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Based on review of facility documents, observation and staff (EMP) interview, it was determined the facility failed to check the emergency code cart every shift as per facility policy for two of six emergency carts reviewed.

Findings include:

Review of facility's "Emergency Code Cart Policy," last reviewed October 2017, revealed "Purpose: To ensure the emergency drugs, as approved by the Critical Care Committee, Medical Care Committee and the Pharmacy and Therapeutic Committee, are in adequate supply in the pharmacy and stocked in code carts in designated UPMC Susquehanna areas. ... Responsibility: ... Nursing staff/Department staff is responsible for checking and documenting code cart integrity as per the UPMC Susquehanna Code Cart Checklist. ..."

Review of the "Susquehanna Health - Code Cart Checklist," dated November 8, 2013, revealed a heading labeled Days with tasks to be completed listed and blocks to check for each day of the month. A section for staff initials and signatures was at the bottom of page one. Page two of the check list revealed headings for Evenings and Nights with tasks to be completed listed and blocks to check for each day of the month. A section for staff initials and signatures was at the bottom of page. The month, year and location of the cart was listed at the top of the form.

Review of Medical Surgical Unit Friday Updates revealed the Friday Update of July 7, 2017, stated "Code cart checks are expected to be done every day every shift by the assigned person."

Review of the adult Emergency Code Cart on the Medical Surgical Unit at 9:30 AM on October 31, 2017, revealed Code Cart Checklists for September 2017 and October 2017. Review of the September 2017 Code Cart Checklist revealed four days the Code Cart check was not completed on day shift; two days the Code Cart check was not completed on evening shift; and one day the Code Cart check was not completed on night shift. Review of the October 2017 Code Cart Checklist revealed seven days the Code Cart check was not completed on day shift; two days the Code Cart check was not completed on evening shift; and one day the Code Cart check was not completed on night shift.

Review of the pediatric Emergency Code Cart on the Medical Surgical Unit at 9:40 AM on October 31, 2017, revealed Code Cart Checklists for September 2017 and October 2017. Review of the September 2017 Code Cart Checklist revealed four days the Code Cart check was not completed on day shift; two days the Code Cart check was not completed on evening shift; and one day the Code Cart check was not completed on night shift. Review of the October 2017 Code Cart Checklist revealed seven days the Code Cart check was not completed on day shift; two days the Code Cart check was not completed on evening shift; and one day the Code Cart check was not completed on night shift.

Interview at 12:30 PM on October 31, 2017 with EMP 3 and EMP4 confirmed the adult and pediatric Emergency Code Cart checks were not completed four days on day shift, two days on evening shift and one day on night shift in September 2017 and seven days on day shift, two days on evening shift, and one day on night shift in October 2017. EMP3 and EMP4 confirmed the Emergency Code Cart checks are to be completed on every shift each day.

Based on observation of the morgue, request for policies and procedures for the morgue temperature monitoring and employee (EMP) interview, the facility failed to ensure the morgue room and the morgue body container temperatures monitored.

Findings include:

Request on November 2, 2017, for a facility policy and procedure for the morgue room temperature monitoring and the body container temperature monitoring revealed no policy or procedure.

Interview with EMP1 and EMP2 on November 2, 2017, at approximately 10:00 AM, confirmed the facility had no facility policy and procedure for the morgue room temperature monitoring and the body container temperature monitoring.

Tour on November 2, 2017 of the facility morgue room and the body container in the morgue revealed a log with a list of the expired patients placed in the room. Log dates were noted from January 2016-October 2017. There was no documentation facility staff monitored the temperature of the body container or the morgue room.

Interview with EMP1 and EMP2 on November 2, 2017, confirmed the log with a list of the expired patients placed in the room with dated noted from January 2106-October 2017. EMP1 and EMP2 confirmed there was no documentation facility staff monitored the temperature of the body container or the morgue room.

Interview with EMP6 on November 2, 2017, at 11:50 AM, revealed and confirmed there was no documentation the temperature was monitored for the body container and morgue room.

Based on review of facility policy, medication refrigerator temperature log, and staff (EMP) interview, it was determined the facility failed to ensure proper medication temperatures were maintained in two of four medication refrigerators reviewed.

Findings include:

Review on November 3, 2017, of the facility policy "Medication Storage Temperature Control and Monitoring," last revised June 2017 revealed "Policy: All medications stored at room temperature, refrigerated, frozen or warmed are maintained at the required temperature, as stated by the manufacturer to assure drug stability... Process: 1. Temperature Ranges: a. Medications refrigerators will be maintained between 36 (degrees) F (Fahrenheit) to 46 (degrees) F... 2.b. Medication refrigerators, freezers and warmers are monitored and temperatures documented daily for manual process... 1. Exception: If vaccines are stored in a refrigerator/freezer the temperature must be checked and recorded at least twice a day..."

Review of medication temperature logs on October 31, 2017, at 9:30 AM for the medical surgical department revealed documentation for the refrigerator to be monitored on day shift and evening shift. Review of two refrigerators on the medical surgical department revealed the medication temperature log had no documented temperatures on seven of 30 days on day shift (3, 20, 23, 24, 28 and 29) and two of 30 days on evening shift (14 and 28) in September 2017. Further review of the medication temperature logs revealed no documented temperatures on seven of 30 days reviewed on day shift (5, 8, 9, 10, 16, 29 and 30) and two of 30 days on evening shift (11 and 16) in October 2017.

Interview with EMP3 on 10/31/17 at 10:00 AM confirmed the medication refrigerator monitoring in medical surgical department at this campus was a manual type of monitoring. EMP3 confirmed the medication temperature logs were not completed and stated the expectation would be medication temperature recordings twice a day.

Based on review of facility policies and procedures and employee (EMP) interview, it was determined the facility failed to ensure policies and procedures were reviewed yearly for four out of seven policies and procedures reviewed.

Findings include:

Review on November 3, 2017 of facility policy "Policies, Administration-Development, Review, and Distribution," last reviewed September 2016, with an expiration date of September 2018, revealed "Purpose To establish guidelines for the development of new Susquehanna Health Administrative Policies and Procedures and for the review/revision of existing policies and procedures. Policy An administrative policy is one that delineates a general direction to be adhered to or the health system's position regarding particular subject matter. The policy content pertains in general to the broader organization or health system. It is intended to provide guidance to more specific departmental policy or to larger complications of policies related to a particular subject, such as HIPPA, or to a functional area, such as Human Resources. However, it may include specific procedural guidance if the process must be the same or very similar from department to department across SH. ... Process/Procedure ... 2. The Policy Oversight Committee has primary responsibility for all policies designated as Administrative policies. The committee will notify policy owners of the timing of required periodic policy review/revision six (6) months in advance of when the Administrative Policy Manual are designated for biannual review unless the responsible Corporate Officer or policy author identifies need for more frequent review. ... Submission of a new/revised policy for approval 7. The author drafts or revises the policy I the electronic policy program using 12pt Arial font. 8. Author/Editor must have the revisions completed and 'pended for approval' to the Administrative Assistant at MVH two weeks prior to the Policy Oversight Committee meeting (1st Tuesday of every month)... ."

Review on November 1, 2017 of facility policy "Restraint and Seclusion," revealed a last documented review date and approval date of June 2016. Documentation noted the expiration date of June 2017.

Interview with EMP1 and EMP2 on November 1, 2017, at approximately 2:30 PM, confirmed the facility policy "Restraint and Seclusion" was last reviewed and approved in June 2016 and expired in June 2017. EMP1 confirmed the policy expiration date is one year after approval.

Review on November 2, 2017 of facility policy "Anatomical Donations," revealed a last documented review date and approval date of September 2016. Documentation noted the expiration date of September 2017.

Interview with EMP1 and EMP2 on November 2, 2017, at approximately 3:15 PM, confirmed the facility policy "Anatomical Donations" was last reviewed and approved in September 2016 and expired in September 2017. EMP1 confirmed the policy expiration date is one year after approval.

Review on November 3, 2017 of facility policy "Care Of the Patient After Death," revealed a last documented review date and approval date of September 2016. Documentation noted the expiration date of September 2017.

Interview with EMP1 and EMP2 on November 3, 2017, at approximately 10:00 AM, confirmed the facility policy "Care Of The Patient After Death" was last reviewed and approved in September 2016 and expired in September 2017. EMP1 confirmed the policy expiration date is one year after approval.

Review on November 3, 2017 of facility policy "Inmate Patient - Care of," revealed a last documented review date and approval date of August 2016. Documentation noted the expiration date of August 2017.

Interview with EMP1 and EMP2 on November 3, 2017, at approximately 9:00 AM, confirmed the facility policy "Inmate Patient - Care of" was last reviewed and approved in August 2016 and expired in August 2017. EMP1 confirmed the policy expiration date is one year after approval.

Based on review of facility documents, medical records (MR) and employee (EMP) interview, it was determined the facility failed to ensure two out of nine patient deaths (MR35 and MR36) were reported to the Organ Procurement Organization (OPO).

Findings include:

Review on November 2, 2017 of facility policy "Anatomical Donations," last reviewed September 2017, revealed "Responsible Person: RN Purpose: To assure that all potential organ, tissue, and eye donors are identified and that all potential donor families are provided the option of donation. 1. Donor Suitability A. On or before the occurrence of each death, a SH Registered Nurse will contact Gift of Life Donor Program (GLDP) (1-800-KIDNEY-1) to determine a patient's suitability for anatomical donation in conjunction with the attending physician or his/her designee. GLDP must be called prior to terminating life-sustaining measures. All patients, including inmate patients and infants 16 weeks or greater gestation must be evaluated for donor suitability by GLDP prior to the patient's Agent under their Health Care Power of Attorney or Family (refer to C.g.) being approached about donation. ..." C. ... h. In addition, the Certificate of Referral/Request for Anatomical Donations Form will be completed and placed in the patient's medical record. ... ."

Review on November 2, 2017 of MR35, revealed the patient expired on April 11, 2017 in the In-Patient Medical/Surgical Unit.

Interview with EMP1 on November 2, 2017, at 2:40 PM, confirmed MR35 expired on April 11, 2017 on the In-Patient Medical/Surgical Unit.

Review on November 22, 2017 of MR36, revealed the patient expired on November 29, 2016, in the In-Patient Medical/Surgical Unit.

Interview with EMP1 on November 2, 2017, at 2:40 PM, confirmed MR36 expired on November 29, 2016, on the In-Patient Medical/Surgical Unit.

Review on November 2, 2017, at 2:40 PM, of the facility "Deaths from Muncy Valley Hospital," document for January 1, 2015-November 2, 2017 and the "Gift of Life Donor Program The Regions Organ & Tissue Transplant Network Donation and Referral Activity," documents for January 1, 2015-September 30, 2017, revealed MR35 was not listed on the GOL network activity document for April 11, 2017. Review of MR35 revealed no documentation of the Certificate of Referral/Request for Anatomical Donations Form. MR36 was not listed on the GOL network activity document for November 29, 2016. Review of MR36 revealed no documentation of the Certificate of Referral/Request for Anatomical Donations Form.

Interview with EMP1 on November 3, 2017, at approximately 10:00 AM, confirmed the facility "Deaths from Muncy Valley Hospital," document for January 1, 2015-November 2, 2017 and the "Gift of Life Donor Program The Regions Organ & Tissue Transplant Network Donation and Referral Activity," documents for January 1, 2015-September 30, 2017, with no documentation noted of MR35 listed on the GOL network activity document for April 11, 2017. EMP1 confirmed no documentation of MR36 listed on the GOL network activity document for November 29, 2016.

EMP1 revealed the Medial Record Department completed the reconciliation of the facility death list and the GOL list monthly, and EMP5 was responsible for the GOL reconciliation.