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Based on staff interviews, tour and observation of the facility, review of pertinent hospital wide policies and procedures, and review of medical records, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with 42 CFR 482.41, Condition of Participation - Physical Environment.

Based on observation, it was determined that the facility failed to ensure that patients were maintained in a safe environment.

Findings include:


Reference #1: Federal Guidelines for Construction and Equipment of Hospital and Medical Facilities, 1996-1997 Edition, section 7.6, states "Psychiatric Nursing Unit....
Security and safety devices should not be presented in a manner to attract or challenge tampering by patients."

1. On 6/28/11 Rooms P09, P18, P19, P20, P21, P22, P24, P25, P26, P27 and P28 contained over the patient bed light fixtures that could support a patient's weight in a suicide attempt.

2. The interior door knobs and the bathroom door knobs were not suicide proof.

3. The bathrooms in Rooms P29, P30, P31, P32, and P33 contained faucets that were not suicide proof.

A. Based on document review, it was determined that the facility failed to ensure that medications were administered in accordance to physician orders and policies.

Findings include:

Reference #1: The facility's Medication Standard Times of Administration policy stated, "Procedure: 6. Insulin orders will be administered at each patient care units scheduled mealtime."

Reference #2: The facility's Blood Glucose/Hypoglycemia Management policy stated, "Fingerstick Blood Glucose Monitoring: Check blood glucose 30 min (minutes) prior to meals with or without bedtime check as per frequency order by MD."

1. On 6/22/11 Medical Record #37 contained the following physician orders:

"6/19/11 at 07:32 for Humalog for sliding scale 100 unit/ml (milliliter) soln (solution) -1 unit for every 30 mg. glucose above 100, sc (subcutaneous) SSI (sliding scale insulin) AC (before meals) + HS (bedtime).

6/19/11 at 6:22 for Levemir 100 UNIT/ML SOLN (solution) 42 UNT (units) sc with B (breakfast);

6/19/11 at 07:15 for Humalog 100 UNIT/ML SOLN 15 UNT sc AC B+L (breakfast and lunch)+D (dinner);

6/19/11 at 7:17 for Levemir 100 UNIT/ML SOLN 30 UNT sc with D (dinner);

6/20/11 at 11:55 for Humalog 100 UNIT/ML SOLN 10 UNT AC B+L+D."

a. On 6/19/11 at 6:13 AM the patient's blood sugar was tested via fingerstick with a result of 187. The patient received Humalog 2 units of insulin coverage at 8:56 AM. As per staff interview, the unit receives breakfast between the hour of 8:45 and 9:30 AM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:13 AM and not 30 minutes prior to the meal, as per Reference #2.

b. On 6/19/11 at 1618 (4:18 PM) the blood glucose fingerstick result was 167. Humalog insulin coverage of 2 units was administered at 5:39 PM. The unit receives dinner between 5:45 PM and 6:15 PM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 1618 (4:18 PM) and not 30 minutes prior to the meal, as per Reference #2.

c. On 6/20/11 Humalog 15 units or Humalog 10 units to be given just before lunchtime was not administered.

d. On 6/21/11 the blood glucose fingerstick result was 183 at 0642 (6:42 AM). The patient received 2 units of Humalog insulin coverage at 7:53. As per staff interview, the unit receives breakfast between the hour of 8:45 and 9:30 AM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:42 AM and not 30 minutes prior to the meal, as per Reference #2.

e. On 6/21/11 the blood glucose fingerstick result at 12:26 was 281. The patient received 5 units of Humalog insulin coverage instead of 6 at 12:28.

f. On 6/21/11 at dinner time there was no fingerstick result documented.

g. On 6/21/11 at 2103 the blood glucose fingerstick result was 332. The patient received 6 units of Humalog insulin coverage instead of 7.

h. On 6/22/11 at 0631 the blood glucose fingerstick result was 298. The patient received 6 units of Humalog coverage insulin at 8:50 AM. The patient did not receive Humalog 10 Units scheduled insulin. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:31 AM and not 30 minutes prior to the meal, as per Reference #2.

2. The above was confirmed with Staff #4.

Reference #3: The Versed policy stated,
Dosing Guidelines: For Mechanically Ventilated Patients: Administer initial dose of 0.02-0.08 mg/kg and repeat at 5 to 15 minute intervals until adequate sedation is achieved. The usual maintenance dosage range is 0.04-0.2 mg./kg/hr.
Monitoring Parameters: 1. Monitor vital signs every 15 minutes x 4, then every 30 minutes x 4, then every hour and more often as patient's condition warrants. Monitor closely for hypotension and respiratory depression. "

1. On 6/21/11, Medical Record # 38 contained information the the patient was intubated. A physician order dated 6/19/11 at 11:30 PM stated, ". . . Midazolam 100 mg/200 ml-0.04 mg/kg/hr IV Titrate to Ramsey Score 3."

a. The ICU 24 hour Supplemental Flow Sheet indicated that Versed was initiated on 6/19/11 at 1:00 AM. The vital signs were taken every hour from 1:00 AM to 6:00 AM instead of every 15 minutes x4 and every 30 minutes x4, as required in Reference #3.

b. There was no documentation during the Versed titration that the level of sedation was monitored using a Ramsey scale of 3 according to physician order.

Reference #4: The Propofol Policy stated, ". . . Modified Ramsey Scale:

Level 1--Patient anxious, agitated or restless

Level II--Patient cooperative, oriented and tranquil

Level III--Patient responds to commands only. . .

Nursing Responsibility: Evaluate and assess CNS function every 2 hours throughout maintenance to determine the minimum dose of propofol injectable emulsion required for sedation (using the Modified Ramsay (sic) Scale . . . Monitor the patient's vital signs including blood pressure, heart rate, and if available, cardiac output and pulmonary capillary wedge pressure every 15 minutes x4, then every 30 minutes x4, and then every hour and more often as patient's condition warrants. Monitor level of sedation using Ramsey scale every two (2) hours . . . . Every shift wake-up must be performed and documented . . . "

1. On 6/19/11 Patient #38 had a physician order written at 3 PM for "Propofol 1 gm (gram)/100ml (milliliter) 5 mcg (microgram)/kg (kilogram)/min (minute) IV (intravenous)Titrate Ramsey 2-3."

2. The ICU 24 hour Supplemental Flow Sheet for Patient #38 indicated that Propofol titration began on 6/19/11 at 3:00 PM and stopped at 6/20/2011 at 12:00AM. Propofol was restarted at 6:00AM and stopped at 10:00AM. There was no evidence that a physician order for the discontinuation and restart of Propofol was obtained.

3. The ICU 24 hour Supplemental Flow Sheet for Patient #38 indicated that vital signs were taken at "256P, 3P, 315P, 330P, 4P, 430P, 5P, 6P, 7P." Vital signs were not taken every 15 minutes x4, then every 30 minutes x4, as required in Reference #4.

4. The Critical Care Patient Assessment Report indicated that CNS (Central Nervous System) functions were performed on 6/19/11 at 1535, partially at 1900 and 2000, on 6/20/11 at 0001, at 4:00 AM and at 7:41 AM. The CNS functions were not assessed every 2 hours, as required by Reference #4.

5. There was no evidence that the level of sedation was monitored using a Ramsey scale as ordered by the physician every 2 hours from beginning to the end of the titration, as required by Reference #4. Furthermore, the physician order needs to be specific to the Ramsey scale, specifically "Ramsey scale of 2, or Ramsey scale of 3."

6. There was no evidence on 6/19/11 at 7:00 PM that the shift wake up was performed, as required by Reference #4.

7. The above was confirmed with Staff #4 on 6/21/11, the day of review of Medical Record #38.

Reference #4: The Physician's Orders Alcohol Detoxification Protocol stated,
"Initial CIWA (Clinical Institute Withdrawal Assessment) scale upon patient arrival on the floor. Repeat assessments based on CIWA score:
If CIWA = 20 or above: Give Ativan 2 mg. (milligrams) po (by mouth) now and repeat CIWA in one hour.
If CIWA = 10-19: Give Ativan 1 mg. po now and repeat CIWA in one hour.
If CIWA = 0-9: Repeat CIWA scale in 6 hours. If patient exhibits signs or symptoms of alcohol withdrawal, repeat CIWA scale at that time.
When CIWA is 0-9 on 3 successive assessments at least 6 hrs. (hours) apart (18 hours total), discontinue this Ativan CIWA protocol ...
Ativan 1 mg. po q 4 hrs. (every 4 hours) PRN (as needed) agitation or signs/symptoms of alcohol withdrawal--Notify physician if given after Ativan CIWA protocol is discontinued.
MAXIMUM ATIVAN (LORAZEPAM) - 12 mg in 24 HOURS."

1. On 6/23/11 Medical Record #39 contained documentation that Patient #39 was admitted to the psychiatric unit on 3/25/11. The CIWA Assessment Log was initiated on 3/25/11 at 1500 and contained the following information:

a. 1500-CIWA score 10. Ativan 2 mg was given instead of 1 mg. as per protocol.

b. . . .2200-CIWA score 4. The patient received Ativan 1 mg. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

On 3/26/11, the CIWA Assessment Log contained the following information:

a. 0200-CIWA score 10. Ativan 2 mg. was given instead of 1 mg. as per protocol. The patient was not reassessed in one hour, as per protocol.

b. 0445-CIWA score 9. Ativan 1 mg. was given. There was no evidence that the patient was agitated. The patient should not have received medication per protocol.

c. . . . 1615-CIWA score 10. Ativan 1 mg. was given. The patient was not reassessed in one hour, as per protocol.

d. 2015-CIWA score 10. Ativan 1 mg. was given. The patient was not reassessed in one hour, as per protocol.

e. 2215-CIWA score 6. Ativan 1 mg. was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication. . . .

On 3/27/11 the CIWA Assessment log contained the following inforation:

a. 0330-CIWA score 10. Ativan 1 mg. was given. The patient was then reassessed, as per protocol, at 0430 with a CIWA score of 0; at 1045 with a CIWA score of 6; at 1630 with a CIWA score of 2;

i. The patient was not reassessed at 2230 as per protocol.

On 3/28/11 the CIWA Assessment log contained the following inforation:

a. 0230-CIWA score 10. Ativan 1 mg. was given. . . .

b. 1545-CIWA score 5. Ativan 1 mg was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

c. 2000-CIWA score 6. Ativan 1 mg. was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

2. The above was confirmed with Staff #1. The above Referenced Protocol #4 was not implemented consistently by staff.

Based on observation, document review, and interview, it was determined that the facility failed to ensure that the hospital was maintained in a manner that ensured the safety and well-being of the patients as evidenced by the lack of compliance with the following regulations:

1. 482.13 (c) (2) - The facility failed to ensure that patient rooms and bathrooms on the Psychiatric Unit were suicide proof.

2. 482.41(a)--The facility failed to maintain the overall environment in such a manner that the safety and well-being of the patients was assured.

A. Based on tours of the facility and staff interviews it was determined that the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained.

Findings include:

1. A tour of the Emergency Department on 6/21/11 at 11:00am indicated:
a. Clean Utility Room: Blue storage bins were found to contain grit, dust, hair, and paper scraps within. The floor had multiple spill stains, dust, grit, and paper scraps.
b. Back Nurse's Station: The bottom drawer under a counter across from Bay 16 was found to contain hair, grit, various types of stains, a bobby pin, cellophane scraps, a used drinking straw and stains on the exterior surface. Another bottom drawer was found to contain heavy clumps of dust, melted candy, cellophane scraps, grit, and hair. A drawer on the far wall as one enters the room contained a thick brown raised stain inside the drawer. Another drawer on the far wall contained unpackaged corn chips, hair, dust, grit, and paper scraps. A drawer beneath the countertop under Cabinet #5 was observed to have raised brown stains, and a candy wrapper. The floor beneath the counter had M&M candy piece, dust, grit, and paper scraps.
c. Children's Waiting Room: Heavy dust was observed behind the cubby holes, atop the picture frame, and the television set.
d. Hallway: The Pyxis refrigerator was observed to have crystallized white and clear stains on the interior shelf. There was heavy dust behind the refrigerator.
e. Nourishment Room:
i. A blue plastic bin in a cabinet above the microwave oven was observed to have stains and crumbs inside of it at the bottom. Another bin containing Graham Crackers was also in the same condition.
ii. A cabinet door beneath the microwave oven was observed to have raised brown, tacky stains on the interior side.
iii. A large drawer to the right of the sink containing Styrofoam cups had crumbs, grit, seeds, and paper scraps inside of it.
iv. A cabinet to the right of the sink was observed to have crushed food residue between the doors and the cabinet frame.
v. Dust was observed atop and behind the water machine.
vi. A shelf in a cabinet above the microwave oven had Graham Cracker crumbs and 2 small, dead, winged insects on it.
vii. A cabinet beneath the water machine containing boxes of sugar, Equal, and SWEET'N LOW PACKETS was observed to have 8 live brown ants walking around on the bottom shelf.
f. ED Satellite Radiology Suite: A gray metal cabinet near the entrance closest to the ED was observed to have heavy dust, a surgical glove, crumpled tissue, and broken pieces of plastic behind it. A CT (Computed Tomography) Reader machine was found to have heavy dust, 2 rolls of plastic tape with dust and grit adhered to them, broken pieces of plastic, grit, and a surgical glove behind it.
g. Nurse's Station: The floor beneath the telemetry area had heavy dust around the surge protector, cellophane wrappers, a crumpled paper towel, Cheerios, hair, an identification sticker dated 5/26/11 for Patient #31.
h. Physician's Charting Area: The floor beneath the counter top had dust, corn chips, grit, paper clips, stains, and other refuse on it. A small computer component set on the floor was stuck to the floor with dried spillage. Drawers had spilt coffee stains on the drawer edges and inside of the drawers.
i. Floor across hall from Bays 3 & 4: Grit, dust, corn chips, hair, and paper scraps were observed on the floor.
j. Decontamination Room:
i. Heavy raised stains, clumps of dust, a 'helicopter seed', and a whitish, powdery residue were observed on the floor.
ii. A ceiling vent was heavily occluded with dust.
iii. A desiccated beetle, a dead centipede, and a live spider were observed on the floor next to the door leading to the outside of the building. There were spider webs around the door. A dead winged insect was also stuck to a tacky fluid dripping down the interior of the door.
k. Patient Room #123: A ceiling vent in the room had dust on it.
j. ED Discharge Window Area: A ceiling light in the hallway was observed to have 5 dead wasps and 1 small bug atop the light cover.


2. A tour of the Physical Therapy Unit, accompanied by Administrator #18, at 2:45pm on 6/24/11 indicated:
a. Waiting Room: Three pieces of chewed gum, grit, candy wrappers, and dust were found between the seat cushions and arm rests of cloth chairs.
b. The face piece for a plint had stains and debris on the interior and exterior pads.

3. A tour of the Labor and Delivery Unit, accompanied by Administrator #26, on the afternoon of 6/22/11 and the morning of 6/23/11 indicated:
a. A medication refrigerator was found to contain grit, hair, and paper scraps inside the refrigerator at the bottom. The moulding around the refrigerator door at the top had an accumulation of grit and food particles in the folds.
b. The Medication / Sharps Stainless Steel Cabinet had raised stains, grit, stained paper taped to the counter, a heavy accumulation of scale in the sink and on the splash areas around the sink.
i. A paper box with surgical tape enclosing it, containing cord clamps and fingercots, had dust and grit adhered to the sticky sections of the tape.
ii. A small plastic, blue bin had dust, grit, and paper scraps at the bottom of the interior.
iii. A small purple bin had dust and grit at the bottom of the interior.
iv. Paper sticker residue was observed on all shelves and counter. A patient identification sticker for Patient #34 who had been admitted to the unit on September 9, 2010 was stuck to a shelf.
v. A white powdery substance was on the stainless steel to the right of the sink, as well as other raised stains on the stainless steel.
vi. Heavy dust was atop the cabinet and plastic tape residue was on the left side of the interior wall of the cabinet.
vii. The face of the cabinet had stains and spillage.
viii. Under the sink, behind the metal door, dust and stains were observed on the shelves. Heavy dust was on the grille.
c. Lorazepam Refrigerator contained heavy raised white spillage on the shelf and base of the interior.
d. Birthing Room:
i. Food particles were observed under the end table.
e. Hallway:
i. A wooden cabinet contained dust, grit, unwrapped candy pieces, corn chip crumbs, seeds, paper clips, and cellophane scraps.
ii. A refrigerator had a smeared butter-like substance under the bottom drawer. The bottom shelf had dried, white, raised and crusty stains. Cracker crumbs, red raised stains, dust, and grit atop the refrigerator (under the microwave which was set atop the refrigerator).
iii. Father's Scrubs Cart had tape and tape residue on much of the exterior of the cart and raised yellow stains atop it.
iv. A stainless steel cart across the hall from the water machine was very dusty.
f. Nutrition Area:
i. The cabinet beneath the water machine had spilt coffee, dust, and grit in it. There were stains atop the cabinet door and tape residue on the exterior of the door.
ii. The wall cabinet above the countertop had coffee spillage and a sugar-like substance on the bottom two shelves.
iii. Coffee machine had spilt coffee, crumbs, and water beneath it.
iv. Water machine had dust atop it and a heavy accumulation of scale around the drain.
g. A tan metal cabinet was observed to have heavy dust, grit, paper scraps, cellophane scraps, and paper clips on the floor beneath it.
h. A tan, metal cabinet with a fax/copy machine atop it had raised brown stains, dust, grit, and paper scraps under the machine.
i. 6 dead bugs were observed atop a ceiling light cover outside of Room 302.
j. Post Partum:
i. Patient Kitchen: Heavy black and brown stains and spilt coffee were observed beneath the coffee machine. The microwave interior had raised brown and tan food stains. A gray plastic cart had raised, tacky, brown stains on it. The refrigerator had tacky stains on the bottom of the door.


4. A tour of the Dental Unit on 6/24/11 at 2:30pm indicated:
a. Waiting Room: The ceiling vent inside of the rest room was heavily occluded with dust. The rest room was found to have a dead fly on the window sill.
b. Treatment Room #5: A desiccated Cicada, approximately 1.5 inches long and 0.5 inches wide was observed inside of a control box with a missing face plate for a suction machine, under a desk.

5. A tour of the Mental Health Unit, accompanied by Administrator #13, on 6/21/11 at 3:05pm indicated:
a. Ante Area: A wall mounted 'Out Box' outside of Room 2305 contained used surgical gloves covered with a heavy coat of dust and grit.

6. A tour of the Blood Bank on the afternoon of 6/24/11 indicated:
a. Countertop beneath the centrifuge had raised white and tan crystals, tacky stains, and grit on it. The entire countertop had raised stains, tape, and residue on it.
b. Storage Area: 16 potted plants were on a counter with dried spillage and soil in front of a platelet rotator.
c. A plastic cabinet had heavy dust, hair, grit, paper scraps, and an identification sticker for Patient #33 inside of it.
d. Reagent refrigerator contained grit, paper scraps, and dried white, powdery stains inside of it.
e. A drawer beneath the countertop within the centrifuge on it had a dried whitish powder on the bottom of the drawer.

7. Elevator #7: On 6/21/11 at 3:05pm, while touring the hospital, two dead bugs were observed atop the light cover in the elevator.

8. A tour of the CT Scan Unit on the afternoon of 6/27/11, accompanied by Administrator #19 indicated:
a. Two dead bugs were observed atop a light cover above the PACS Review Station.
b. Wires taped to the floor had a heavy accumulation of dust on the sticky parts of the wire and the tape.
c. Countertop refrigerator freezer was heavily frosted and the bottom interior was sticky. Beneath the refrigerator were tacky stains, a juice wrapper, a vial cover, dust, and tape residue.
d. Cabinet beneath the refrigerator had a dusty and tacky bottom shelf.

9. A tour of the Surgical Services Unit, accompanied by Administrator #21, on the afternoon of June 24, 2011 indicated:
a. PACU: Top left drawer of a cabinet had a heavy accumulation of grit, paper scraps, candy wrappers, food particles, and tape residue inside of the drawer. The bottom left drawer was in the same condition.
b. IV Supply Room: Covered carts had a heavy coat of dust on the shelves. The power cord for the Tek Vision monitor was taped with surgical tape to the wall. Dust was adhered to the sticky sections of the cord and tape.
c. Holding Area Storage Room: The floor had holes through the tiles at the entrance. The tiles were crumbled and the debris filled the holes. Three floor tiles outside of the door were broken and the floor had raised tar-like stains.

10. A tour of the Radiology Department on the afternoon of June 24, 2011 accompanied by Administrator #19 indicated:
a. X-Ray:
i. Room 7: Heavy dust, a book, screws, wires, pieces of equipment, plastic bags, and other debris were observed behind the generator. Coiled wires had clumps of dust on them.
ii. Sink: Beneath the sink was a puddle of water. Particle board under the sink was warped and water was dripping from the bottom of the sink.
b. Dark Room: A silver reclaimer was set on top of a heavily stained towel. The floor had heavy white, residue stains. The wall was crumbling near the floor. The engine to the machine had heavy black and brown stains on, and around, it. The floors had a heavy accumulation of dust and grit.
c. Control Area Outside of Dark Room:
i. Floor tiles were missing beneath the counter.
ii. Floor tiles were dirty around the Diagnostic Imaging Machine.
iii. A white residue, raised black and brown stains, rusted paper clips, plastic caps, dust, grit, cellophane, tape, and other debris were observed beneath a metal cabinet.
iv. Dust, grit, rust stains, paper scraps, and tape residue were observed beneath the computer counter.



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B. Based on a tour of the Psychiatric Unit in the presence of administrative staff #28 and #29, it was determined that the facility failed to ensure the condition of the physical plant and overall hospital environment is maintained.

Findings include:

1. Throughout the unit in the patient rooms, the floors were dusty, scuffed and accumulations of dirt were noted along the perimeter of the rooms, and black residue was noted.between the floor tiles.


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C. Based on observation, on the days of the survey, 6/20/2011 & 6/22/2011, in the presence of Staff #2 & #17, it was determined that the facility failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients was assured.

Findings include:

1. At 10:30 am , the sixth floor housekeeping closet, next to room 6186, had dirt and dust on the floor and in the sink receptor.

2. At 10:40 am, there was dirt under the staff locker room sink, in room number 6171.

3. At 10:50 am, in Soiled Utility Room, 4155, there was rust on the flushing rim sink .

4. At 11:00 am, in Soiled Utility Room, 6188, the bed pan spray hot water supply did not function.

5. At 11:10 am, in the 6th floor Gym Room, a section of the upper wall/ceiling wallcovering was peeling near an area where a previous leak had been repaired.

6. At 11:20 am, in Soiled Utility Room, 4188, there was grime, peeling wall finish and rust at the sink counter.

7. At 11:40 am, in the 4th floor Schuman Building Clean Utility Room, the flushing rim sink did not function, and there was a swelling in the wall filled with a white powdery material, under an access box near the flushing rim sink.

8. At 11:50 am, there were holes through to the wall cavity in the blue ceramic tile facing of the 3rd floor East Wing service company storage area, near Stair #8.

9. At 12:05 pm, in the Basement Environmental Services Locker Room there were missing/stained ceiling tiles, rust stains and dirt on the floor by the lockers and dirt and grimy stains on the lockers.

10. At 12:15 pm, the former ground floor laundry area is now used primarily as a Storage Area of ordinary hazard classification. The area has a variety of floor finishes, most of which have dirt/debris, stains, marring and gouges. Walls throughout are stained, scratched, marred and have holes through to the wall cavity. Ceiling tiles are dirty and missing.

A. Based on interviews with administrative staff it was determined that the infection control officer did not develop a system for identifying and controlling communicable diseases of personnel.

Findings include:

1. Administrator #22 on 6/22/11 at 2:45pm stated: "The MEC (Medical Executive Committee) does not require all physicians working in the hospital to show rubella or rubeola status. The only physicians required to have them are physicians employed by the hospital."

2. Administrator #22 on 6/22/11 at 2:45pm stated: "The MEC (Medical Executive Committee) does not require all physicians, born in 1957 or later, working in the hospital to show rubella or rubeola status. The only physicians required to have them are physicians employed by the hospital."


B. Based on observation, staff interview and review of facility documents, it was determined that the hospital did not develop policies based on nationally recognized standards for the reprocessing and maintenance of medical devices.

Findings include:

Reference #1: The Association for the Advancement of Medical Instrumentation (AAMI) publication "Comprehensive guide to Steam Sterilization and sterility assurance in health care facilities, ST79:2006 (ST 79 replaces and supercedes ST46 by consolidating ST 46 with 4 other AAMI standards [ST33, ST37, ST42, and ST35] approved 7/10/2009)." AAMI ST 79 section 7.2.2 'Manufacturer's instructions' state: "The written recommendations of the device manufacturer should always be followed."

Reference #2: Manufacturer's written recommendations on WLORENZ 1.5mm Neuro T1-Osteosyn System' implant tray states that it should be "sterilized at 270 degrees Farenheit with 4 minute exposure time and 30 minute minimum drying time ....Staining and spotting may result on instruments that are steam sterilized if the instruments are not completely rinsed and free from residual chemicals. It is vital that proper drying cycles are followed to prevent the formation of excess moisture and resultant water spotting."

Reference #3: Manufacturer's instructions on cleaning and sterilization of Stryker Osteosynthesis instrument states, 'Stryker Osteosynthesis does not define the maximum number of uses appropriate for re-usable medical devices. The useful life of these depends on many factors including the method and duration of each use, and the handling between uses. Careful inspection and functional test of the device before use is the best method of determining the end of serviceable life for the medical device."

1. On 6/27/11, an implant tray containing 'WLORENZ 1.5mm Neuro T1-Osteosyn System' was closely examined in sterile storage room of the operating room suites. Numerous bone plates were observed with stains and water spots. The tray was processed at 270 degrees F (Fahrenheit) with 8 minute exposure time and 15 minute drying time. This does not comply with manufacturer's recommendations, as stated in Reference #2.

2. On 6/27/11, an implant tray labeled as 'Omega Plus & Screw' was examined in the sterile storage room of the operating room suites. This tray was later identified as Stryker Osteosynthesis instrument tray by Staff #21. A plastic 'impactor' observed inside the implant tray was in poor condition with the plastic side pitted and broken. Staff #21 stated that it is natural for this piece of instrument to get damaged during the procedure.

Reference #4: AAMI RD52:2004 section 6.2.3 on 'Cartridge Filters' states, "Cartridge filters should be monitored on a periodic basis. There is no easy test to determine the effectiveness of a cartridge filter; however, pressure drop across the filter can be used to determine when the filter is retaining particulate matter to the point that the filter will no longer allow the required water flow without an excessive reduction in pressure at the outlet of the filter. A log sheet should be developed to record the pressure drop measurements."

1. A cartridge filter installed as a final filtration step prior to reverse osmosis was observed in the water treatment room. Currently, policies and procedures have not been developed for this cartridge filter change.

2. Staff #30 stated that although the filter is being changed on a monthly basis or when the delta pressure goes above 10 PSI (pounds per square inch), filter changes have not been documented and delta pressure across the cartridge filter is not being documented on the facility water log.

Based on a review of an emergency department policy and procedure and the medical records of five patients treated in the emergency department it was determined that the facility had a policy and procedure that was not always implemented properly.

Findings include:

Reference #1: The PROCEDURE section of hospital policy titled 'Triage guidelines and Procedures' indicated: ".....
H. The triage nurse classifies the patient into one of five categories:
1. Immediate Life Threatening: Patient must be seen immediately.
2. Unstable - High priority - patient needs to be seen as soon as possible.
3. Urgent - Patients in this category should be seen by a physician within 1 hour, if possible.
4. Stable - Patients in this category have acute injuries or medical problems but are comfortable to wait over 1 hour to see a physician.
....."

Reference #2: The 'Appendix B: ESI (Emergency Severity Index) Algorithm, v3 A Five-Level Triage System' section of hospital policy titled 'Triage Guidelines and Procedures' indicated that a patient presenting to the ED with a high risk situation; confused, lethargic, or disoriented; or in severe pain or distress be assigned a triage classification of "2" (Unstable).

1. Review of the TRIAGE section dated 5/25/11 at 11:13am in Emergency Department Medical Record #22 indicated: ".....
COMPLAINT: NUMBNESS TO RT (right) ARM/ DIZZYNESS [sic].
NURSE TRIAGE ASSESSMENT: PT (patient) C/O (complaint of) NUMBNESS IN LT (left) ARM AT 1030AM LASTING A SECOND AND GOT DIZZYNESS [sic] DENIES ANY WEAKNESS.
.....
TRIAGE VS (vital signs): BP (blood pressure): 149,/99 [sic] ....."
The patient was assigned a triage classification of "URGENCY: 3 URGENT." The ESI section of the the ED record indicated the entry: 'ESI level 0.'
The patient was diagnosed as having had a TIA (transient ischemic attack) at 1:02pm.
Based on the patient's symptoms on arrival, the patient should have been assigned an ESI classification of '2.' There is no ESI level of '0' on the algorithm.

2. Review of the medical record of Patient #31 indicated that he/she presented to the emergency department on 5/26/11 with a complaint of a pain level of "10" on a scale of 1-10. The patient was assigned a triage classification of "URGENCY: 4 NON-URGENT." The ESI section of the the ED record indicated the entry: 'ESI level 3.' Based on the patient's complaint of severe pain, he/she should have been assigned an ESI classification of '2.'

Based on staff interviews, tour and observation of the facility, review of pertinent hospital wide policies and procedures, and review of medical records, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with 42 CFR 482.41, Condition of Participation - Physical Environment.

Based on observation, it was determined that the facility failed to ensure that patients were maintained in a safe environment.

Findings include:


Reference #1: Federal Guidelines for Construction and Equipment of Hospital and Medical Facilities, 1996-1997 Edition, section 7.6, states "Psychiatric Nursing Unit....
Security and safety devices should not be presented in a manner to attract or challenge tampering by patients."

1. On 6/28/11 Rooms P09, P18, P19, P20, P21, P22, P24, P25, P26, P27 and P28 contained over the patient bed light fixtures that could support a patient's weight in a suicide attempt.

2. The interior door knobs and the bathroom door knobs were not suicide proof.

3. The bathrooms in Rooms P29, P30, P31, P32, and P33 contained faucets that were not suicide proof.

A. Based on document review, it was determined that the facility failed to ensure that medications were administered in accordance to physician orders and policies.

Findings include:

Reference #1: The facility's Medication Standard Times of Administration policy stated, "Procedure: 6. Insulin orders will be administered at each patient care units scheduled mealtime."

Reference #2: The facility's Blood Glucose/Hypoglycemia Management policy stated, "Fingerstick Blood Glucose Monitoring: Check blood glucose 30 min (minutes) prior to meals with or without bedtime check as per frequency order by MD."

1. On 6/22/11 Medical Record #37 contained the following physician orders:

"6/19/11 at 07:32 for Humalog for sliding scale 100 unit/ml (milliliter) soln (solution) -1 unit for every 30 mg. glucose above 100, sc (subcutaneous) SSI (sliding scale insulin) AC (before meals) + HS (bedtime).

6/19/11 at 6:22 for Levemir 100 UNIT/ML SOLN (solution) 42 UNT (units) sc with B (breakfast);

6/19/11 at 07:15 for Humalog 100 UNIT/ML SOLN 15 UNT sc AC B+L (breakfast and lunch)+D (dinner);

6/19/11 at 7:17 for Levemir 100 UNIT/ML SOLN 30 UNT sc with D (dinner);

6/20/11 at 11:55 for Humalog 100 UNIT/ML SOLN 10 UNT AC B+L+D."

a. On 6/19/11 at 6:13 AM the patient's blood sugar was tested via fingerstick with a result of 187. The patient received Humalog 2 units of insulin coverage at 8:56 AM. As per staff interview, the unit receives breakfast between the hour of 8:45 and 9:30 AM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:13 AM and not 30 minutes prior to the meal, as per Reference #2.

b. On 6/19/11 at 1618 (4:18 PM) the blood glucose fingerstick result was 167. Humalog insulin coverage of 2 units was administered at 5:39 PM. The unit receives dinner between 5:45 PM and 6:15 PM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 1618 (4:18 PM) and not 30 minutes prior to the meal, as per Reference #2.

c. On 6/20/11 Humalog 15 units or Humalog 10 units to be given just before lunchtime was not administered.

d. On 6/21/11 the blood glucose fingerstick result was 183 at 0642 (6:42 AM). The patient received 2 units of Humalog insulin coverage at 7:53. As per staff interview, the unit receives breakfast between the hour of 8:45 and 9:30 AM. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:42 AM and not 30 minutes prior to the meal, as per Reference #2.

e. On 6/21/11 the blood glucose fingerstick result at 12:26 was 281. The patient received 5 units of Humalog insulin coverage instead of 6 at 12:28.

f. On 6/21/11 at dinner time there was no fingerstick result documented.

g. On 6/21/11 at 2103 the blood glucose fingerstick result was 332. The patient received 6 units of Humalog insulin coverage instead of 7.

h. On 6/22/11 at 0631 the blood glucose fingerstick result was 298. The patient received 6 units of Humalog coverage insulin at 8:50 AM. The patient did not receive Humalog 10 Units scheduled insulin. The Humalog insulin coverage dosage administration was based on a blood fingerstick result done at 6:31 AM and not 30 minutes prior to the meal, as per Reference #2.

2. The above was confirmed with Staff #4.

Reference #3: The Versed policy stated,
Dosing Guidelines: For Mechanically Ventilated Patients: Administer initial dose of 0.02-0.08 mg/kg and repeat at 5 to 15 minute intervals until adequate sedation is achieved. The usual maintenance dosage range is 0.04-0.2 mg./kg/hr.
Monitoring Parameters: 1. Monitor vital signs every 15 minutes x 4, then every 30 minutes x 4, then every hour and more often as patient's condition warrants. Monitor closely for hypotension and respiratory depression. "

1. On 6/21/11, Medical Record # 38 contained information the the patient was intubated. A physician order dated 6/19/11 at 11:30 PM stated, ". . . Midazolam 100 mg/200 ml-0.04 mg/kg/hr IV Titrate to Ramsey Score 3."

a. The ICU 24 hour Supplemental Flow Sheet indicated that Versed was initiated on 6/19/11 at 1:00 AM. The vital signs were taken every hour from 1:00 AM to 6:00 AM instead of every 15 minutes x4 and every 30 minutes x4, as required in Reference #3.

b. There was no documentation during the Versed titration that the level of sedation was monitored using a Ramsey scale of 3 according to physician order.

Reference #4: The Propofol Policy stated, ". . . Modified Ramsey Scale:

Level 1--Patient anxious, agitated or restless

Level II--Patient cooperative, oriented and tranquil

Level III--Patient responds to commands only. . .

Nursing Responsibility: Evaluate and assess CNS function every 2 hours throughout maintenance to determine the minimum dose of propofol injectable emulsion required for sedation (using the Modified Ramsay (sic) Scale . . . Monitor the patient's vital signs including blood pressure, heart rate, and if available, cardiac output and pulmonary capillary wedge pressure every 15 minutes x4, then every 30 minutes x4, and then every hour and more often as patient's condition warrants. Monitor level of sedation using Ramsey scale every two (2) hours . . . . Every shift wake-up must be performed and documented . . . "

1. On 6/19/11 Patient #38 had a physician order written at 3 PM for "Propofol 1 gm (gram)/100ml (milliliter) 5 mcg (microgram)/kg (kilogram)/min (minute) IV (intravenous)Titrate Ramsey 2-3."

2. The ICU 24 hour Supplemental Flow Sheet for Patient #38 indicated that Propofol titration began on 6/19/11 at 3:00 PM and stopped at 6/20/2011 at 12:00AM. Propofol was restarted at 6:00AM and stopped at 10:00AM. There was no evidence that a physician order for the discontinuation and restart of Propofol was obtained.

3. The ICU 24 hour Supplemental Flow Sheet for Patient #38 indicated that vital signs were taken at "256P, 3P, 315P, 330P, 4P, 430P, 5P, 6P, 7P." Vital signs were not taken every 15 minutes x4, then every 30 minutes x4, as required in Reference #4.

4. The Critical Care Patient Assessment Report indicated that CNS (Central Nervous System) functions were performed on 6/19/11 at 1535, partially at 1900 and 2000, on 6/20/11 at 0001, at 4:00 AM and at 7:41 AM. The CNS functions were not assessed every 2 hours, as required by Reference #4.

5. There was no evidence that the level of sedation was monitored using a Ramsey scale as ordered by the physician every 2 hours from beginning to the end of the titration, as required by Reference #4. Furthermore, the physician order needs to be specific to the Ramsey scale, specifically "Ramsey scale of 2, or Ramsey scale of 3."

6. There was no evidence on 6/19/11 at 7:00 PM that the shift wake up was performed, as required by Reference #4.

7. The above was confirmed with Staff #4 on 6/21/11, the day of review of Medical Record #38.

Reference #4: The Physician's Orders Alcohol Detoxification Protocol stated,
"Initial CIWA (Clinical Institute Withdrawal Assessment) scale upon patient arrival on the floor. Repeat assessments based on CIWA score:
If CIWA = 20 or above: Give Ativan 2 mg. (milligrams) po (by mouth) now and repeat CIWA in one hour.
If CIWA = 10-19: Give Ativan 1 mg. po now and repeat CIWA in one hour.
If CIWA = 0-9: Repeat CIWA scale in 6 hours. If patient exhibits signs or symptoms of alcohol withdrawal, repeat CIWA scale at that time.
When CIWA is 0-9 on 3 successive assessments at least 6 hrs. (hours) apart (18 hours total), discontinue this Ativan CIWA protocol ...
Ativan 1 mg. po q 4 hrs. (every 4 hours) PRN (as needed) agitation or signs/symptoms of alcohol withdrawal--Notify physician if given after Ativan CIWA protocol is discontinued.
MAXIMUM ATIVAN (LORAZEPAM) - 12 mg in 24 HOURS."

1. On 6/23/11 Medical Record #39 contained documentation that Patient #39 was admitted to the psychiatric unit on 3/25/11. The CIWA Assessment Log was initiated on 3/25/11 at 1500 and contained the following information:

a. 1500-CIWA score 10. Ativan 2 mg was given instead of 1 mg. as per protocol.

b. . . .2200-CIWA score 4. The patient received Ativan 1 mg. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

On 3/26/11, the CIWA Assessment Log contained the following information:

a. 0200-CIWA score 10. Ativan 2 mg. was given instead of 1 mg. as per protocol. The patient was not reassessed in one hour, as per protocol.

b. 0445-CIWA score 9. Ativan 1 mg. was given. There was no evidence that the patient was agitated. The patient should not have received medication per protocol.

c. . . . 1615-CIWA score 10. Ativan 1 mg. was given. The patient was not reassessed in one hour, as per protocol.

d. 2015-CIWA score 10. Ativan 1 mg. was given. The patient was not reassessed in one hour, as per protocol.

e. 2215-CIWA score 6. Ativan 1 mg. was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication. . . .

On 3/27/11 the CIWA Assessment log contained the following inforation:

a. 0330-CIWA score 10. Ativan 1 mg. was given. The patient was then reassessed, as per protocol, at 0430 with a CIWA score of 0; at 1045 with a CIWA score of 6; at 1630 with a CIWA score of 2;

i. The patient was not reassessed at 2230 as per protocol.

On 3/28/11 the CIWA Assessment log contained the following inforation:

a. 0230-CIWA score 10. Ativan 1 mg. was given. . . .

b. 1545-CIWA score 5. Ativan 1 mg was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

c. 2000-CIWA score 6. Ativan 1 mg. was given. There was no evidence that the patient was agitated or showed sign/symptoms of withdrawal requiring medication. According to protocol the patient should not have received medication.

2. The above was confirmed with Staff #1. The above Referenced Protocol #4 was not implemented consistently by staff.

Based on observation, document review, and interview, it was determined that the facility failed to ensure that the hospital was maintained in a manner that ensured the safety and well-being of the patients as evidenced by the lack of compliance with the following regulations:

1. 482.13 (c) (2) - The facility failed to ensure that patient rooms and bathrooms on the Psychiatric Unit were suicide proof.

2. 482.41(a)--The facility failed to maintain the overall environment in such a manner that the safety and well-being of the patients was assured.

A. Based on tours of the facility and staff interviews it was determined that the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained.

Findings include:

1. A tour of the Emergency Department on 6/21/11 at 11:00am indicated:
a. Clean Utility Room: Blue storage bins were found to contain grit, dust, hair, and paper scraps within. The floor had multiple spill stains, dust, grit, and paper scraps.
b. Back Nurse's Station: The bottom drawer under a counter across from Bay 16 was found to contain hair, grit, various types of stains, a bobby pin, cellophane scraps, a used drinking straw and stains on the exterior surface. Another bottom drawer was found to contain heavy clumps of dust, melted candy, cellophane scraps, grit, and hair. A drawer on the far wall as one enters the room contained a thick brown raised stain inside the drawer. Another drawer on the far wall contained unpackaged corn chips, hair, dust, grit, and paper scraps. A drawer beneath the countertop under Cabinet #5 was observed to have raised brown stains, and a candy wrapper. The floor beneath the counter had M&M candy piece, dust, grit, and paper scraps.
c. Children's Waiting Room: Heavy dust was observed behind the cubby holes, atop the picture frame, and the television set.
d. Hallway: The Pyxis refrigerator was observed to have crystallized white and clear stains on the interior shelf. There was heavy dust behind the refrigerator.
e. Nourishment Room:
i. A blue plastic bin in a cabinet above the microwave oven was observed to have stains and crumbs inside of it at the bottom. Another bin containing Graham Crackers was also in the same condition.
ii. A cabinet door beneath the microwave oven was observed to have raised brown, tacky stains on the interior side.
iii. A large drawer to the right of the sink containing Styrofoam cups had crumbs, grit, seeds, and paper scraps inside of it.
iv. A cabinet to the right of the sink was observed to have crushed food residue between the doors and the cabinet frame.
v. Dust was observed atop and behind the water machine.
vi. A shelf in a cabinet above the microwave oven had Graham Cracker crumbs and 2 small, dead, winged insects on it.
vii. A cabinet beneath the water machine containing boxes of sugar, Equal, and SWEET'N LOW PACKETS was observed to have 8 live brown ants walking around on the bottom shelf.
f. ED Satellite Radiology Suite: A gray metal cabinet near the entrance closest to the ED was observed to have heavy dust, a surgical glove, crumpled tissue, and broken pieces of plastic behind it. A CT (Computed Tomography) Reader machine was found to have heavy dust, 2 rolls of plastic tape with dust and grit adhered to them, broken pieces of plastic, grit, and a surgical glove behind it.
g. Nurse's Station: The floor beneath the telemetry area had heavy dust around the surge protector, cellophane wrappers, a crumpled paper towel, Cheerios, hair, an identification sticker dated 5/26/11 for Patient #31.
h. Physician's Charting Area: The floor beneath the counter top had dust, corn chips, grit, paper clips, stains, and other refuse on it. A small computer component set on the floor was stuck to the floor with dried spillage. Drawers had spilt coffee stains on the drawer edges and inside of the drawers.
i. Floor across hall from Bays 3 & 4: Grit, dust, corn chips, hair, and paper scraps were observed on the floor.
j. Decontamination Room:
i. Heavy raised stains, clumps of dust, a 'helicopter seed', and a whitish, powdery residue were observed on the floor.
ii. A ceiling vent was heavily occluded with dust.
iii. A desiccated beetle, a dead centipede, and a live spider were observed on the floor next to the door leading to the outside of the building. There were spider webs around the door. A dead winged insect was also stuck to a tacky fluid dripping down the interior of the door.
k. Patient Room #123: A ceiling vent in the room had dust on it.
j. ED Discharge Window Area: A ceiling light in the hallway was observed to have 5 dead wasps and 1 small bug atop the light cover.


2. A tour of the Physical Therapy Unit, accompanied by Administrator #18, at 2:45pm on 6/24/11 indicated:
a. Waiting Room: Three pieces of chewed gum, grit, candy wrappers, and dust were found between the seat cushions and arm rests of cloth chairs.
b. The face piece for a plint had stains and debris on the interior and exterior pads.

3. A tour of the Labor and Delivery Unit, accompanied by Administrator #26, on the afternoon of 6/22/11 and the morning of 6/23/11 indicated:
a. A medication refrigerator was found to contain grit, hair, and paper scraps inside the refrigerator at the bottom. The moulding around the refrigerator door at the top had an accumulation of grit and food particles in the folds.
b. The Medication / Sharps Stainless Steel Cabinet had raised stains, grit, stained paper taped to the counter, a heavy accumulation of scale in the sink and on the splash areas around the sink.
i. A paper box with surgical tape enclosing it, containing cord clamps and fingercots, had dust and grit adhered to the sticky sections of the tape.
ii. A small plastic, blue bin had dust, grit, and paper scraps at the bottom of the interior.
iii. A small purple bin had dust and grit at the bottom of the interior.
iv. Paper sticker residue was observed on all shelves and counter. A patient identification sticker for Patient #34 who had been admitted to the unit on September 9, 2010 was stuck to a shelf.
v. A white powdery substance was on the stainless steel to the right of the sink, as well as other raised stains on the stainless steel.
vi. Heavy dust was atop the cabinet and plastic tape residue was on the left side of the interior wall of the cabinet.
vii. The face of the cabinet had stains and spillage.
viii. Under the sink, behind the metal door, dust and stains were observed on the shelves. Heavy dust was on the grille.
c. Lorazepam Refrigerator contained heavy raised white spillage on the shelf and base of the interior.
d. Birthing Room:
i. Food particles were observed under the end table.
e. Hallway:
i. A wooden cabinet contained dust, grit, unwrapped candy pieces, corn chip crumbs, seeds, paper clips, and cellophane scraps.
ii. A refrigerator had a smeared butter-like substance under the bottom drawer. The bottom shelf had dried, white, raised and crusty stains. Cracker crumbs, red raised stains, dust, and grit atop the refrigerator (under the microwave which was set atop the refrigerator).
iii. Father's Scrubs Cart had tape and tape residue on much of the exterior of the cart and raised yellow stains atop it.
iv. A stainless steel cart across the hall from the water machine was very dusty.
f. Nutrition Area:
i. The cabinet beneath the water machine had spilt coffee, dust, and grit in it. There were stains atop the cabinet door and tape residue on the exterior of the door.
ii. The wall cabinet above the countertop had coffee spillage and a sugar-like substance on the bottom two shelves.
iii. Coffee machine had spilt coffee, crumbs, and water beneath it.
iv. Water machine had dust atop it and a heavy accumulation of scale around the drain.
g. A tan metal cabinet was observed to have heavy dust, grit, paper scraps, cellophane scraps, and paper clips on the floor beneath it.
h. A tan, metal cabinet with a fax/copy machine atop it had raised brown stains, dust, grit, and paper scraps under the machine.
i. 6 dead bugs were observed atop a ceiling light cover outside of Room 302.
j. Post Partum:
i. Patient Kitchen: Heavy black and brown stains and spilt coffee were observed beneath the coffee machine. The microwave interior had raised brown and tan food stains. A gray plastic cart had raised, tacky, brown stains on it. The refrigerator had tacky stains on the bottom of the door.


4. A tour of the Dental Unit on 6/24/11 at 2:30pm indicated:
a. Waiting Room: The ceiling vent inside of the rest room was heavily occluded with dust. The rest room was found to have a dead fly on the window sill.
b. Treatment Room #5: A desiccated Cicada, approximately 1.5 inches long and 0.5 inches wide was observed inside of a control box with a missing face plate for a suction machine, under a desk.

5. A tour of the Mental Health Unit, accompanied by Administrator #13, on 6/21/11 at 3:05pm indicated:
a. Ante Area: A wall mounted 'Out Box' outside of Room 2305 contained used surgical gloves covered with a heavy coat of dust and grit.

6. A tour of the Blood Bank on the afternoon of 6/24/11 indicated:
a. Countertop beneath the centrifuge had raised white and tan crystals, tacky stains, and grit on it. The entire countertop had raised stains, tape, and residue on it.
b. Storage Area: 16 potted plants were on a counter with dried spillage and soil in front of a platelet rotator.
c. A plastic cabinet had heavy dust, hair, grit, paper scraps, and an identification sticker for Patient #33 inside of it.
d. Reagent refrigerator contained grit, paper scraps, and dried white, powdery stains inside of it.
e. A drawer beneath the countertop within the centrifuge on it had a dried whitish powder on the bottom of the drawer.

7. Elevator #7: On 6/21/11 at 3:05pm, while touring the hospital, two dead bugs were observed atop the light cover in the elevator.

8. A tour of the CT Scan Unit on the afternoon of 6/27/11, accompanied by Administrator #19 indicated:
a. Two dead bugs were observed atop a light cover above the PACS Review Station.
b. Wires taped to the floor had a heavy accumulation of dust on the sticky parts of the wire and the tape.
c. Countertop refrigerator freezer was heavily frosted and the bottom interior was sticky. Beneath the refrigerator were tacky stains, a juice wrapper, a vial cover, dust, and tape residue.
d. Cabinet beneath the refrigerator had a dusty and tacky bottom shelf.

9. A tour of the Surgical Services Unit, accompanied by Administrator #21, on the afternoon of June 24, 2011 indicated:
a. PACU: Top left drawer of a cabinet had a heavy accumulation of grit, paper scraps, candy wrappers, food particles, and tape residue inside of the drawer. The bottom left drawer was in the same condition.
b. IV Supply Room: Covered carts had a heavy coat of dust on the shelves. The power cord for the Tek Vision monitor was taped with surgical tape to the wall. Dust was adhered to the sticky sections of the cord and tape.
c. Holding Area Storage Room: The floor had holes through the tiles at the entrance. The tiles were crumbled and the debris filled the holes. Three floor tiles outside of the door were broken and the floor had raised tar-like stains.

10. A tour of the Radiology Department on the afternoon of June 24, 2011 accompanied by Administrator #19 indicated:
a. X-Ray:
i. Room 7: Heavy dust, a book, screws, wires, pieces of equipment, plastic bags, and other debris were observed behind the generator. Coiled wires had clumps of dust on them.
ii. Sink: Beneath the sink was a puddle of water. Particle board under the sink was warped and water was dripping from the bottom of the sink.
b. Dark Room: A silver reclaimer was set on top of a heavily stained towel. The floor had heavy white, residue stains. The wall was crumbling near the floor. The engine to the machine had heavy black and brown stains on, and around, it. The floors had a heavy accumulation of dust and grit.
c. Control Area Outside of Dark Room:
i. Floor tiles were missing beneath the counter.
ii. Floor tiles were dirty around the Diagnostic Imaging Machine.
iii. A white residue, raised black and brown stains, rusted paper clips, plastic caps, dust, grit, cellophane, tape, and other debris were observed beneath a metal cabinet.
iv. Dust, grit, rust stains, paper scraps, and tape residue were observed beneath the computer counter.



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B. Based on a tour of the Psychiatric Unit in the presence of administrative staff #28 and #29, it was determined that the facility failed to ensure the condition of the physical plant and overall hospital environment is maintained.

Findings include:

1. Throughout the unit in the patient rooms, the floors were dusty, scuffed and accumulations of dirt were noted along the perimeter of the rooms, and black residue was noted.between the floor tiles.


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C. Based on observation, on the days of the survey, 6/20/2011 & 6/22/2011, in the presence of Staff #2 & #17, it was determined that the facility failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients was assured.

Findings include:

1. At 10:30 am , the sixth floor housekeeping closet, next to room 6186, had dirt and dust on the floor and in the sink receptor.

2. At 10:40 am, there was dirt under the staff locker room sink, in room number 6171.

3. At 10:50 am, in Soiled Utility Room, 4155, there was rust on the flushing rim sink .

4. At 11:00 am, in Soiled Utility Room, 6188, the bed pan spray hot water supply did not function.

5. At 11:10 am, in the 6th floor Gym Room, a section of the upper wall/ceiling wallcovering was peeling near an area where a previous leak had been repaired.

6. At 11:20 am, in Soiled Utility Room, 4188, there was grime, peeling wall finish and rust at the sink counter.

7. At 11:40 am, in the 4th floor Schuman Building Clean Utility Room, the flushing rim sink did not function, and there was a swelling in the wall filled with a white powdery material, under an access box near the flushing rim sink.

8. At 11:50 am, there were holes through to the wall cavity in the blue ceramic tile facing of the 3rd floor East Wing service company storage area, near Stair #8.

9. At 12:05 pm, in the Basement Environmental Services Locker Room there were missing/stained ceiling tiles, rust stains and dirt on the floor by the lockers and dirt and grimy stains on the lockers.

10. At 12:15 pm, the former ground floor laundry area is now used primarily as a Storage Area of ordinary hazard classification. The area has a variety of floor finishes, most of which have dirt/debris, stains, marring and gouges. Walls throughout are stained, scratched, marred and have holes through to the wall cavity. Ceiling tiles are dirty and missing.

A. Based on interviews with administrative staff it was determined that the infection control officer did not develop a system for identifying and controlling communicable diseases of personnel.

Findings include:

1. Administrator #22 on 6/22/11 at 2:45pm stated: "The MEC (Medical Executive Committee) does not require all physicians working in the hospital to show rubella or rubeola status. The only physicians required to have them are physicians employed by the hospital."

2. Administrator #22 on 6/22/11 at 2:45pm stated: "The MEC (Medical Executive Committee) does not require all physicians, born in 1957 or later, working in the hospital to show rubella or rubeola status. The only physicians required to have them are physicians employed by the hospital."


B. Based on observation, staff interview and review of facility documents, it was determined that the hospital did not develop policies based on nationally recognized standards for the reprocessing and maintenance of medical devices.

Findings include:

Reference #1: The Association for the Advancement of Medical Instrumentation (AAMI) publication "Comprehensive guide to Steam Sterilization and sterility assurance in health care facilities, ST79:2006 (ST 79 replaces and supercedes ST46 by consolidating ST 46 with 4 other AAMI standards [ST33, ST37, ST42, and ST35] approved 7/10/2009)." AAMI ST 79 section 7.2.2 'Manufacturer's instructions' state: "The written recommendations of the device manufacturer should always be followed."

Reference #2: Manufacturer's written recommendations on WLORENZ 1.5mm Neuro T1-Osteosyn System' implant tray states that it should be "sterilized at 270 degrees Farenheit with 4 minute exposure time and 30 minute minimum drying time ....Staining and spotting may result on instruments that are steam sterilized if the instruments are not completely rinsed and free from residual chemicals. It is vital that proper drying cycles are followed to prevent the formation of excess moisture and resultant water spotting."

Reference #3: Manufacturer's instructions on cleaning and sterilization of Stryker Osteosynthesis instrument states, 'Stryker Osteosynthesis does not define the maximum number of uses appropriate for re-usable medical devices. The useful life of these depends on many factors including the method and duration of each use, and the handling between uses. Careful inspection and functional test of the device before use is the best method of determining the end of serviceable life for the medical device."

1. On 6/27/11, an implant tray containing 'WLORENZ 1.5mm Neuro T1-Osteosyn System' was closely examined in sterile storage room of the operating room suites. Numerous bone plates were observed with stains and water spots. The tray was processed at 270 degrees F (Fahrenheit) with 8 minute exposure time and 15 minute drying time. This does not comply with manufacturer's recommendations, as stated in Reference #2.

2. On 6/27/11, an implant tray labeled as 'Omega Plus & Screw' was examined in the sterile storage room of the operating room suites. This tray was later identified as Stryker Osteosynthesis instrument tray by Staff #21. A plastic 'impactor' observed inside the implant tray was in poor condition with the plastic side pitted and broken. Staff #21 stated that it is natural for this piece of instrument to get damaged during the procedure.

Reference #4: AAMI RD52:2004 section 6.2.3 on 'Cartridge Filters' states, "Cartridge filters should be monitored on a periodic basis. There is no easy test to determine the effectiveness of a cartridge filter; however, pressure drop across the filter can be used to determine when the filter is retaining particulate matter to the point that the filter will no longer allow the required water flow without an excessive reduction in pressure at the outlet of the filter. A log sheet should be developed to record the pressure drop measurements."

1. A cartridge filter installed as a final filtration step prior to reverse osmosis was observed in the water treatment room. Currently, policies and procedures have not been developed for this cartridge filter change.

2. Staff #30 stated that although the filter is being changed on a monthly basis or when the delta pressure goes above 10 PSI (pounds per square inch), filter changes have not been documented and delta pressure across the cartridge filter is not being documented on the facility water log.

Based on a review of an emergency department policy and procedure and the medical records of five patients treated in the emergency department it was determined that the facility had a policy and procedure that was not always implemented properly.

Findings include:

Reference #1: The PROCEDURE section of hospital policy titled 'Triage guidelines and Procedures' indicated: ".....
H. The triage nurse classifies the patient into one of five categories:
1. Immediate Life Threatening: Patient must be seen immediately.
2. Unstable - High priority - patient needs to be seen as soon as possible.
3. Urgent - Patients in this category should be seen by a physician within 1 hour, if possible.
4. Stable - Patients in this category have acute injuries or medical problems but are comfortable to wait over 1 hour to see a physician.
....."

Reference #2: The 'Appendix B: ESI (Emergency Severity Index) Algorithm, v3 A Five-Level Triage System' section of hospital policy titled 'Triage Guidelines and Procedures' indicated that a patient presenting to the ED with a high risk situation; confused, lethargic, or disoriented; or in severe pain or distress be assigned a triage classification of "2" (Unstable).

1. Review of the TRIAGE section dated 5/25/11 at 11:13am in Emergency Department Medical Record #22 indicated: ".....
COMPLAINT: NUMBNESS TO RT (right) ARM/ DIZZYNESS [sic].
NURSE TRIAGE ASSESSMENT: PT (patient) C/O (complaint of) NUMBNESS IN LT (left) ARM AT 1030AM LASTING A SECOND AND GOT DIZZYNESS [sic] DENIES ANY WEAKNESS.
.....
TRIAGE VS (vital signs): BP (blood pressure): 149,/99 [sic] ....."
The patient was assigned a triage classification of "URGENCY: 3 URGENT." The ESI section of the the ED record indicated the entry: 'ESI level 0.'
The patient was diagnosed as having had a TIA (transient ischemic attack) at 1:02pm.
Based on the patient's symptoms on arrival, the patient should have been assigned an ESI classification of '2.' There is no ESI level of '0' on the algorithm.

2. Review of the medical record of Patient #31 indicated that he/she presented to the emergency department on 5/26/11 with a complaint of a pain level of "10" on a scale of 1-10. The patient was assigned a triage classification of "URGENCY: 4 NON-URGENT." The ESI section of the the ED record indicated the entry: 'ESI level 3.' Based on the patient's complaint of severe pain, he/she should have been assigned an ESI classification of '2.'