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Based on tours of the CAH on September 18-20, 2012, it was determined that the CAH failed to ensure safety of patients at all times.

Findings include:

1. During a tour of the Surgical Suite on September 19, 2012, the following was observed:

a. Operating Rooms 1, 2 and 3 had rusty castors on carts and intravenous poles; therefore, allowing rust to contaminate the floors;

b. Operating Rooms 1, 2 and 3 had return air vents near the base of the walls that had grates that were not secure and tight; therefore, allowing dust from the cinder block wall to flow back into the rooms;

c. Operating Room 3 had a brown stain on the floor; therefore, the floor could not be properly sanitized; and

d. The Procedure Room had rusty castors on intravenous poles; therefore, allowing rust to contaminate the floor.

2. In Central Sterile Supply there was a crack in the floor inside the door; therefore, the floor could not be properly sanitized.

3. In the Surgical Suite Sterile Supple Storage Room there were two (2) ceiling tiles that were scraped; therefore, allowing ceiling tiles particles to fall on the sterile supplies.

4. It was observed throughout the CAH that walls had scraped paint; therefore, were unable to be sanitized properly.

5. These findings were confirmed by the Engineering Department Leader, an Operating Room Staff Nurse and the Intensive Care Unit Charge Nurse.

Based on review of Mayo Regional Hospital's Medical Staff Bylaws, review of the Board of Trustees meeting minutes and interviews with key staff September 18-20, 2012, it was determined that the CAH failed to ensure that the medical staff operated under current bylaws.

Findings include:

1. Article 8, Section 7 of the Mayo Regional Hospital Medical Staff Bylaws stated: Duties of the Officers 8.7.1 President: Preside at all meetings of the medical staff, and attend all regularly scheduled meetings of the Board of Trustees.

2. Meeting minutes of the Board of Trustees from October 26, 2011 through August 22, 2012 were reviewed. There were eleven (11) meetings held during that time frame. Five (5) of the meetings there was no medical staff report presented by the President.

3. The Medical Staff President is responsible for reporting the activities of the Medical Staff to the Governing Body. This was confirmed by the Director of Quality and the Credentialing Coordinator.

Based on policy review and interviews with key personnel on September 19, 2012, it was determined that the facility failed to assure services were furnished in accordance with appropriate written policies.

Findings include:

1. The facility policy PSYCH.POL.50, "Substance Abuse Related Inpatient Service Coordination" stated: "The Counseling Program of Mayo Regional Hospital shall perform a consultative function to complement the services provided to (1) patients who are admitted under another diagnosis but who, during the hospitalization, are identified as having a substance-related or mental health problem and (2) patients who are admitted under the physician directed detoxification protocol." Further, the policy stated: "The record from the hospitalization will be reviewed for Quality Assurance purposed and data will be collected for the purpose of assessing the effectiveness's of the clinical pathway."

2. In an interview with the Program Director of Psychiatric Services, on September 19, 2012, he stated that "we haven't been collecting data for that that I know of. We haven't since I came here in January."

3. The facility policy PSYCH.POL.23, "Individual Treatment Planning, Provision and Review" stated, "The treatment plan, and progress toward its successful completion, shall be conducted at intervals of every 90 days."

4. Review of the treatment plan, in the medical record of Patient Y's record indicated that the plan had been in effect from March 22, 2012 with a target date of June 22, 2012, and then the plan was reviewed and entered from August 17, 2012 with a target date of November 7, 2012. There was no indication that the treatment plan had been reviewed and was in effect from June 22 until August 17.

5. Review of the treatment plan, in the medical record of Patient Z's record indicated that the plan had been in effect from November 17, 2011 with a target date of February 17, 2012, and then the plan was reviewed and entered from August 21, 2012 with a target date of November 21, 2012. There was no indication that the treatment plan had been reviewed and was in effect from February 17 until August 22.

6. The above findings were confirmed by the Quality and Compliance Specialist on September 19, 2012.

Based on observation and interviews with key personnel on September 18 & 19, 2012, it was determined that the facility failed to assure that drugs and biological's which are outdated are not available for patient use.

Findings include:

1. During a tour of the Emergency Department, it was observed that in three of the patient rooms each had a bottle of "Gastroccult" for testing of stomach contents for occult blood. The expiration of all three bottles was March 2012.

2. When checking the supply cabinet for replacement bottles, it was observed that the replacement bottles also expired on March 2012.

3. These findings were confirmed by the Emergency Department Manager on September 18, 2012.

4. During tour of the Mayo Women's Health, Outpatient Clinic, it was observed that the Ultrasonic Vaginal Probe was being cleaned in a solution of Cidex. The Cidex test strips used to confirm solution strength, indicated that they expired on August 2012.

5. This finding was confirmed by the Medical Assistant, responsible for cleaning of the probe, on September 19, 2012.

Based on observations and interviews with key personnel on September 19, 2012, it was determined that the facility failed to ensure safeguards against loss, destruction or unauthorized use of medical records at the Mayo Orthopaedic's Out-Patient Clinic.

Findings include:

1. During tour of the Mayo Orthopaedic's Out-Patient Clinic, it was observed that medical records were stored in the front office, which did not contain a door, and that the records were stored in an open file without a way of securing them.

2. In an interview with the Orthopaedic Office Coordinator, she stated that "It has been that way for the past six (6) years, and noone is here when housekeeping comes in to clean".

3. This was confirmed by the Quality and Compliance Specialist on September 19, 2012.