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A. Based on observational tour, review of Hospital documents, and interview, it was determined, that for 13 of 13 patients (Pts. 21, 22, 24 - 34), in the psychiatric unit (5W), the Hospital failed, by providing patients with electronically operated bed, to ensure patients' safety. Thus placing 13 of 13 patients on the psychiatric unit on 12/4/12 at risk for self inflicted injury.

Findings include:

1. On 12/4/12, an observational tour was conducted at approximately 12:40 PM, on the psychiatric unit (5W) of the Hospital. The Unit was a 17 bed unit with a census of 13, adult and adolescent patients. During the survey, it was observed that all rooms were furnished with electronically operated beds, which included an electrical cord and could be operated from the bed rail, thus allowing patient self harm.

2. Hospital policy entitled, "Patient Rights and Responsibilities" ( revised date 9/17/04) required, "II. A. 1. Patients Rights (e) Patient has the right to expect reasonable safety insofar as the facilities practices and environment are concerned."

3. The Hospital's "Contraband List", (revised 11-29-12) for the psychiatric unit (5W) required, "Items to be sent home or locked...items not listed will be evaluated for safety; any electronic device."

4. The Manager of Inpatient Behavioral Medicine was interviewed on 12/4/12 at approximately 2:00 PM. During the interview, the Manager stated that the Unit uses electric beds to accommodate their patient populations' comfort needs.

5. The Director of Nursing (DON) was interviewed on 12/5/12 at approximately 1:00 PM. The DON stated that even though the cords to the beds have been shortened, the Hospital cannot ensure patients cannot harm themselves by becoming entangled in the bed rail as it lowers.

B. Based on review of Hospital documents, observational tour, and interview, it was determined that for 13 of 13 patients (Pts. 21, 22, 24 - 34), in the psychiatric unit (5W), the Hospital failed to ensure patient safety rounds were conducted as required.

Findings include:

1. Hospital policy entitled, "Patient Safety Rounds/Environment of Care Safety Rounds," (effective date of 8/12/11) required, "Procedure I: Unit rounds are conducted every 15 minutes."

2. An observational tour was conducted on the Hospital's inpatient psychiatric unit on 12/4/12 at approximately 12:40 PM. During the tour it was discovered that the last documented 15 minute patient safety checks for the 13 patients (Pts. 21, 22, 24 - 34) on the unit were conducted at 12:00 PM. Safety rounds at 12:15 PM and 12:30 PM had not been done.

3. The 13 patients on the psychiatric unit were:

- Pt #21, 69 year old female, admitted on 12/1/12, diagnosis Depression, admit order - suicide precautions;

- Pt #22, 16 year old female, admitted on 12/2/12, diagnosis Depression with Suicide Ideation, admit order - suicide precautions;

- Pt #24, 77 year old female, admitted on 12/2/12, diagnosis Major Depression, admit order - close observation;

- Pt #25, 55 year old female, admitted on 11/20/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #26, 56 year old female, admitted on 12/3/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #27, 21 year old female, admitted on 11/30/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #28, 24 year old female, admitted on 11/27/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #29, 54 year old male, admitted on 11/29/12, diagnosis Major Depression, admit order - close observation;

- Pt #30, 20 year old male, 59 year old female, admitted on 12/2/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #31, 59 year old female, admitted on 12/2/12, diagnosis Major Depression, admit order - close observation;

- Pt #32, 66 year old male, admitted on 12/1/12, diagnosis Bipolar Disorder, admit order - suicide precautions;

- Pt #33, 73 year old female, admitted on 11/30/12, diagnosis Major Depression, admit order - suicide precautions;

- Pt #34, 14 year old female admitted on 12/3/12, diagnosis Major Depression, admit order - suicide precautions.

4. The Manager of Inpatient Behavioral Medicine was interviewed on 12/4/12 at approximately 2:00 PM. During the interview, the Manager stated that between 12:00 PM and 12:40 PM, the 15 minute checks had not been completed as required.

Based on review of documents, observation, and staff interview, it was determined, that for 1 of 1 Certified Registered Nurse Anesthetist (CRNA) (E #4), the Hospital failed to ensure the CRNA adhered to Hospital policy governing aseptic technique with multidose vials.

Findings include:

1. The Hospital Policy #(RG)PTC.811, titled "Multidose Vial" (revised 11/8/12) was reviewed and required, "D. Use "aseptic technique"...F.4. Swab the vial top with an alcohol pad."

2. On 12/4/12 at approximately 7:55 AM, during an observational tour of Operating Room #6, a CRNA (E #4) was observed withdrawing medications from vials without first swabbing the tops of the vials with alcohol wipes.

3. The finding was discussed with the Nurse Manager of Surgery during an interview on 12/4/12 at approximately 10:00 AM.

Based on document review and staff interview, it was determined that for one of one medical records department, the Hospital failed to ensure that medical records were completed within 30 days after discharge. This potentially affected all of the 249 patients whose charts were incomplete as of 12/3/12.

Findings include:

1. The Hospital's "Rules and Regulations of the Medical Staff" (amended 9/14/12) required, "Delinquent Medical Records...Delinquent status indicates that a physician has deficient records over 30 days post discharge..."

2. The Hospital presented the surveyor with a letter of attestation dated 12/3/12 and signed by the Manager of the Health Information Management Department that included, "I attest to the fact that the total number of incomplete charts for the Hospital on December 3, 2012 is 249 charts."

3. The above findings were confirmed with the Manager of Health Information Management during an interview on 12/03/12 at approximately 3:00 PM.

Based on observation, review of Hospital documents and interview, it was determined that in 2 of 2 (adult and pediatric) crash carts in the PACU (post anesthesia care unit) the Hospital failed to ensure outdated medications and supplies were not available for patient use. This placed all 23 surgical patient cases scheduled on 12/4/12, at risk.

Findings include:

1. On 12/4/12 at approximately 8:45 AM, a tour was conducted in the PACU. During the tour, the adult and pediatric crash carts were examined and did not have expiration tags. The following were found to be expired: in the adult cart; two (2) 10 millimeter ampules of Procainamide with expiration date of 11/2012 and in the pediatric cart: one of one 3 - 7 kg oxygen delivery system device with expiration dated 11/2012 and 1 of 6 (size 5.5) tracheotomy tube set with expiration date 11/2012.

2. Hospital policy entitled, "Pharmacy Code Cart Responsibilities," (Revised 12/04) required, "II. Procedure: 3. The pharmacist will document the restock or monthly inspection process on the code cart daily log and affix an expiration tag to the cart to indicate when the cart expires."

3. The Director of Peri-operative Services stated during an interview on 12/4/12 at approximately 8:45 AM that the Procainamide, peds oxygen delivery device, and trach tube had expired.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to Complaint conducted on 12-03-12 to 12-06-12 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to Complaint conducted on 12-03-12 to 12-06-12, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, datedDATE

A. Based on observation, document review, and interview, it was determined that for 1 of 1 patient (Pt. #35) scheduled for a cystoscopy on 12/4/12, the Hospital failed to ensure open sterile packs were constantly monitored, to ensure sterility.

Findings include:

1. On 12/4/12 between approximately 7:30 AM and 8:15 AM, an observational tour of the Surgical Department was conducted. Open sterile equipment was observed in the cysto room, without a staff member being present to monitor the sterile equipment

2. The Association of periOperative Registered Nurses (AORN) 2012 Perioperative Standards and Recommended Practices required, "Recommendation V: A sterile field should be maintained and monitored constantly... An open sterile field requires continuous observation."

3. The Nurse Manager of Surgery stated during an interview on 12/4/12 at approximately 9:00 AM that the sterile supplies were open in the cysto room when no staff member was present.


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B. Based on document review, observation, and interview, it was determined, that for 5 of 14 (E #1, 2, 3, 4 and 5) operating room staff in OR (operating room) #3 and OR #6, the Hospital failed to ensure OR staff adhered to the policy for proper surgical attire, in order to help prevent infection.

Findings include:

1. The Hospital's policy entitled, "Infection Control: Surgical Attire" (approved 5/17/12) required, "All personnel will cover head and facial hair, including sideburns and the nape of the neck...All individuals entering the restricted areas will wear a surgical mask...and will be secured to prevent venting".

2. During a tour of OR #3 on 12/4/12 between approximately 7:30 am and 8:10 am, the following was observed:

- At approximately 7:37 am, E #1 (CRNA) entered OR #3 with her surgical mask unsecured at the bottom.

- At approximately 8:00 am, E #2 (a Surgeon) and E #3 (Anesthesia Supervisor) entered OR #3 with approximately 1-2 inches of exposed hair (not covered by the surgical cap) to the back of their heads.

3. During an observational tour in OR #6 on 12/4/12 at approximately 7:50 AM, a Vendor (E#5) entered the OR and was observed with approximately 2 inches of hair exposed from the sides and rear of the head cover; at approximately 8:20 AM, a surgeon (E#6) entered the OR and was observed with approximately 2 inches of hair exposed from the sides and rear of the head cover.

4. The above findings were discussed with the Nurse Manager of Surgery during an interview on 12/4/12 at approximately 8:30 am.

B. Based on document review, observation, and interview, it was determined that for 1 of 2 (OR #3) operating rooms observed, the Hospital failed to ensure that the Operating Room was clean and sanitary, potentially affecting all patients scheduled for surgery (23 patients on 12/4/12).

Findings include:

1. The Hospital's policy entitled, "Housekeeping: Operating Room Sanitation" (approved 1/10) required, "...Clean all operating room furniture with disinfectant...clean all surfaces...Give extra attention to lower portions of all equipment..."

2. During a tour of OR #3 on 12/4/12 between approximately 7:30 am and 8:10 am, the following was observed:

- 5 of 6 wheeled carts contained rust collection around all of the wheel bases, rendering these surfaces uncleanable.

- 1 metal waste cart contained tape wrapped entirely around one side of the base and adhesive residue covering the other side of the base, rendering these surfaces uncleanable.

3. The above findings were discussed with the Nurse Manager of Surgery during an interview on 12/4/12 at approximately 8:30 am.