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Based on a review of Hospital Rules and Regulations, a review of Delinquent Record List and staff interview, it was determined the governing body failed to ensure policies regarding the suspension of clinical privileges for incomplete medical records were followed. This failure has the potential to affect all patients receiving care and services.
Findings include:

1. A review of the Hospital Rules and Regulations, revision date 03/13 was completed during the survey. The Rules and Regulations indicated on page 15 "3.18.2 Suspension of Clinical Privileges for Incomplete Records, If a practitioner fails to comply with the medical records completion guidelines, the Medical Staff Office shall notify the practitioner. The Medical Staff President shall notify the practitioner for a second failure to comply with medical records completion. At the 3rd violation within a year, the practitioner will undergo a two (2) day suspension and at the 4th violation within a year, the practitioner will undergo a five (5) day suspension. At the 5th occurrence within a year, the practitioner will undergo a seven (7) day suspension and must report to the MEC regarding his/her failure to comply.

2. A review of the Medical Records Delinquencies report requested on 3/11/13 indicated a total of 352 delinquent records. An additional request was made to further identify the specific deficiencies and indicated of the 352 records 6 were 31-62 days late on discharge summaries, 3 records were 33-50 days late on history and physicals, 1 record was 62 days late on operative report, 332 failed to include physician signatures and 10 records were late in completing missing text for coding and facesheets

3. During an interview with the Director of Quality on 3/13/13 at 4:00 PM, it was indicated the Health Information Manager sends letters every 2 weeks followed by a letter from the Director of Organizational Effectiveness at 30 days. The Director indicated they were unaware of the number of delinquent records until the report was requested during the survey. The Director indicated to her knowledge there are no physicians on any suspensions at this time.

Based on a review of Medical Staff Bylaws, a review of credential files, a review of the MEC meeting minutes, and staff interview, it was determined in 1 of 1 Surgical Assistant, who requested Temporary Privileges, the Hospital failed to ensure its process for completion of the Temporary Privilege request and subsequent approval process was followed.
Findings include:

1. The Medical Staff Bylaws (revised and approved by the Board of Directors on 1/4/11) were reviewed. It indicated "Section 6. Clinical Privileges: 6.1 Exercise of privileges: A practitioner providing clinical services at the hospital may exercise only those privileges granted to him/her by the Board... Privileges may be granted by the Board upon recommendation of the MEC to practitioners who are not members of the medical staff.... or others deemed appropriate by the MEC and Board... 6.10 Temporary Privileges: ...."

2. The credential file of the Surgical Assistant was reviewed on 3/14/13. It indicated "Specific Policies and Delineation of Services for Non-Physician Surgical Assistants." The Surgical Assistants name and an "X" was next to "Initial" and it was dated by the Surgical Assistant on 2/29/12 and by P1 on 3/5/12. The form was otherwise completely blank. The "Medical Executive/ Credentialing Committee Review" indicated "Allied Health... Surgical Assistant.... Surgery.... 90 days temporary." and was signed on 3/8/12 by the President of the MEC. It failed to indicate whether it was "Approved as requested", "Defer", "Deny", or "Approve with Conditions/ Modifications".

3. The MEC meeting minutes for 3/12 thru 5/12 were reviewed. There was no documentation to indicate the Temporary Privileges for the Surgical Assistant were discussed and/or approved by the MEC.

4. During a staff interview, conducted with the Medical Staff Specialist and the Quality Management Supervisor on 3/14/13 at 10:00 AM, it was confirmed by both that the Surgical Assistant was "a last minute fill in" for P1 and "we had to hurry to get what we could get done. It is the practice of the Hospital to credential outside Surgical Assistants for practice in their Hospital. It was confirmed by both that the privilege for did not specify what privileges the Surgical Assistant was requesting; the MEC/ Credentialing Committee Review form did not specify whether the Surgical Assistant was Approved, Denied, Deferred, or Approved with Conditions; and there was no documentation to indicate the MEC had discussed and/or approved the Surgical Assistant in any of their meetings.

A. Based on a review of Medical Staff Bylaws, a review of physician credential files, and staff interview, it was determined in 1 of 11 (P6) physician credential files, in which the physician was due for reappointment, the Hospital failed to ensure practicing physicians maintained current privileges, in accordance with the Medical Staff Bylaws.
Findings include:

1. The Medical Staff Bylaws (revised and approved by the Board of Directors on 1/4/11) was reviewed. It indicated "Section 5: Reappointment:...5.2.4. Failure, without good cause, to provide any requested information, at least 45 calendar days prior to the expiration of appointment will result in a cessation of processing of the application and automatic expiration of appointment when the appointment period is concluded..."

2. The credential file of P6 was reviewed on 3/13/4. P6 was last reappointed to the Medical Staff on 11/30/10 and the privileges expired on 11/30/12. At the time of the credential file review; there was no current State Medical License, Federal DEA license, or State Controlled Substance License. During a staff interview, conducted with the Medical Staff Specialist on 3/13/13 at 3:00 PM, it was verbalized that all the forms and information needed to complete the recredentialling process had not been sent in by P6 and that the current licenses were not on file at this time.

3. During a staff interview, conducted with the Quality Management Supervisor and the Medical Staff Specialist on 3/14/13 at 9:00 AM, it was confirmed by both that P6's privileges were expired; however, P6 continued to provide active services in the Hospital. Current license checks for P6 were presented at this time.

B. Based on a review of Medical Staff Bylaws, a review of physician credential files, and staff interview, it was determined in 6 of 11 (P2, P3, P8, P9, P10, P11) physician credential files reviewed, in which the physician applied for reappointment, the Hospital failed to ensure an evaluation of services was completed, in a accordance with its Medical Staff Bylaws.
Findings include:

1. The Medical Staff Bylaws (revised and approved by the Board of Directors on 1/4/11) was reviewed. It indicated "Section 5 Reappointment: 5.2.3. The following information is also collected and verified: b. Performance and conduct in this hospital and other healthcare organizations... f. Compliance with all applicable bylaws, policies, rules, regulations, and procedures of the hospital and medical staff... j. When sufficient peer review data is not available to evaluate competency, one or more peer recommendations, as selected by the credentials committee, chosen from practitioner(s) who have observed the applicant's clinical and professional performance and can evaluate the applicant's current medical/ clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism as well as the physical, mental and emotional ability to perform requested privileges..."

2. The credential file of P2 was reviewed on 3/14/13. P2 was reappointed to the Medical Staff on 2/28/13. The "Recommendation/ Action of Clinical Privileges For Reappointment," to be completed by the Division Chair, was completely blank except for the signature of the Surgery Division Chair.

3. The credential file of P3 was reviewed on 3/13/13. P3 was reappointed to the Medical Staff on 3/6/13. The "Recommendation/ Action of Clinical Privileges For Reappointment," to be completed by the Division Chair, was completely blank except for the signature of the Surgery Division Chair.

4. The credential file of P8 was reviewed on 3/14/13. P8 was reappointed to the Medical Staff on 7/11. The "Recommendation/ Action of Clinical Privileges For Reappointment," to be completed by the Division Chair, was blank except for the signature of the Surgery Division Chair and was dated 9/13/12, 14 months after the reappointment.

5. The credential file of P9 was reviewed on 3/14/13. P9 was reappointed to the Medical Staff on 8/8/12. The "Recommendation/ Action of Clinical Privileges For Reappointment," to be completed by the Division Chair, was blank except for the signature of the Surgery Division Chair and was dated 9/26/12, almost 2 months after the reappointment.

6. The credential file of P10 was reviewed on 3/13/13. P10 was reappointed to the Medical Staff on 8/31/12. P10 provided services under both the Division of Obstetrics/ Gynecology and Surgery. The "Recommendation/ Action of Clinical Privileges For Reappointment," completed by the Obstetrics Division was blank except for the signature of the Obstetrics/ Gynecology Chairman. The "Recommendation/ Action of Clinical Privileges For Reappointment," completed by the Surgery Division was completely blank except for the signature of the Surgery Division Chair.

7. The credential file of P11 was reviewed on 3/14/13. P11 was reappointed to the Medical Staff on 6/8/11. The "Recommendation/ Action of Clinical Privileges For Reappointment," to be completed by the Division Chair, was completely blank except for "Approved as requested" and the signature of the Surgery Division Chair.

8. During a staff interview, conducted with the Medical Staff Specialist on 3/13/13 thru 3/13/14 while conducting the review of credential files, it was confirmed that the expectation is that all forms be completed in their entirety. It was confirmed that the above files were blank with the exception of a date and/or signature and one with "Approved as requested" marked.

Based on document review and staff interview, it was determined the Hospital failed to provide patients the address to file a grievance with the State Agency, potentially affecting 100% of patients receiving care at the Hospital.
Findings include:

1. During a tour of the 2nd Floor, Medical Surgical Unit on 3/12/13 at 1:00 PM it was determined the Hospital provided each patient the policy titled "Patient Rights & Responsibilities" (revised 11/11). The policy indicated "If you wish to issue a complaint directly to the State of Illinois, you may call ... at... You may also complain in writing to: Region V Office of Civil Rights..." There is no documentation indicating the Hospital provided the mailing address to submit written complaints to the Illinois Department of Public Health, Springfield, Illinois.

2. An interview was conducted with the Quality Manager on 3/13/13 at 10:00 AM. It was confirmed that the Patients Rights sheet, provided to all patients did not contain the address to the Illinois Department of Public Health for complaints.

Based on review of Hospital policy, observation, a review of job assignment and staff interview, it was determined the Hospital failed to ensure staff were educated in quality control and cleaning of glucose monitoring equipment potentially affecting all patients receiving glucose monitoring.
Findings include:

1. The Hospital policy titled, "Capillary Blood Glucose Monitoring", revised 9/12 under "Procedure 15. Wipe the Accu-Check inform system with alcohol hospital applied disinfectant (per after use manufacture's instruction).

2. During a tour of the Care Today Urgent Care Center on 3/12/13 at 6:00 PM, the Radiation Technician assigned to perform lab tests and quality control was asked to explain the use of the glucose monitor including quality checks and cleaning the meter. The technician was able to explain the process to complete the quality controls but could not explain the meaning of the numbers produced with the check and did not know how the monitor was to be cleaned. The technician reported she has not performed a glucose test since being trained since none had been ordered.

3. A review of the undated Nurse Task Reassignment indicated under the column "Rad Tech" line 4 "Specimen collection, perform lab tests and perform lab QC."

4. During an interview with the Director of Quality on 3/13/13 at 7:30 AM, it was reported the technician is new to the position but has received education on use, care and control checks for the glucometer. The Director indicated the duties of the nurse were reassigned to other staff when changes in staffing occurred. The Director reported the technician would receive reeducation.

Based on a review of Hospital contracts with the two anesthesiologists, a review of the QAPI program and QAPI committee meeting minutes, and staff interview, it was determined the Hospital's QAPI program failed to include the Anesthesia Department. This has the potential to affect 100% of those patients receiving anesthesia or sedation in the Hospital.
Findings include:

1. The contract for Anesthesiologist #1 was reviewed on 3/13/13. It indicated under "2. Responsibilities of Anesthesiologist. B. Services to Hospital. 3) participate in the Hospital's overall continuous quality improvement program (CQI), establishing procedures to assure the consistency and quality of all services in the Department by Anesthesiologist and CRNA's;"

2. The contract for Anesthesiologist #2 was reviewed on 3/13/13. It indicated under 2. Responsibilities of Anesthesiologist. B. Services to Hospital. 3) participate in the Hospitals overall continuous quality program (CQI), establishing procedures to assure the consistency and quality of all services in the Department by Anesthesiologist and CRNAs;"

3. The QAPI program and its minutes for 2012 were reviewed. There was no documentation that indicated the Anesthesia Department was submitting QA date to the Hospital's QAPI.

4. During an interview with the Supervisor of QM, conducted on 3/14/13 at 10:45 AM, it was verbalized that for more than a year the Quality program has attempted to get the Anesthesia Department to submit quality data to the program for review. As of survey date 3/14/13, no quality data has been submitted by the Anesthesia Department to the Quality Program.

Based on review of policy and procedure, clinical record review and staff interview it was determined that in 2 of 30 (Pt #8, 9) medical records reviewed the facility failed to ensure all entries in the medical record were dated, timed and authenticated.
Findings include:

1. The policy titled "Nursing Service: Documentation" (revised 10/10) was reviewed. The policy indicated under the implementation section "3. Current date and military time of recorded note must be entered..."

2. A review of the medical record of Pt # 8 was conducted on 3/12/13. Pt #8 was admitted on 3/11/13 with a diagnosis of Pneumonia. The Emergency Room Physician's note, Emergency Room Nurse's note, and the History and Physical have no date or time of author's entry.

3. A review of the medical record of Pt #9 was conducted on 3/12/13. Pt #9 was admitted on 3/10/13 with a diagnosis of Congestive heart Failure. The Combined Home Medication and Inpatient Medication Reconciliation Order Form pages 1 thru 3 have no date or time of author's entry, page 4 has no signature. The Emergency Room Physician's note and Emergency Room Nurse's note have no date or time of author's entry.

4. An interview with the Quality Manager conducted 3/15/13 at 2:00 PM was conducted. The Quality Manager confirmed documentation in the medical record should be dated, timed and authenticated by the author.

Based on review of policy and procedure, clinical record review and staff interview it was determined in 3 of 30 (Pt #9, 12, 23) medical records reviewed the facility failed to ensure verbal orders were repeated back, dated, timed and authenticated according to Hospital policy.
Findings include:

1. The policy titled "Administration: Physician Orders" (revised 3/13) was reviewed. The policy indicated "All verbal/phone orders will be repeated back to the provider to confirm the order given. The orders are to be recorded with the name and title of provider followed by name and title of person receiving the orders. The time and date that the order was received...."

2. The policy titled "Nursing Service: Documentation" (revised 10/10) was reviewed. The policy indicated "3. Physicians Orders... b. Verbal/telephone orders from physicians to an RN are to be recorded... Include the time and date that the order was received..."

3. A review of the medical record of Pt #9 was conducted on 3/12/13. Pt #9 was admitted on 3/10/13 with a diagnosis of Congestive heart Failure. A telephone order with an entry date of 3/10/13 at 1755 was authenticated without a date or time.

4. A review of the medical record of Pt #12 was conducted on 3/15/12. Pt #12 was admitted on 3/28/12 with a diagnosis of Bacterial Meningitis. A telephone order taken by a nurse on 4/2/12 did not indicate the order was read-back, and there was no date or time of entry.

5. A review of the medical record of Pt #23 was conducted on 3/14/13. Pt #23 was admitted on 3/11/13 for observation for post surgical bleed. A verbal order was documented under a physician order that was dated 3/11/13 at 1000. There was no date or time to indicate when the verbal order was written.

6. An interview with the Quality Manager conducted 3/15/13 at 2:00 PM was conducted. The Quality Manager confirmed all physician orders are to be dated and timed including verbal and telephone orders. The Quality Manager also confirmed that verbal and telephone order documentation should indicate that the order was read-back to the physician.

Based on review of policy and procedure, clinical record review and staff interview it was determined in 2 of 30 (Pt #12, 23) medical records reviewed the Hospital failed to ensure verbal and telephone orders were authenticated according to Hospital policy.
Findings include:

1. The policy titled "Administration: Physician Orders" (revised 3/13) was reviewed. The policy indicated "Verbal orders must be signed before the provider leaves the area. Telephone orders... must be signed within 72 hours."

2. A review of the medical record of Pt # 12 was conducted on 3/15/13. Pt #12 was admitted on 3/28/12 with a diagnosis of Bacterial Meningitis. A telephone order dated 4/2/12 had not been authenticated by the Physician.

3. A review of the medical record of Pt #23 was conducted on 3/14/13. Pt #23 was admitted on 3/11/13 for observation for post surgical bleed. A verbal order was documented under a physician order dated 3/11/13 at 1000. The verbal order had not been authenticated by the Physician prior to leaving the area.

4. An interview with the Quality Manager conducted 3/15/13 at 2:00 PM was conducted. The Quality Manager confirmed the physician is to authenticate verbal orders prior to leaving the area and telephone orders within 72 hours.

Based on Hospital Rules and Regulations, a review of Delinquent Records list, and staff interview, it was determined the Hospital failed to ensure that all medical records were completed in a timely manner, potentially affecting all patients receiving care and services. As of 3/11/13 the Hospital had a total of 352 delinquent records.
Findings include:

1. A review of the Hospital Rules and Regulations was completed during the survey. The Hospital Rules and Regulations, revision date 03/13 indicates on pages 14-15 under 3.18.1 "Requirements for Timely Completion of Medical Records, Medical records should be completed in accordance with the following standards: a. An Admission History and Physical Examination ...must be completed by the attending physician...within 24 hours... d. An Operative Report must be entered in the medical record by the performing practitioner immediately following the surgery or procedure...i. A Discharge Summary must be entered in the medical record by the attending physician...within 21 days of an inpatient or observation discharge..."

2. A review of the Medical Records Delinquencies report requested on 3/11/13 indicated a total of 352 delinquent records. An additional request was made to further identify the specific deficiencies and indicated of the 352 records 6 were 31-62 days late on discharge summaries, 3 records were 33-50 days late on history and physicals, 1 records was 62 days late on operative report, 332 failed to include physician signatures and 10 records were late in completing missing text for coding and facesheets.

3. During an interview with the Quality Manager on 3/13/13 at 4:00 PM, she indicated letters are sent to the physicians who are delinquent every 2 weeks and do follow the guidelines in the Rules and Regulations. The Quality Manager reported the larger number of delinquencies involves signatures which are viewed as less of a priority.

A. Based on review of Hospital policy and procedure, observation, and staff interview it was determined that the Hospital failed to ensure narcotic wastes were countersigned according to the Hospital's policy, this has the potential to affect 100% of the patients who receive services at the hospital.
Findings include:

1. The Hospital policy titled, "Hospital-wide Pharmacy Floor Checks" (no issue date) under "Procedure C" in regards to narcotics indicated "wastes are countersigned".

2. During a tour of the Day Surgery Unit on 3/13/13 at 9:00 AM, documentation on the "Controlled Drug Administration Record" indicated on 11/15/13, Meperidine, 50 mg IV was signed out. Documentation indicated that 25 mg was given to patient and 25 mg was wasted. Under "record of waste and spoilage" it indicated one Nurse signed for the wastage but there is no documentation to indicate there was a witness signature.

3. An interview with the Day Surgery Charge Nurse was conducted on 3/13/13 at 9:10 AM. It was confirmed that there was not a witness signature on the Controlled Drug Administration Record.

B. Based on review of policy and procedure, a review of the Narcotic and Controlled Drug Administration Records, observation, and staff interview, it was determined that the Hospital failed to ensure an accurate distribution of use and an accurate inventory count of medications were maintained and recorded. This has the potential to affect 100% of the patients who receive services at the hospital.
Findings include:

1. The policy titled "Pharmacy: Recording Procedures" (effective date 3/86) was reviewed. The policy indicated under "Procedure: 11. Description of areas on the Pharmacy Department Controlled Substances form. #1-Clearly written, name of drug and strength and route... #9-Continuous adding and subtracting to have accurate daily numbers."

2. A protocol titled "Pharmacy: Perpetual C II Inventory" (revised 4/2004) indicated the Pharmacist is responsible to verify "an accurate amount of inventory on every C II that leaves and arrives in the pharmacy."

3. A review of the Controlled Drug Administration Records for January were reviewed on 3/14/13. The records listed had the following discrepancies:

Midazolam 5 mg/5 ml, quantity #25 issued 1/3/13 had no waste witnessed for 9 discarded entries from 1/4/13 thru 1/10/13; an entry dated 1/4/12 indicated 2 mg given and 2 mg discarded which leaves 1 mg unaccounted for.

Hydrocodone/APAP 5 mg/325 mg quantity #25 issued 1/4/13 has 20 tablets recorded which leaves 5 tablets unaccounted for.

Fentanyl 500 mcg/10 ml quantity #10 issued 1/3/13, the dosage given and discarded equals 2450 mcg which leaves 50 mcg unaccounted for.

Fentanyl 500 mcg/10 ml quantity #5 issued 1/10/13 has 46.5 ml recorded which leaves 3.5 ml unaccounted for.

Fentanyl 10 ml quantity #2 issued 1/7/13 has no dosage strength to identify if given dose is accurate with count.

Fentanyl 10 ml quantity #2 issued 1/10/13 has no dosage strength to identify if dose given is accurate with the count.

4. During a tour of the Pharmacy 3/13/13 at 12:30 PM, a controlled substance (C II's) count was conducted. The Narcotic Master Control Sheet titled "Meperidine" indicated an inventory balance of "0." Meperidine 300 mg/ml injectables x 14 were found in the expired medication drawer of the controlled substance safe.

5. An interview with the Director of Pharmacy was conducted on 3/14/13 at 3:00 PM. The Director of Pharmacy confirmed that the Controlled Drug Administration Records nor the Narcotic Master Control Sheets accurately reflect the inventory count. The Director of Pharmacy indicated the records are not monitored to assure the counts are accurate, waste is documented and/or witnessed and the forms are completed with the medication drug strength.

A. Based on review of policy and procedures, observation and staff interview it was determined the facility failed to ensure that 2 of 2 expired C II controlled substances were kept in a locked area. This has the potential to affect 100% of the patients who receive services at the hospital.
Findings include:

1. The policy titled "Pharmacy: Recording Procedures" (effective date 3/86) was reviewed. The policy indicated under "Procedure: 9. Storage of Outdated Controlled Drugs-- In the course of checking outdated drugs, all controlled drugs found will be stored... C II's are stored in the safe.

2. During a tour of the Pharmacy 3/13/13 at 12:30 PM, a Duragesic 100 mcg/h patch x 1 with an expiration date of 2/13 and Hydrocodone with Acetaminophen 7.5 mg/ 325 mg tablets x 18 expired 2/13 were located on the counter within the pharmacy.

3. An interview with the Pharmacist on 3/13/13 at 1:00 PM was conducted. The Pharmacist confirmed the medication were C II controlled substances and should be locked in the safe.

B. Based on review of policies and procedures, observation, review of the pharmacy tracking log and staff interview, it was determined that the hospital failed to ensure 1 of 1 patient's home controlled medications were logged and located in a secure area and limited to appropriate staff. This has the potential to affect 100% of the patients who receive services at the hospital.
Findings include:

1. A review of the Hospital's policy titled "Medications Brought From Home By The Patient" (effective date: 6/86) was reviewed. The policy indicated that the patient's home medications will be logged-in when received in the Pharmacy and logged out when notified of the patient's discharge.

2. A review of the Hospital's policy titled "Nursing Services/Pharmacy: Omnicell" (revised 2/11) indicated under "Procedure: 1. Authorized Access- Access will be strictly maintained to ensure adequate security for medications including controlled substances."

3. A review of the Hospital's policy titled "Nursing Service: Narcotics-Signing For Use" (revised 12/10) indicated the objective is to "maintain an accurate record of narcotics used and kept on the unit."

4. During a tour of the second floor medical surgical floor medication storage room titled "Omnicell Room" was conducted 3/12/13 at 12:30 PM with a staff nurse present. A medication bottle labeled from an outside facility with a patient name, filled on 2/4/13, as Hydrocodone/APAP 5/500 mg Quantity #50 was identified in a biohazard bag with "To Pharmacy" written on the outside of the bag. The medication bottle had a note rubber banded which read "Please take this home. We do not want to be responsible for a controlled substance." The nurse verbalized the medication bottle was a patient's home medication, contained Hydrocodone/APAP 5/500 mg a controlled substance and the quantity was unknown. The nurse reported the patient's medication was placed on the counter by the pharmacy staff after being notified of discharge and should have been returned to the Omnicell. The nurse reported the Unit Clerks and Respiratory Therapists have full access to the Omnicell Room.

5. During a tour of the Pharmacy conducted 3/13/13 at 11:00 AM, the home medication log sheets were reviewed. The home medication log sheets did not have the patient's medication logged in or out of the pharmacy.

6. A staff interview with the Pharmacist was conducted 3/13/13 at 11:00 AM. The Pharmacist confirmed no entry was entered into the home medication log sheet either signing the patient's medication in or out. The pharmacy staff confirmed the patient's Hydrocodone is a controlled substance and the quantity was unknown.

Based on review of the Radiation Dosimetry Report, and staff interview, it was determined the Hospital failed to ensure proper safety precautions were taken for 40 of 83 personnel that are exposed to radiation.
Findings include:

1. During a tour of the Radiology Department on 03/11/13 at 1:00 PM, documentation on the Radiation Dosimetry Report, account #186819 indicated 43 personnel received dosimetry badges and had the badges tested for radiation dose equivalent (mrem).

2. An interview with the Director of Radiology was conducted on 03/11/13 at 1:10 PM. The Director was asked if all personnel, who required dosimetry badges, had received them; the Director's reply was "Yes". During the survey, it was discovered that 40 surgical personnel, who are present during radiology tests in the OR and have the potential to be exposed to mrem, had not received dosimetry badges. Another interview was conducted with the Director of Radiology on 3/14/13 at 2:00 PM. The Director indicated that Surgery Staff were only issued badges if they requested them.

3. An interview with the Director of Quality was conducted on 3/14/13 at 2:20 PM. The Director confirmed that the surgical staff had only received dosimetry badges on request.

A. Based on a review of the Custom Solutions test instructions and staff interview, it was determined that the Dietary staff were unable to verbalize the proper method to ensure the PPM of the Quat Sanitizer to ensure proper sanitization of items cleaned in the 3 tub sink. This has the potential to affect 100% of the patients who receive Dietary services.
Findings include:

1. The "Custom Solutions" manual for the "procedure for Testing Third Sink Sanitizing Solutions Using Quat Check Paper" was reviewed. It indicated "...Water should be at room temperature (65 - 75F) 3. Dip Quat Check Paper into solution for ten (10) seconds. Be sure to dip paper into still solution, do not allow paper to contact bubbles... Caution: Inaccurate readings can be produced under the following conditions: warm or hot water, moving water, variance in "dip" time, or contamination of solution by anything other than sanitizer solution."

2. During a tour of the Dietary Department, conducted on 3/12/13, a dietary staff member using the three tub sink was asked to verbalize the procedure to ensure the Quat sanitizer was at the proper strength (200 PPM). It was verbalized that the test paper is simply dipped into the solution and read. She did not verbalize a timeframe to dip the paper or verbalize that there were certain conditions that would give an inaccurate reading. The Dietary Manager was asked the procedure for testing the Quat solution. It was verbalized that the test strip was dipped into the solution for 15 seconds and then read. Again, there was no verbalization of certain conditions that might give an inaccurate reading. The Dietary Manager stated that the staff would have to be retrained in test the Quat Sanitizer solution to achieve the proper concentration.

B. Based on a review of Hospital policy and procedure, a review of the dishwasher temperature logs, and staff interview, it was determined in 6 out of 45 dishwasher cycles the Hospital failed to ensure the dishwasher temperatures were recorded in accordance with policy and procedure. This has the potential to affect 100% of patients who receive Dietary services.
Findings include:

1. The Hospital policy and procedure titled, "Dishroom Temperature Records" (with a reviewed date of 2/03) was reviewed. It indicated under, "Procedure: 1. Prior to beginning of the shift the dish room aide will record the dish machine temperatures on the log sheet. 2. The day and time will be recorded for all 3 tanks. 3. Temperature will be recorded for the Scrapper Tank, Wash Tank, Power Rinse and the Final Rinse - Wash: 150 Rinse: 160 Final Rinse 180. Any discrepancies with the temperatures will be reported immediately to supervisor. 5. Corrective action will be taken."

2. The dishwasher temperature log was reviewed for the dates 1/9 to 3/12/13. Documentation indicated that 6 out of 45 times the dishwasher temperatures were not recorded in accordance with Hospital policy and procedure by documenting the Scrapper Tank, Wash Tank, Power Rinse and the Final Rinse temperatures.

3. During an interview with the Dietary Manager, conducted on 3/12/13, at 10:45 AM it was verbalized that the dishwasher room staff were under the impression that when a temperature test strip was run, it was not necessary to record the temperatures of the dishwasher. It was also stated that the Dietary staff should have recorded the temperatures on the other days without recorded temperatures.

C. Based on a review of Hospital policy and procedure, a review of the hot food temperature logs, and staff interview, it was determined that 35 of 137 occasions the required food temperatures were not documented according to policy and procedure. This has the potential to affect 100% of patients who receive Dietary services.
Findings include:

1. The Hospital policy and procedure titled, "Food Temperature Records" (last revised 9/08) was reviewed on 3/13/13. It indicated under "Food Service - The temperatures of all foods on the serving line will be recorded prior to tray service before each meal...."

2. The "Hot Food Temperature Checks" log was reviewed for 2/28/13 to 3/12/13. Documentation indicated that on 35 out of 137 occasions the hot food temperatures were not documented.

3. During an interview with the Dietary Manager, conducted on 3/12/13 at 10:45 AM, it was verbalized that the staff are constantly reminded to record food and cooler/freezer temperatures. It was further verbalized that the dietary should have recorded the food temperatures on those occasions the temperatures were not documented.

D. Based on a review of Hospital policy and procedure, observation, and staff interview it was determined the Hospital failed to ensure all opened/prepared food items that went into storage were properly labeled. This has the potential to affect 100% of patients who receive Dietary services.
Findings include:

1. The Hospital policy and procedure titled, "Food Production Guidelines" (last reviewed 9/08) was reviewed. It indicated under "Procedure 23. ...All stored prepared foods must be labeled and dated."

2. During a tour of the Dietary Department, conducted on 3/12/13 at 10:15 AM it was observed that in the Dietary Reach-in freezer there were more than 12 plastic bags of opened food that included meat, vegetables, and french fries that had no labeling to identify the items in the bag or the date.

3. During an interview with the Dietary Manager, conducted on 3/12/13 at 10:25 AM, it was verbalized that all of the opened food items stored in the Reach-in freezer should have been correctly dated and labeled.

Based on random observation during the survey walk-through, staff interview, and document review during the Non-Accredited Hospital Federal Re-Certification Survey conducted on April 17 - 18, 2013, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Non-Accredited Hospital Federal Re-Certification Survey conducted on April 17 - 18, 2013, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 18, 2013.

Based on review of Hospital policy and procedure, observation and staff interview it was determined that the Hospital failed to ensure that all medical supplies are safe for patient usage. This has the potential to affect 100% of the patients who receive services.
Findings include:

1. The Hospital policy titled, "Crash Cart Check Procedure, Pharmacy Department is responsible for replacing all crash cart drawers that have been used during a code or as medications are outdating in the crash cart drawers".

2. During a tour of the 2nd floor, Medical Surgical Unit on 3/12/13 at 1:00 PM, it was observed that the following medical supplies were expired:
1-CO2 Indicator-expired 02/2013

3. During an interview with the Charge Nurse on 3/12/12 at 1:10 PM, it was confirmed that the medical supplies were expired and should have been removed from the patient care area.

4. During a tour of the 3rd floor, Medical Surgical Unit on 3/12/13 at 3:00 PM, it was observed that the following medical supplies, in the Crash Cart, were expired:
2-packages ECG electrodes-expired 06/2009
1-package ECG electrodes-expired 01/2009
2-packages ECG electrodes-expired 05/2012
1-package ECG electrodes-expired 07/2012

5. During an interview with the Charge Nurse on 3/12/13 at 3:10 PM, it was confirmed that the medical supplies were expired and should have been removed from the patient care area.

6. During a tour of the EKG/Stress Test Lab on 3/13/13 at 9:00 AM, it was observed that the following medical supplies, in the Crash Cart, were expired:
2-14FR Suction Cath-N-Glove kit-expired 12/2009
1-Yankauer Suction Catheter-expired 06/2011
2-packages Adult EKG electrodes-expired 05/2011
1-package defib pads-expired 08/2012

7. During an interview with the Charge Nurse on 3/13/13 at 9:10 AM, it was confirmed that the medical supplies were expired and should have been removed from the patient care area.

8. During a tour of the Cardiac Rehabilitation Unit on 3/13/13 at 10:00, it was confirmed that the medical supplies, in the Crash Cart, were expired:
1-box Epinephrine, 1:10,000 Inj.-expired 3/1/13
3-package adult ECG electrodes-expired 05/2012
2-packages Defib pads-expired 06/2010
2-suction Cath-N-Gloves kit-expired 02/2010
1-Yankuer suction catheter-expired 06/2011

9. During an interview with a Cardiac Rehabilitation Nurse, on 3/13/12 at 10:10 PM, it was confirmed that the medical supplies were expired and should have been removed from the patient care area.

A. Based on review of policies and procedures, medication refrigerator logs, and staff interview it was determined the Hospital failed to ensure nursing unit refrigerator and freezer temperatures were monitored and recorded according to hospital policy to ensure medications and food were stored at appropriate temperatures. This has the potential to affect 100% of patients receiving care at the Hospital.
Findings include:

1. The review of the Hospital's policy titled "Medication Refrigerator" (revised 11/06) was reviewed. The procedure section indicated "The temperature of the interior is checked, recorded and initialed by unit personnel on a daily basis.

2. The Hospital policy titled " Refrigerator / Freezer, Food" (revised 11/06) indicated "The temperature of the interior is checked, recorded and initialed by Nursing Personnel or Unit Clerk on a daily basis.

3. During a tour of the second floor Omnicell Room conducted on 3/12/13 at 12:30 PM, the medication refrigerator log for March indicated 11 of 12 days the daily temperatures were not monitored and documented. The second floor Kitchenette food refrigerator log for March indicated 8 of 12 days the daily refrigerator temperatures were not monitored and recorded, and 11 of 12 days the freezer temperatures were not monitored and recorded.

4. During an interview with the Nurse Manager on 3/12/13 at 12:45 PM, it was confirmed that daily checks of the medication and food refrigerators and freezers were not performed. The Nurse Manager confirmed that perishable food for patient use was stored in the refrigerator and freezer.



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B. Based on review of policy and procedure, observation and staff interview it was determined the Hospital failed to ensure all items stored in nursing unit refrigerators were labeled and discarded according to policy. This has the potential to affect 100% of patients receiving care at the Hospital.
Findings include:

1. The Hospital policy titled " Refrigerator/Freezer, Food" (revised 11/06) indicated "Each Nursing Unit will have a refrigerator... All other foods are labeled with owner's name, Pt room #, and date put in refrigerator. Items not retrieved in two days will be discarded."

2. During a tour of the second floor Omnicell Room conducted 3/12/13 at 12:30 PM, an unlabeled and undated tube feeding was observed in the refrigerator.

3. During an interview with the Nurse Manager on 3/12/13 at 12:45 PM, the Nurse Manager confirmed that no patients on the 2nd floor were receiving a tube feeding at this time and it is the nurse's responsibility to discard unused medication at the patient's discharge.

Based on a review of Hospital internal documentation, medical record review, and staff interview, it was determined that in 3 of 10 (Pt #7, 10, 23) medical records reviewed in which the patient received anesthesia services, the Hospital failed to ensure a post-anesthesia evaluation was conducted.
Findings include:

1. The Hospital's internal documentation titled, "Memorandum...Re: Post Anesthesia Evaluation" (dated 4/29/2009) was presented as Hospital notation related to the expectations of the Anesthesia Department to conduct post-anesthesia evaluations. It indicated under "3. With respect to inpatients, a post-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia within 48 hours after surgery."

2. The medical record of Pt #7 was reviewed on 3/14/13. It indicated Pt #7 presented to the ED with Abdominal Pain. Pt #7 was admitted on 3/10/13 and received an appendectomy under general sedation. As of survey date 3/14/13, there was no documentation that indicated a post-anesthesia evaluation was conducted within the 48 hour time frame.

3. The medical record of Pt #10 was reviewed on 3/13/13. It indicated Pt #10 was admitted on 4/28/12 with diagnosis of Hyperglycemia. Documentation indicated that on 4/25/12 Pt #10 received an Anterior Cervical Disectomy and Fusion of C-5, C-6. The Post-Operative evaluation that was to be conducted within 48 hours was blank.

4. The medical record of Pt #23 was reviewed on 3/14/13. It indicated Pt #23 was admitted on 3/11/13 with a Benign Prostatic Hypertrophy with obstruction. On 3/11/13 Pt #23 received a Trans- Urethral Resection/ Prostate and was discharged on 3/12/13. There was no documentation in the medical record that Pt #23 had a post-anesthesia evaluation within the 48 hour time frame.

5. During an interview with the Quality Manager, conducted on 3/14/13 at 2:35 PM, it was verbalized that all patients that receive anesthesia should have a post-anesthesia evaluation within the 48 hour time frame.