain the signature of the physician.

b. The post-anesthesia recovery unit (PACU) orders did not contain the time and date of the order and did not contain the physician ' s signature/authentication.

c. The physician did not sign/authenticate the dictated Operative Report.


5. Record #14 - admission 04/26/2010 through 04/29/2010:
The physician did not sign the 04/27/2010 order for the PCA (patient controlled anesthesia) pump.


6. Record #16 - admission 03/19/2010 through 04/08/2010:
a. Three orders did not contain the time the physician wrote the order.

b. The record did not contain a History and Physical.


7. Record #17 - admission 02/13/2010 through 02/14/2010:
Two of ten orders did not contain the time the physician wrote the orders.


8. Record #18 - admission 02/04/2010 and left AMA (against medical advise) same day:
The admission order did not contain the date and time the order was written.

9. The findings were reviewed with administrative staff on the afternoon of 05/04/2010.