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A. Based on review of Hospital policy, contractual agreements, Quality Resource Management program and staff interview, it was determined, that for 6 of 6 contacts reviewed, the governing body failed to ensure that services performed under contractual agreement, were evaluated for quality to ensure safe and effective services were provided.

Findings include:

1. On 3/8/12 at 2:00 PM, the "Contract Management and Review" policy, effective date 10/1/10, was reviewed. The policy required, "Through the authority of the Board of Directors and President/ Chief Executive Officer, the Hospital Vice President's or designee responsible for the contract shall review contracts for content and effectiveness in conjunction with other department affected by the contract. Specific attenuation shall be made to ... quality of services."

2. The Hospital's "Quality Resource Management Program-approval date 7/14/11" was reviewed on 3/9/12 at approximately 11:10AM. The Program's purposes included," to improve quality of care, improve utilization management, coordinate medical staff services. and reduce and when possible, eliminate the potential for injury to patients, visitors and employees" The Program failed to include, evaluation of contracted services.

3. On 3/8/12 at 10:00 AM, the hospital lists of contractual services was reviewed and evidence of governing body evaluation of services for 6 contractual providers was requested. These included:

- GE Healthcare (effective May 2007)
- Hospital Laundry Services (effective Aug 2009)
- Waste Management (effective Sept. 2009)
- Siemens Medical (effective Oct. 2007)
- Allied Anesthesia Associate (effective June 2008)
- EM Strategies (effective July 2007)

A request was made to the Director of Patient Safety for documentation regarding evaluation of contractural services and the evidence was not provided.

4. These findings were confirmed by the Director of Patient Safety during an interview on 3/8/12 at 2:00 PM.

A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 2 of 3 patients (#12 and #23) with an Advanced Directive (Do- Not Resuscitate Form-DNR) and 1 of 1 Pt. without an Advanced Directive (Pt. #25), the Hospital failed to ensure DNR orders were reviewed by the physician, and failed to obtain an informed consent in accordance with policy.

Findings include:

1. On 3/6/12 at approximately 2:50 PM, Hospital policy titled, "Do Not Resuscitate Orders-approved 10/5/09" included, "Physician: A DNR order is a physician written order. When the physician determines that no additional course of therapy or treatment offers any reasonable expectation of remission from a terminal condition...The ultimate responsibility for obtaining informed consent and writing the order rests with the attending physician. The attending physician should initiate discussions regarding CPR with the patient, family or appropriate surrogate. If the Patient presents a properly executed Do-Not -Resuscitate (DNR) Order Form that order is to be added to the Medical record and honored by all medical providers. The completed form constitutes an advanced directive. Once presented, the form should be reviewed to assure it was executed properly. The attending physician will be informed of the existence of the DNR order (Addendum) The form should be reviewed for completeness as well as accuracy after having a discussion with the patient regarding his/her wishes. Date and annotate the form to identify the patient's current wishes..."

2. On 3/6/12 between 10:00 AM and 11:30 AM clinical records that contained DNR Advance Directives were reviewed on unit 4-1(Telemetry).

* The clinical record for Pt. #12, a 76 year old female, admitted on 3/1/12 with diagnoses of Fever and Diarrhea, contained a previous DNR Form (Advanced Directive) dated 3/16/11. The physician failed to review the previous DNR status and sign the form to indicate no change.

* The clinical record for Pt. #23, an 80 year old female, admitted on 2/29/12 with a diagnosis of Shortness of Breath, contained a previous DNR order Form dated 10/09/09. The physician failed to review the previous DNR form to identify the patient's current wishes in accordance with policy.

* The clinical record for Pt. #25, a 90 year old male, admitted on 3/3/12 with a diagnosis of New Onset Seizure, contained an unsigned DNR telephone order dated 3/2/12. The physician failed to initiate discussions with the family and failed to write an appropriate DNR order.

3. The above findings were verified with the Administrative Director during an interview on 3/6/12 at approximately 3:15 PM.

4. On 3/7/12 at approximately 9:30 AM the Director of Patient Safety was interviewed. The Director stated that the forms for Pt's #12 and #23 should have been reviewed by the physician and a note placed in the medical record that the DNR order was still in effect.

A. Based on clinical record review and staff interview, it as determined that for 1 of 3 (Pt. #11) clinical records reviewed of patients that had an order for blood transfusions, the Hospital failed to ensure timely administration of the blood product.

Findings include:

1. The clinical record of Pt #11 was reviewed on 3/6/12 at approximately 9:45 AM. Pt #11 was a 74 year old female admitted on 3/5/12 with a diagnosis of Right Total Hip Revision. The clinical record contained a physician's order dated 3/6/12 at 5:50 AM that required, "Transfuse 2 units of PRBC (packed red blood cells) now." As of 9:45 AM on 3/6/12, the PRBC's had not been transfused.

2. At 9:45 AM the 5-2 Unit Manager was interviewed regarding the blood transfusion. The Manager contacted the Hospital's blood bank and was informed by the Blood Bank Manager, that the blood, which had been ordered for a "now" transfusion, had been ready since 6:22 AM.

3. The finding was verified by the 5-2 Unit Manager and Manager of Clinical Effectiveness during an interview on 3/6/12 at approximately 10:15 AM.

A. Based on review of Hospital policy, observation, and staff interview, it was determined that for 1 of 2 Certified Registered Nurse Anesthetist (CRNA) (E #20) observed preparing medications in the Operating Room (OR) Suite #2, the Hospital failed to ensure staff disinfect the septum of the medication vial prior to insertion of the syringe needle. This could potentially effect all surgical patients (48 surgical cases were scheduled on 3/7/12).

Findings include:

1. The Hospital policy entitled, "Multiple Dose Sterile Medication" (revised 10/01/07), was reviewed on 3/7/12 at approximately 10:35 AM and required, "...Disinfect the septum of the vial by wiping it with alcohol..."

2. An observational tour of the OR Suite was conducted on 3/7/12 between approximately 6:45 AM and 8:00 AM. At 7:10 AM, in OR #2, E #20 (CRNA) removed the plastic cap from a medication vial and inserted the syringe needle into the rubber stopper without wiping the septum of the vial with alcohol.

3. The above finding was confirmed with the Administrative Director Procedural Care Unit and the Manager of Surgery/Endoscopy during an interview on 3/7/12 at approximately 8:30 AM.

A. Based on review of the Hospital's "Medical Staff Rules and Regulations", clinical records, and staff interview, it was determined that for 5 of 34 clinical records reviewed (Pts. #2, 3, 5, 6, and 14), the Hospital failed to ensure telephone orders were authenticated by the ordering physician within 48 hours as required. This could potentially effect all inpatients on census on 3/5/12 (205).

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (amended 10/20/11) was reviewed on 3/5/12 at approximately 10:10 AM and required, "...Telephone orders must be authenticated (signed, dated and timed) within 48 hours by the ordering physician or another practitioner who is responsible for the care of the patient..."

2. The clinical record for Pt #2 was reviewed on 3/5/12 at approximately 10:30 AM. Pt #2 was a 78 year old female admitted on 2/23/12 with diagnoses of Dehydration and Hyponatremia. The clinical record included telephone orders that lacked a physician's signature of authentication on the following dates: 2/24/12 and 3/2/12 (E #3); 2/24/12 and 2/27/12 (E #2); and 2/26/12 and 2/28/12 (E #6).

3. The clinical record for Pt #3 was reviewed on 3/5/12 at approximately 10:45 AM. Pt #3 was a 40 year old male admitted on 1/14/12 with diagnoses of Abdominal Pain and Intractable Vomiting. The clinical record included telephone orders that lacked a physician's signature of authentication on the following dates: 2/20, 2/23, and 2/23/12 (E #1); 2/24/12 and 2/26/12 (E #7); and 2/26/12 (E #8).

4. The clinical record for Pt #5 was reviewed on 3/5/12 at approximately 11:00 AM. Pt #5 was a 61 year old male admitted on 3/1/12 with diagnoses of Pneumonia and Cellulitis. The clinical record included a telephone order from E #9 dated 3/2/12 that lacked a signature of authentication.

5. The clinical record for Pt #6 was reviewed on 3/5/12 at approximately 1:00 PM. Pt #6 was an 84 year old female admitted on 2/20/12 with a diagnosis of Urosepsis. The clinical record included telephone orders that lacked a physician's signature of authentication on the following dates: 2/21/12 and 2/23/12 (E #10); and 2/22/12 and 3/2/12 (E #11).

6. The clinical record for Pt # 14 was reviewed on 3/5/12 at approximately 1:15 PM. Pt #14 was a 25 year old male admitted on 2/27/12 with diagnoses of Drug Overdose, Altered Level of Consciousness, and Pneumonia. The clinical record included telephone orders that lacked a physician's signature of authentication on the following dates: 2/27/12 (E #14); 2/27/12 (E #6); 2/27/12 ( E #12); 3/1/12 (E #15); and 3/1/12 (E #16).

7. The above findings were confirmed during an interview with the Administrative Director of Nursing Practice and Operations on 3/5/12 at approximately 3:30 PM.

A. Based on review of Hospital's Medical Staff Rules and Regulations, letter of attestation from the Medical Records Department, and staff interview, it was determined that the Hospital failed to ensure completion of medical records within 30 days post discharge.

Findings include:

1. The Hospital's "Rules and Regulations" (amended 10/20/11) was reviewed on 3/7/12 at approximately 11:00 AM and required, "...The records of the discharged patient shall be completed within a period of time that will in no event, exceed thirty (30) days from discharge..."

2. A letter of attestation presented by the Director of Health Information Management on 3/7/12 at approximately 12:30 PM indicated that as of date 3/7/12, there were 295 delinquent medical records at the Hospital, greater that 30 days post discharge.

3. The above findings were confirmed during an interview with the Director of Patient Safety during an interview on 3/7/12 at approximately 2:00 PM.

A. Based on review of Hospital protocol. clinical records, and staff interview, it was determined that in 3 of 3 (Pt #8, 29 and 30) clinical records reviewed, the Hospital failed to ensure staff adhere to the Dietary tube feeding protocol regarding the monitoring of patient daily weights.

Findings include:

1. Hospital protocol entitled, "Protocol for Parenteral and Enteral Nutrition Support," approved 10/11/11, reviewed on 3/6/12 at approximately 12:30 PM required, "Orders for Tube Feedings:..C. Monitoring Tube Feeding: 1. Daily (if Dietician is writing order): a. Weight (if available)...e. Residuals..Hold if aspirate greater than 200 ml or patient vomiting."

2. The clinical record of Pt #8 was reviewed on 3/6/12 at approximately 10:00 AM. Pt #8 was a 63 year old female admitted on 2/17/12 with a diagnosis of Incomplete Paraplegia. The clinical record contained a physician's order dated 2/20/12 at 3:25 PM that included, "Tube feeding order: OK for RD to manage tube feeding." another order dated 2/21/12 included, "Osmolite 1.5 run 7 PM to 7 AM, 65 ml/hr." The clinical record lacked documentation of Pt #8's daily weight from 2/19/12 to 3/6/12 (17 days) without documentation of why the weight was not available. The clinical record lacked daily gastric residual checks on 2/29, 3/1, 3/4, and 3/5/12.

3. The clinical record of Pt #29 was reviewed on 3/7/12 at approximately 1:30 PM. Pt #29 was an 86 year old female admitted on 1/28/12 with diagnoses of Fever and Bladder Infection. The clinical record contained a Dietician's order dated 2/15/12 at 2:50 PM that included: "When OK with G.I. (Gastrointestinal) Service, Start G-Tube tube feedings with Osmolite 1.5 at 10 ml/hr. Run continuously..." The clinical record lacked documentation that Pt #29 was weighed daily from 2/15/12 (start of tube feeding) to 2/18/12 (date of discharge), without documentation of why the weight was not available, as required.

4. The clinical record of Pt #30 was reviewed on 3/7/12 at approximately 1:30 PM. Pt #30 was an 85 year old female admitted on 1/27/12 with a diagnosis of Altered Mental Status. The clinical record contained a Dietician's order dated 2/8/12 at 11:30 AM that included: "Start G tube feedings with Osmolite 1.5 at 10 ml/hr. Run continuously..." The clinical record lacked documentation of Pt #30's daily weight from 2/8/12 (start of tube feeding) until 2/10/12 (Pt. #30 was weighed on 2/11/12) and from 2/12/12 to 2/14/12 (date of discharge), without documentation of why the weight was not available, as required.

5. The findings were verified by Manager of Clinical Effectiveness during an interview on 3/6/12 at approximately 12:45 PM and on 3/7/12 with the Director of Patient Safety at approximately 2:00 PM.

A. Based on review of Hospital policies, manufacturer's recommendations, observational tour, clinical records, and staff interview, it was determined that, for 2 of 3 of patients (Pt. #13 and #12) who were on contact precautions, the Hospital failed to ensure staff adherence to infection control policies.

Findings include:

1. Hospital policy titled, "Isolation Precautions-approved 1/9/12" reviewed on 3/6/12 at approximately 11:30 AM included, "Wear clean-nonsterile gloves when touching blood or body fluids...Wear a clean, non-sterile, fluid resistant gown to protect skin and prevent soiling..."

2. The manufacturer's recommendations for the use of "Sani- cloth bleach wipe" was reviewed on 3/6/12 at approximately 1:40 PM. The recommendations included," Directions for use: tear open packet and unfold wipe. Wipe down area to be cleaned. Let air dry."

3. On 3/6/12 at approximately 9:00 AM, an observational tour of unit 4-1 (Telemetry) was conducted. The door to room 4113 contained a sign that read, "Contact precautions... wear gloves when entering room, wear gown when entering room." On 2/6/12 at 9:00 AM, Physician #5 entered room 4113 without first doning a gown.

The clinical record for Pt. #13 in room 4113 was reviewed on 3/6/12 at approximately 10:00 AM. Pt. #13, an 86 year old female, was admitted on 3/3/12 with a diagnosis of Congestive Heart Failure. The clinical record contained documentation that Pt. #13 was placed on contact precautions on 3/3/12 to rule out MRSA.


4. On 3/5/12 at approximately 9:35 AM, E#4 was observed cleaning contact precaution room 4106. E#4 wiped the horizontal surface near the sink using a Sani-cloth bleach wipe (1:10 dilution). After cleaning the horizontal surface near the sink, E#4 used a dry wash cloth to remove the bleach disinfectant. E#4 failed to let the solution air dry in accordance with the manufacturer's directions.

The clinical record for the Pt. in room 4106 (Pt #12) was reviewed on 3/6/12 at approximately 10:30 AM. Pt. #12, a 76 year old female was admitted on 2/29/12 with a diagnosis of Diarrhea. The Pt. was placed on contact precautions on 2/29/12 and a Clostridium Difficile (C-Diff) culture returned positive on on 3/3/12.

5. The above finding was verified with the Administrative Director during an interview on 3/6/12 at approximately 1:30 PM.

B. Based on observational tour, review of clinical records, Facility stated practice and staff interview, it was determined that for 1 of 2 patients ( Pt. #12) who required isolation for Clostridium Diffcile, the Hospital failed to ensure the correct signage was posted on the patient's door.

Findings include:

1. On 3/6/12 at approximately 9:00 AM, an observational tour was conducted on unit 4-1 (Telemetry). The Pt. In room 4106 was on contact precautions. Signage on the door read,"Contact Precautions". According to Facility stated practice the signage should have read "Contact Precaution Special Enteric...disinfect equipment with bleach."

2. The clinical record for Pt. #12 in room 4106 was reviewed on 3/6/12 at approximately 10:30 AM. Pt. # 12, a 76 year old female was admitted on 2/29/12 with a diagnosis of Diarrhea. The Pt. was placed on contact precautions on 2/29/12 and a Clostridium Difficile (C-Diff) culture returned positive on on 3/3/12.

3. A housekeeper (E#4) was interviewed on 3/6/12 at approximately 9:20 AM. E#4 stated that the signage on the door was incorrect. It is Hospital practice, according to the E#4, to place a sign on the door that instructs housekeeping to clean with bleach wipes.

4. The above finding was verified with the Administrative Director during an interview on 3/6/12 at approximately 1:30 PM.

A. Based of review of Association of Operating Room Nurses (AORN) Standards, observation, and staff interview, it was determined that for 3 of 3 (E#17, 18, &19) employees observed in the Surgical Department, the Hospital failed to ensure adherence to dress code.

Findings include:

1. The Hospital's 2011 "Perioperative Standards and Recommended Practices," revised 10/2010, reviewed on 3/6/12 at approximately 1:00 PM required, "...Recommendation IV: All personnel should cover head and facial hair including sideburns and nap of the neck, when in the semi-restricted and restricted areas... Recommendation VI: All individuals entering the restricted areas should wear a surgical mask when open sterile supplies and equipment are present. VI.a. The mask should cover the mouth and nose and be secured in a manner to prevent venting. VI.b.1. Masks should not be worn hanging down from the neck..."

2. On 3/7/12 an observational tour was conducted in the Hospital's Surgical Department from 7:00 AM until approximately 8:45 AM.

This was observed in OR #9

* On 3/7/12 approximately 7:25 AM, E #17 was observed entering OR room 9 with facial hair exposed from his beard. At approximately 7:35 AM, E #17 was observed walking in the hall with a surgical mask hanging from his neck.

This was observed in OR #5

* On 3/7/12 at approximately 7:34AM, a Vendor (E# 18) entered OR #5 while wearing a ring and wrist watch.

* A Surgeon (E#19) entered OR#5 while tying his surgical mask.

3. The findings were verified by the Administrative Director of the Procedural Care Unit and the Manager of Surgery during an interview on 3/7/12 at approximately 8:45 AM.

surveyors: 15168 & 07105

B. Based on observation, staff interview and Hospital policy review, it was determined that for 1 of 3 surgical preps observed (OR #5), staff failed to ensure contaminated swabs were disposed of in accordance with policy.

Findings include:

1. On 3/7/12 at 8:16 AM, E#21, in OR#5, began an abdominal surgical prep for Pt. #24. A Q-tip swab was used to cleanse Pt. #24's umbilicus. The contaminated Q-tip was placed on a shelf that contained a monitor. E#21 failed to dispose of the contaminated Q-tip in a garbage receptacle in accordance with policy.

2. The above finding was verified with the Manager of Clinical Effectiveness during an interview on 3/7/12 at approximately 8:25 AM.

3. Hospital policy titled,"Infection Control Management of All Surgical Procedures in the Intraoperative Setting-approved 11/28/05" was reviewed on 3/7/12 at approximately 10:30 AM. The policy included,"To prevent the spread of pathogens in the operating room. All disposable items are discarded."

4. The findings were verified by the Administrative Director of the Procedural Care Unit and the Manager of Surgery during an interview on 3/7/12 at approximately 8:45 AM.