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Based on review of the Performance Improvement Plan, Quality Council minutes, and review of quality indicator data, the hospital failed to ensure that Nursing Service and the Laboratory were measuring, analyzing, and tracking quality indicators.

Findings include:

Review of the hospital's Performance Improvement Plan, Quality Council minutes, and review of quality indicator data revealed the laboratory was providing data for Quality Assessment, and Performance Improvement, but was failing to analyze the data, and track quality indicators.

Review of the Performance Improvement Plan, Quality Council minutes, and review of quality indicator data revealed that Nursing Service was not providing quality indicator data to be used in measuring, analyzing and tracking quality indicators.

Based on observation and interview with hospital staff, the hospital failed to ensure on two (2) of two (2) days of survey that the medical record department had adequate filing space to properly file medical records and sufficient work space for the employees of the department.

Findings include:

Interview with the Director of the Department on 04/20/11 revealed that medical records filed in open shelf files in the department go back to the year 2000. All shelves were observed to be full with no available space to accommodate any additional records. There were boxes stacked on the floor of the department being used to store recently discharged medical records.

The overcrowded condition of the department with open shelf files left very narrow aisles to walk from the front of the department to the back. Files were observed with little space between them, making filing medical records difficult. Other than employee desks, there was only one small table situated in a cross space between aisles which could be used as a work space.

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries in 22 of 22 medical records were timed.

Findings include:

During record review, 16 discharged records were selected at random from a list of recent discharges from February and March 2011, along with six (6) inpatient medical records and reviewed for a total of 22 medical records. Of the 22 medical records reviewed all progress notes had not been timed when entered in the medical record, all physician's orders were not timed when entered into the medical records. All dictated reports found in the 22 medical records reviewed did not include the time the reports were dictated, or the time that they were transcribed. All x-ray reports reviewed were signed electronically by the reading radiologist. These electronically signed reports did not show the date and time the reports are signed.

Based on observation, and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and staff interview, the facility failed to maintain the hospital environment in a manner that protected the safety and well-being of patients, as evidenced by call lights (communication system for patients) was not functioning properly.

Findings include:

Observation with the Chief Operating Officer (COO) during environmental tour on 04/20/11 between 10:00 a.m. and 10:30 a.m. revealed the call lights in Patient Rooms #305 and #306 were not functioning properly. The patient's common bathroom (Bathroom #3C) on the third (3rd) floor was also not functioning properly. The light in the hallway did not have a cover and the common bathroom (Bathroom #2C) on the second (2nd) floor was not functioning properly. Interview with the COO during the environmental tour confirmed these findings. The COO stated that the rooms with call lights that did not function properly would be put out of commission until they were repaired.

Observation with the COO during a second (2nd) environmental tour on 04/21/11 between 1:00 p.m. and 1:15 p.m. revealed the call lights in Patient Rooms #305 and #306 were now functioning properly. The patient's common bathroom (Bathroom #3C) on the third (3rd) floor and common bathroom (Bathroom #2C) on the second (2nd) floor were also functioning properly at that time.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintain to ensure the safety of the patients.

Findings include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to K-017 - The hospital failed to properly protect corridors from use areas as directed by NFPA 101 Chapter 19.3.6.2.2

Refer to K-018 - The hospital failed to properly protect corridor openings.

Refer to K-021 - The hospital failed to insure automatic closing of the smoke barrier doors.

Refer to K-027 - The hospital failed to properly maintain the door openings in the smoke barrier walls.

Refer to K-029- The hospital failed to properly protect hazardous areas.

Refer to K-038 - The hospital failed to properly maintain exit egress as per NFPA 101 Chapter 19 .2.2.2.4 and NPFA 101 Chapter 7.1.9

Refer to K-039 - The hospital failed to provide clear and unobstructed corridors.

Refer to K-046 - The hospital failed to provide emergency lighting for at least one and a half (1.5) hours.

Refer to K-047 - The hospital failed to provide properly displayed exit signs as required by NFPA 101 7.10.2

Refer to K-050 - The hospital failed to properly perform fire drills quarterly for each shift.

Refer to K-051 - The hospital failed to provide armed forces Notification for the fire alarm system as required by NFPA 101, Chapter 19 3.4.3.2 and NFPA 101 Chapter 9.6.4.

Refer to K-052- The hospital failed to properly maintain the fire alarm system.

Refer to K-054 - The hospital failed to properly maintain and test the smoke detectors as required by NFPA 101 section 9.6.1.3 and NFPA 72 section 7-3.2.1.

Refer to K-064 - The hospital failed to properly maintain fire extinguishers as per NFPA 10 Chapter 4 - 4.1. and 4-3.1

Refer to K-069 - The hospital failed to properly maintain the kitchen hood suppression system as per NFPA 17 A 5-3.1 and NFPA 96 8-3.

Refer to K-104 - The hospital failed to properly protect smoke barrier wall penetrations.

Refer to K-106 - The hospital failed to provide an adequate Essential Electrical System as prescribed in NFPA 99 3-4.1.1.8.

Refer to K-144- The hospital failed to provide monthly generator testing in accordance with NFPA99.