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Based on document review, observation, and interview, it was determined, for 19 of 19 patients (Pts. #4 and 41 - 58) on the 6 West unit and 21 of 21 patients (Pts. 7, 8, & 59 -77) on the 8 Hamilton unit, the Hospital failed to ensure psychiatric patients were properly monitored and cared for in a safe environment.

Findings include:

1. The Hospital failed to ensure safety checks for psychiatric patients were performed every 15 minutes, as required by policy and practice. (See deficiency at A 144 A)

2. The Hospital failed to ensure contraband items were not available to psychiatric patients with suicidal ideation and/or aggressive disposition. (See deficiency at A 144 B)

The cumulative effects of these systemic practices resulted in the Hospital potentially risking the safety of all patients on both the 6 West and 8 Hamilton units. As a result, it was determined the Condition of Participation at 42 CFR 482.13, Patient Rights, was not in compliance.

Based on document review and interview, it was determined for 1 of 32 (Pt #27) patients, Advance Directive status was not assessed and information was not given upon admission.

Findings include:

1. The policy titled "Advance Directives" (revised 9/13) was reviewed on 4/9/14 at 2:45 PM. The policy stated "V. Procedure: H. During the admission process on the nursing unit, the patient is asked if they have an advance directive by the admitting nurse... M. When the answer is 'No' that the patient does not have an advance directive: a. Provide booklet. b. If the patient requests more information..."

2. Pt # 27 was admitted to the Obstetric (OB) unit on 4/7/14 with the diagnosis of active labor. The admission nursing assessment failed to include an assessment of Pt #27's advance directive status and whether Pt #27 was offered and/or given information on advance directives so as to make an informed decision.

3. An interview was conducted with Pt #27 on 4/9/14 at 9:50 AM. The OB Nurse Manager (E2) and an OB Registered Nurse (RN) (E32) were present during the interview. Pt #27 stated "I don't think so" when asked if nursing staff had asked if Pt #27 had an advance directive. Pt #27 also stated "I don't remember" when asked if staff had offered and/or given any information concerning advance directives. There were no papers or booklets observed in the room concerning advance directives.

4. An interview was conducted with E2 on 4/9/14 at 1:00 PM. E2 reviewed the record of Pt #27. E2 stated nurses are expected to ask patients when they are admitted whether or not they have an advance directive. If they don't have one, they are to give them a booklet on advance directives. They are suppose to document the answer and any information given to the patient in the record. E2 agreed that there was no information in Pt #27's room, during the interview with the patient, about advance directives.

A. Based on document review, observational tour, and interview, it was determined, for 19 of 19 patients (Pts. #4 and 41 - 58) on the 6 West unit and 21 of 21 patients (Pts. 7, 8, & 59 -77) on the 8 Hamilton unit, the Hospital failed to ensure safety checks for psychiatric patients were performed every 15 minutes, as required by policy and practice.

Findings include:

1. On 4/8/14 at 10:10 AM, the "Behavioral Health Precautions Flow Sheet" was reviewed. The flow sheet required 15 minutes monitoring for all psychiatric patients. Each 15 minutes interval required documentation of where the patient was located and the initials of the staff member performing the observation.

2. On 4/8/14 at approximately 11:00 AM, the safety rounding policy for 15 minute observations was requested. The manager of the 8 Hamilton unit stated there was no safety rounding policy.

3. Hospital policy #B-01, titled, "Suicide Prevention", revised 10/13, was reviewed on 4/10/14 at 10:15 AM. The policy required, "Behavioral Health Services... SSRS [Columbia Suicide Risk Scale] = endorsement of questions 1 and of 2 = 15 minute check..." SSRS utilized 6 questions requiring increased levels of monitoring for potential suicidal patients. Even the lowest level of monitoring (question 1) required 15 minute monitoring.

4. Hospital policy #40, titled, "Management of Sexual Misconduct and Aggression", revised 3/14, was reviewed on 4/10/14 at 10:30 AM. The policy required, "A. All patients will be assessed upon admission for recent or past history of sexual misconduct or aggression... C. Staff will initiate the every 15 minute check flow sheet..."

5. On 4/8/14 from 10:10 AM to 11:30 AM, an observational tour was conducted on 6 West, an adult psychiatric unit. At 10:10 AM, a certified nurse attendant (E #8) had the unit's 15 minute safety rounding sheets for all 19 patients (Pts. #4 and 41 - 58). All the rounding sheets had only E #8's initials recorded for 9:45 AM, 10:00 AM, and 10:15 AM. The patients' location was not documented. The 10:15 AM recording was 5 minutes early.

6. On 4/8/14 at 10:12 AM, an interview was conducted with E #8. E #8 stated that she had initialed all the observation sheets (19) for 9:45 AM, 10:00 AM, and 10:15 AM at one time, not every 15 minutes, and would include the patient's location later.

7. On 4/8/14 at 10:15 AM, an interview was conducted with the 6 West unit nurse manager. The nurse manager stated that all unit patients are to be included in 15 minute safety checks and safety check should be done every 15 minutes.

8. Six (6) West unit patients (all 19 patients) included:

- Pt. #4 was a male, admitted on 4/7/14, with a diagnosis of psychosis. Pt. #4's physician's orders included 15 minute safety checks for elopement and aggression.

- Pt. #41 was a male, admitted on 4/2/14, with a diagnosis of depressive disorder.

- Pt. #42 was a female, admitted on 3/17/14, with a diagnosis of schizoaffective disorder.

- Pt. #43 was a male, admitted on 4/6/14, with a diagnosis of psychosis.

- Pt. #44 was a female, admitted on 4/2/14, with a diagnosis of psychosis. Pt. #44's physician's orders included 15 minute safety checks for sexually acting out and aggression.

- Pt. #45 was a male, admitted on 4/4/14, with a diagnosis of bipolar disorder.

- Pt. #46 was a male, admitted on 4/4/14, with a diagnosis of psychosis.

- Pt. #47 was a female, admitted on 3/26/14, with a diagnosis of psychosis.

- Pt. #48 was a female, admitted on 2/19/14, with a diagnosis of episodic mood disorder.

- Pt. #49 was a male, admitted on 4/4/14, with a diagnosis of psychosis.

- Pt. #50 was a male, admitted on 4/5/14, with a diagnosis of episodic mood disorder.

- Pt. #51 was a female, admitted on 3/31/14, with a diagnosis of psychosis.

- Pt. #52 was a female, admitted on 4/7/14, with a diagnosis of psychosis.

- Pt. #53 was a male, admitted on 4/2/14, with a diagnosis of psychosis.

- Pt. #54 was a male, admitted on 3/18/14, with a diagnosis of schizoaffective disorder.

- Pt. #55 was a male, admitted on 4/3/14, with a diagnosis of episodic mood disorder.

- Pt. #56 was a male, admitted on 3/31/14, with a diagnosis of psychosis.

- Pt. #57 was a male, admitted on 3/31/14, with a diagnosis of psychosis.

- Pt. #58 was a male, admitted on 4/5/14, with a diagnosis of psychosis. Pt. #58's physician's orders included 15 minute safety checks for suicide precautions, elopement and aggression.

9. On 4/8/14 from 1:45 PM to 2:30 PM, an observational tour was conducted on 8 Hamilton, another adult psychiatric unit. At 1:45 PM, a certified nurse attendant (E #4) had the unit's 15 minute safety rounding sheets for all 21 patients (Pts. #7, 8, & 59 -77). All the rounding sheets had only E #4's initials recorded for 1:30 PM, 1:45 PM, and 2:00 PM. The patients' location was not documented. The 2:00 PM recording was 15 minutes early.

10. On 4/8/14 at 10:12 AM, an interview was conducted with E #4. E #4 stated that she was nervous and had initialed all the observation sheets (21) for 1:30 PM, 1:45 PM, and 2:00 PM at the same time.

11. On 4/8/14 at 1:50 PM, an interview was conducted with the 8 Hamilton unit nurse manager. The nurse manager stated that all unit patients are to be included in 15 minute safety checks and safety check should be done every 15 minutes.

12. Eight Hamilton unit patients (all 21 patients) included:

- Pt. #7 was a female, admitted on 1/21/14, with a diagnosis of bipolar disorder.

- Pt. #8 was a male, admitted on 2/5/14 with a diagnosis of episodic mood disorder.

- Pt. #59 was a female, admitted on 3/30/14, with a diagnosis of psychosis.

- Pt. #60 was a male, admitted on 3/12/14, with a diagnosis of delusional disorder.

- Pt. #61 was a female, admitted on 4/3/14, with a diagnosis of depressive disorder.

- Pt. #62 was a female, admitted on 4/2/14, with a diagnosis of depressive disorder.

- Pt. #63 was a female, admitted on 4/1/14, with a diagnosis of depressive disorder.

- Pt. #64 was a female, admitted on 4/2/14, with a diagnosis of episodic mood disorder.

- Pt. #65 was a female, admitted on 4/8/14, with a diagnosis of depressive disorder.

- Pt. #66 was a female, admitted on 4/7/14, with a diagnosis of depressive disorder. Pt. #66's physician's orders included 15 minute safety checks for suicide precautions.

- Pt. #66 was a female, admitted on 4/7/14, with a diagnosis of depressive disorder.

- Pt. #67 was a female, admitted on 4/4/14, with a diagnosis of drug abuse.

- Pt. #68 was a female, admitted on 3/31/14, with a diagnosis of suicidal ideation.

- Pt. #69 was a female, admitted on 3/26/14, with a diagnosis of episodic mood disorder.

- Pt. #70 was a female, admitted on 4/1/14, with a diagnosis of episodic mood disorder.

- Pt. #71 was a male, admitted on 3/20/14, with a diagnosis of depressive disorder.

- Pt. #72 was a male, admitted on 4/3/14, with a diagnosis of drug abuse

- Pt. #73 was a male, admitted on 4/5/14, with a diagnosis of episodic mood disorder.

- Pt. #74 was a male, admitted on 4/6/14, with a diagnosis of overdose

- Pt. #75 was a female, admitted on 4/6/14, with a diagnosis of episodic mood disorder.

- Pt. #76 was a male, admitted on 4/4/14, with a diagnosis of episodic mood disorder.

- Pt. #77 was a male, admitted on 4/5/14, with a diagnosis of psychosis. Pt. #77's physicians's orders included 15 minute safety checks for suicide precautions.

B. Based on document review, observational tour, and interview, it was determined, for 6 of 6 potential suicidal patients (Pts. #42, 43, 49, 50, 52, & 58) and 7 of 7 aggressive patients (Pts. #4, 44, 52, 53, 55, 57, & 58) on the 6 West unit and for 1 of 1 aggressive patient (Pt. #72) on the 8 Hamilton unit, the Hospital failed to ensure contraband items were not available to psychiatric patients with suicidal ideation and/or aggressive disposition.

Findings include:

1. On 4/8/14 at approximately 11:00 AM, the behavioral unit policy for contraband was requested. The manager of the 8 Hamilton unit stated there was no contraband policy, but staff are trained during orientation and periodically thereafter.

2. On 4/10/14 at 2:50 PM, the "Unit Safety & Supervision Precautions, Rounding and Contraband..." training presentation was reviewed. Instructions included, "Anything a patient can use to harm themselves or other should send up a red flag... On rounding always inspect for and remove/address suspected or seen contraband..."

3. On 4/8/14 from 10:10 AM to 11:30 AM, an observational tour was conducted on 6 West, an adult psychiatric unit. There were for 6 potential suicidal patients (Pts. #42, 43, 49, 50, 52, & 58) and 7 aggressive patients (Pts. #4, 44, 52, 53, 55, 57, & 58) on the 6 West unit. The following items were found in open/unlocked rooms, and accessible to other patients:

- room 634 - 3 pens/ pencils were available to aggressive patients.

- room 631 - 2 small tooth paste containers with sharp metal edges were available to suicidal patients.

- day room - 1 large plastic garbage bag used as a waste container liner was available to suicidal patients.

4. On 4/8/14 at 10:30 AM, an interview was conducted with the 6 West unit nurse manager. The nurse manager stated that there were no suicidal patients in room 631 and the waste container with the plastic liner could be seen from the nursing station. The nurse manager did not agree that pens and pencils were dangerous.

5. On 4/8/14 from 1:45 PM to 2:30 PM, an observational tour was conducted on 8 Hamilton, an adult psychiatric unit. There was 1 aggressive patient (Pt. #72) on the 8 Hamilton unit. Two pens were found in open room 804 and were available to aggressive patients.

6. On 4/8/14 at 1:50 PM, an interview was conducted with the 8 Hamilton unit nurse manager. The nurse manager stated that plastic bags were not allowed on her unit and pens were not considered contraband.



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C. Based on document review and interview, it was determined that the Hospital failed to ensure safe water for dialysis treatments. This potentially affected all patients receiving in-house hemodialysis.

Findings include:

1. The "AAMI (Association for the Advancement of Medical Instrumentation) standards and Recommended Practices" (Dialysis 2013 Edition) was reviewed. It indicated under, "G.3.4 Carbon media... Testing to demonstrate that the level of total chlorine is less than 0.1 mg/l should be performed before each treatment using a sample obtained from a port located between the two beds of filters...."

2. During a tour of the dialysis unit, conducted on 4/9/14 at 10:15 AM, the documents titled, "RO Daily Checklist" were reviewed for 2013. There is documentation that indicated on 12/20/13 the value for "Total Chlorine" was recorded as .22. This value exceeds the AAMI standard of 0.1. There was no documentation that indicated a repeat chlorine test was conducted where the port was after the polisher carbon tanks to ensure there was no chlorine breakthrough thereby allowing the RO water to be contaminated with chlorine.

3. During an interview with the Lead Nurse Dialysis Services (E-7), conducted on 4/9/14 at 10:15 PM, it was stated that they process their dialysis water in accordance with AAMI standards and only use the value of the Total Chlorine to calculate Total Chloramines. Recent changes in the AAMI standards has moved away from Chloramines and look at Total Chlorine. When asked if there was a policy or procedure in the event there were elevated chlorine tests, E-7 stated they only had a policy and procedure in case there were elevated Total Chloramines.

Based on document review and interview, it was determined, for 2 of 4 adverse patient event reports (Pts. #12 & 13) on the Cardio Pulmonary Rehabilitation Unit from 9/3/13 to 3/7/14, the Hospital failed to ensure adverse events were reported and subsequently tracked.

Findings include

1. Hospital policy No. B-5.3, titled, "Patient Safety Plan", effective 10/08/13 was reviewed on 4/10/14 at 3:30 PM. The policy required, "Section VI. RESPONSIBILITY FOR PATIENT SAFETY-E... All departments/hospital based clinics; UnityPoint clinics within the organization (patients care and non-patient care areas) are responsible for reporting patient safety occurrences and potential occurrences..."

2. Pt. #12's incident report was reviewed on 4/10/14 at 2:00 PM. The report included, "became dizzy, diaphoretic, and ashen after bending over to tie shoe. BP (blood pressure) decreased to 40..." "Patient transported to Methodist ED [Emergency Department]". The event was not reported to the hospital quality assurance council.

3. Pt. #13's incident report was reviewed on 4/10/14 at 2:05 PM. The report included, "Pt HR [Heart Rate] increased on the treadmill to 156... He indicated he felt more short of breath on the treadmill today... 911 was called to transport Patient to the ED." The event was not reported to the hospital quality assurance council.

4. During an interview with the Patient Safety Officer/Risk Manager (E #15), conducted on 4/10/14 at 2:30 PM, E15 stated Pts. #12 & 13's adverse events, were not reported to the hospital quality assurance council.

A. Based on document review and interview, it was determined that for 2 of 2 (Pt #1 and 3) clinical records reviewed of patients requiring neurological checks, the Hospital failed to ensure physicians' orders were followed, as written.

Findings include:

1. The clinical record of Pt #1 was reviewed on 4/8/14 at approximately 10:55 AM. Pt #1 was a 51 year old female admitted on 4/7/14 with a diagnosis of disc herniation. Pt #1 underwent an Anterior Decompression and Fusion of disk C (cervical) 5 and 6 on 4/7/14. The clinical record of Pt #1 contained a physician's order dated 4/7/14 at 10:11 AM that required "Neurovascular checks q (every) 2 hours for 24 hours and then q shift." Pt #1's clinical record contained documentation of Pt #1's neurological check at 7:42 PM on 4/7/14 and not again until 7:32 AM on 4/8/14 (12 hours later).


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2. The clinical record of Pt#3 was reviewed on 4/8/14 at 10:55 AM. Pt#3 was a 51 year old female admitted on 4/4/14 with a diagnosis of osteoarthritis. Pt #1's clinical record included on 4/4/14 Pt #1 underwent bilateral knee replacements. Pt #3's clinical record contained a physician's order dated 4/4/14 at 2:17 PM that required, "assess for color, movement, sensation, swelling, pulses and cap (capillary) refill and temp (temperature) q (every) four hours and prn (as needed). " Pt #3's record included assessments on 4/4/14 at 7:54 PM and again at 4/5/14 at 7:54 AM (12 hours later). Pt#3's record included assessments on 4/5/14 at 7:54 AM and 4/5/14 at 10:40 AM (15 hours later) as well as assessment on 4/5/14 at 10:40 PM and then again on 4/6/14 at 8:05 AM (14 hours later).

3. The Nurse Manager of Orthopedic/Neurosurgery (E#1) was interviewed on 4/8/14 at 10:55 AM and 2:00 PM. During the interviews, E#1 stated the assessments were not done as the physician ordered.


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B. Based on document review and interview, it was determined for 1 of 1 (Pt #16) wound patient reviewed for wound care, wound care was not provided in accordance with the physician's orders.
Findings include:

1. Pt #16 was admitted to the Hospital on 2/6/14 with the diagnosis gangrene of foot. Pt #16's record was reviewed on 4/11/14 at 9:45 AM with the Nurse Systems Manager (E21). On 2/6/14, there was a physician's order for wound care to the right coccyx, gluteal, right foot, right great toe, right 2nd toe, and right heel daily. On 2/6/14 at 2:30 PM, the wound care nurse documented initial care to all wounds. Between 2/6/14 2:30 PM and 2/10/14 at 3:35 PM, there was no nursing documentation of wound care to right foot, right great toe, right 2nd toe, and right heel daily, as ordered. Nursing documentation further stated wound care was provided a 2nd time to both the right coccyx and gluteal wounds on 2/6/14. On 2/7/14, nursing documentation failed to show dressing changes to the right gluteal wound. On 2/8/14, there was documentation of 2 dressing changes to the right gluteal wound. On 2/9/14, there was no dressing change to the right gluteal wound. On 2/10/14, there was no dressing change to the midline coccyx. There was no documentation the physician was notified of the need for extra dressing changes, when provided, or of the lack of dressing changes being provided.

2. An interview was conducted with E21 on 4/11/14 at 10:15 AM. E21 reviewed the record of Pt #16 and stated there was no documentation of the physician being notified of the need for extra dressing changes on the days of extra dressing changes being done and the nurse should have notified them. E21 further stated there was no documentation of daily wound care to the right foot, right great toe, right 2nd toe, and right heel daily as ordered. The physician should have been notified of these omissions in care also.

Based on document review and interview, it was determined for 1 of 32 (Pt #22) patents, care was provided without physicians' orders.
Findings include:

1. The policy titled "Orders for Medications, Treatments, and Diagnostic Tests" (revised 3/14) was reviewed on 4/11/14 at 11:00 AM. The policy stated "I. Policy: Orders will be placed by a physician/LIP... The RN/LPN is responsible for the implementation of physician/LIP orders."

2. Pt #22 presented to the OB unit on 4/7/14 with the CC of gallbladder attack and decreased fetal movement. OB documentation stated an intravenous (IV) was started and 2 liters of Lactated Ringers (LR) were given. There was no physician's order for the LR.

3. An interview was conducted with E2 on 4/10/14 at 1:20 PM. E2 reviewed the record of Pt #22 and stated there was no physician's order for the 2 liters of LR to be given and there should have been one written and signed by the physician.

Based on document review and interview, it was determined in 1 of 2 (Pt #1) records reviewed in which the patient received blood transfusions, the Hospital failed to ensure all vital signs were documented in accordance with Hospital policy and procedure.
Findings include:

1. The Hospital policy and procedure titled, "Blood Administration" was reviewed on 4/8/14. The policy included, "Monitoring: Check the patient's temperature, pulse, respiration, blood pressure according to the following schedule and document on the chart copy of the transfusion tag... After 15 minutes of starting the transfusion... One (1) hour after starting the transfusion... Every hour during the transfusion... At the completion of the transfusion."

2. The medical record of Pt #1 was reviewed on 4/8/14. It indicated Pt #1 was admitted on 4/6/14 with a diagnosis of gastrointestinal bleed. Documentation indicated that on 4/6/14 Pt #1 received a unit of packed red cells. There were no documented vital signs at the 15 minute, 1 hour, 2 hour, 3 hour and upon completion of the packed red cells.

3. During an interview with the VP of Care Transformation, conducted on 4/8/14 at 1:25 PM, it was stated that the nurse should have documented Pt #1's vital signs where the time line was appropriate, in accordance with policy and procedure.

Based on document review and interview, it was determined for 3 of 32 (Pts #26, #27, #28) patients, documentation failed to reflect all information related to care provided.
Findings include:

1. Pt #26 was admitted to the newborn nursery on 4/7/14 at 10:01 AM. On 4/7/14 at 10:00 AM, there was a physician's order "Medications: Vitamin K (phytonadione) 1 mg (milligram) IM (intramuscular) one time. Erythromycin ophth. (ophthalmic) ointment 1 cm (centimeter) ribbon both eyes one time." Nursing documentation stated "Erythromycin ointment: Applied to both eyes. Vitamin K injection: Given left thigh". The documentation failed to state the dose and time of the Erythromycin ointment and the dose, time, and route of injection for the Vitamin K.

2. Pt # 27 was admitted to the OB unit on 4/7/14 with the CC of leaking and contractions, and was admitted in active labor with subsequent cesarean section delivery of a live newborn. The pre-anesthesia evaluation failed to include the time of the evaluation.

3. Pt # 28 was admitted to the newborn nursery 4/7/14 at 11:43 PM. On 4/7/14 at 11:15 PM, there was a physician's order "Medications: Vitamin K (phytonadione) 1 mg (milligram) IM (intramuscular) one time. Erythromycin ophth. (ophthalmic) ointment 1 cm (centimeter) ribbon both eyes one time." Nursing documentation stated "Erythromycin ointment: Applied to both eyes. Vitamin K injection: Given left thigh". The documentation failed to state the dose and time of the Erythromycin ointment and the dose, time, and route of injection for Vitamin K.

4. An interview was conducted on 4/10/14 at 1:20 PM with the E2 and the Director of OB and Pediatrics (E30). E2 reviewed the records of Pts #26, #27 and #28. E2 stated the nurses were expected to document the medication, dose, route, and time of administration of medications. When asked for the Medication Administration Records for Pts #26 and #28, E2 stated that newborns do not have one at the time of admission to the nursery, as they have not been entered into the system at that time. The time in the upper left corner is the time the admission is "opened". The nurses are then to document the medications in the area on the right with all the expected information, medication, dose, time, and route. When asked if there was anywhere else this information could be documented, E2 stated "no". E2 further stated all entries in the medical record should be timed and that the pre-anesthesia evaluation of Pt # 27 was not timed and should have been.

Based on document review and interview, it was determined for 1 of 5 (Pt #16) patients who were discharged greater than 30 days, the Hospital failed to ensure discharge summaries were completed within the required timeframe after discharge.
Findings include:

1. The Medical Staff Rules and Regulations (reapproved with revisions MEC 2/3/14 and Board 2/11/14) was reviewed on 4/11/14 at 10:15 AM. The Rules and Regulations stated on page 10 "L. Discharge Summary: A discharge clinical resume (summary) shall be completed on all medical records of all inpatients and observation patients hospitalized... R. Completion of Medical Records: All available medical records shall be complete within fourteen (14) days after discharge or will become delinquent at that time..."

2. Pt #16 was admitted to the Hospital on 2/6/14 with the diagnosis of gangrene of the foot and was discharged from the Hospital on 3/10/14. Pt #16's record was reviewed on 4/11/14 at 9:45 AM with the E21. As of the time of the record review, there was no discharge summary present.

3. An interview was conducted with the Manager of Medical Records (E34) and the Manager for Medical Records (E35) on 4/10/14 at 10:00 AM. E34 and E35 both stated all physician records are required to be completed within 14 days of discharge or they are considered delinquent and are put on suspension effective the 14th day. An interview was conducted with E21 on 4/11/14 at 10:15 AM, during the record review of Pt #16, and E21 stated it is the expectation that the whole medical record is completed within 30 days of discharge and Pt #16's record was not complete.

Based on document review and staff interview, it was determined, for weekly narcotic count logs on 2 of 18 units (8 Crescent and 7 Hamilton), between 12/25/13 and 4/2/14, the hospital failed to ensure scheduled weekly narcotic counts were completed. This had the potential to affect all 31 patients on 8 Crescent unit and all 22 patients on 7 Hamilton unit.

Findings include

1. Hospital policy No. S-18, titled, "Omnicell Medication Distribution System", effective 3/1/2014, was reviewed on 4/10/14 at 10:00 AM. The policy required, "Section G. Controlled Substance Inventory... "A cycle count will be performed every week for CII-C5 controlled substances. Two nurses will complete the inventory..."

2. Hospital floor narcotic count sheet titled, "Omnicell Controlled Substance Inventory Count Checklist" for the 8 Crescent and 7 Hamilton units was reviewed on 4/10/14 at 10:10 AM. The checklist lacked weekly narcotic cycle counts for the weeks of 12/25/2013 and 1/1/14 on 8 Crescent and for the weeks of 1/1/14, 1/8/14, and 1/15/14 on 7 Hamilton.

3. During an interview with the director of pharmacy (E #12), conducted on 4/10/14 at 10:30 AM, E #12 stated the weekly narcotic cycle counts were not performed on the weeks of 12/25/2013 and 1//1/14 on 8 Crescent and on the weeks of 1/1/14, 1/8/14, and 1/15/14 on 7 Hamilton.

Based on observation and interview, it was determined that on the OB Labor and Delivery and the 8 Crescent units, the Hospital failed to ensure outdated biologicals were not available for patient use. This potentially affected all patients serviced on these units.
Findings include:

1. A tour of the OB Labor and Delivery unit was conducted on 4/8/14 at 1:20 PM with the OB Nurse Manager (E2), the OB Assistant Manager (E29) and the Director of OB and Peds (E30). In the OB clean utility, 3 Hibiclens 4 ounce bottles, expired 2/14 were observed available for use on the stock cart.

2. An interview was conducted with E2 on 4/8/14 at 1:30 PM. E2 observed the outdated Hibiclens and stated the Hibiclens is given to the cesarean section patients to wash the abdomen before delivery. E2 stated outdated supplies should not be available on the stock cart.



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3. A tour of 8 crescent medication area was conducted with the E21 and the 8C Nurse Manager (E25) on 4/7/14 at 10:30 AM. A box of BD vacutainers (Sodium Heparin 95 USP units and blood collection tubes), expired 2/14, was available for patient use.
4. An interview was conducted 4/7/14 at 10:30 AM with E25. E stated "I didn't know those were up there" then disposed of the vacutainers.

Based on document review and interview, it was determined that the Hospital failed to ensure all laboratory specimens sent out to a reference lab were monitored to ensure a result was provided within the established time frames. The cumulative effect of this systemic practice potentially affected all patients with specimens sent out to a reference lab. Therefore, the Hospital was not in compliance with the Condition of Participation for Laboratory Services.

Findings include:

1. The Hospital policy and procedure titled, "Specimen Priorities and of Results" (with a date of 6/1/12 was reviewed. It included, "The Department of Pathology has established various collection and testing priorities for the improved medical management of patients. These priorities include... STAT... vital to the immediate medical management of the patient...will be drawn in 15 minutes and reported...within 60 minutes... ROUTINE...should be utilized... when the physician ... would like a report on the same day..."

2. During a tour of the Hospital's laboratory, conducted on 4/8/14 at 2:10 PM, the log for tests/specimens sent out to a reference lab was reviewed. On the log there were 17 entries that exceeded a 5 day turn around time. Fifteen (15) tests (collected from 4/2/14 through 4/4/14)were ROUTINE priority, and two (2) tests (collected on 3/31/14) were STAT priority. As of survey date 4/8/14 at 2:25 PM, there was no documentation to indicate the Hospital received the results of the tests/specimens sent out.

3. During an interview with the Referral Technician, (E-11) conducted on 4/8/14 at 2:10 PM, E-11 was asked what is the average turn around time for specimens sent out to the reference laboratory. It was stated that the usual turn around time is 3 to 4 days but that depends on the type of test to be performed.

4. During an interview with the Director of Laboratory (E-10), conducted on 4/9/14 at 10:20 AM, it was verbalized that there is a problem with the way the Hospital's computer and the reference lab's computers interconnect. This causes the delay of the results of some of the tests/specimens being reported as completed. There was no documentation or process that indicated laboratory personnel were monitoring the length of time the tests/specimens were sent out and the date the results were returned or if the results were being returned late.

Based on document review, observation and interview, it was determined that for 1 of 1 Dietary Department, the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment. This has the potential to affect all patients receiving dietary food services in the hospital.

Findings include:

1. Hospital policy titled "Dress Code & Personal Grooming" (revised 3/2014), "III. Procedure: 2. No...hats or other covers are to be worn with exception of the designated department caps or hairnets".

2. On 4/10/14 between 11:30 AM and 12:30 PM an observational tour was conducted in the Dietary Department. E #13 and E #14 (cooks) were wearing baseball caps.

3. The Support Services Director, E #16, stated during the tour of the Dietary Department on 4/10/14 at approximately 11:50 AM, "The cooks should be wearing a net hat to cover all their hair".

4. Hospital policy titled "Policy Guideline on Sanitation of Food Service Equipment" (revised 3/2014) required, "III. General Information: 4. Can opener blades are cleaned daily".

5. On 4/10/14 during the observational tour the can opener in the hot food station, had dried food particles on the blade and surrounding areas of the can opener.

6. The Food and Nutrition Services Manager (E #17) stated during the tour of the Dietary Department on 4/10/14 at 12:00 PM "the blade was dirty".

7. Hospital policy titled "Prevention of Contamination" (revised 3/2014) required, "III. All food...Containers will be labeled and dated".

8. On 410/14 during the observation tour, there was approximately 50 containers of opened undated spices in the hot food area, examples included: 5 pounds Chili Powder, 6 ounces Oregano, 5 pound container of Paprika, 3 pounds white pepper and 3 pounds red pepper.

9. The Food and Nutrition Service Manager (E #17) stated during an interview on 4/10/14 at 12:15 PM, "the spices are undated".

Surveyor: Jones, Terry

10. Hospital policy entitled, "Policy Guideline on Sanitation of Food Service Equipment," (revised March 2014) required, "III. General Information:...5. The dish machine will be operated according to the manufacturer's instructions. a. Water temperatures are checked before each dishwashing period and recorded on the dishmachine temperature log."

11. On 4/10/14 at approximately 11:20 AM the Hospital's dietary dishwashing logs were reviewed and required: wash temperature of 150 degrees; rinse temperature of 160 degrees; and final rinse of 180 degrees. The logs failed to include documentation that on 3/27 and 3/28/14 the dishwashing water temperatures were monitored, as required.

12. Hospital policy entitled. "Monitoring Food in Refrigerators and Freezers," (revised March 2014) required, "1. Refrigerators...will be maintained at the following temperatures: Refrigerators - Reach in refrigerators 33 degrees F to 40 degrees F."

13. On 4/10/14 at approximately 11:20 AM the Hospital's Refrigerator/Freezer Temperature Log was reviewed which required: "Coolers Acceptable Range: 32 - 41 degrees F (Fahrenheit): Freezers Acceptable Maximum +10 degrees F."

14. The Hospital's Refrigerator/Freezer Temperature Log for the month of March 2014 was reviewed on 4/10/14 at approximately 11:00 AM. The log contained documentation that on the AM temperature checks for 4/6, 4/7/ 4/8, 4/9, and 4/10/14 the milk cooler had documented temperatures of 30 degrees without corrective action being completed and on 4/6, 4/7, 4/8/14 the PM temperature checks were documented as 30 degrees without corrective action.

15. The Director of Support Services stated during an interview on 4/10/14 at approximately 11:00 AM, that the dishwasher temperatures were not done as required on 3/27 and 3/28/14 and the refrigerator checks were outside parameters with no corrective action noted.

CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Full Survey due to Complaint conducted on April 9 - 11, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see A 710

End

STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Full Survey due to Complaint conducted on April 9 - 11, 2014, the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see K-tags Cited for Survey dated 04/11/2014

End

Based on observation and interview, it was determined the facility failed to ensure equipment was maintained for safety. This has the potential to affect all patients receiving cardio-pulmonary services.
Findings include:

1. A tour of the Cardio-Pulmonary services area in the Atrium building was conducted 4/10/14 at 10:30 AM. Four of five treadmills and four stationary bicycles were not periodically maintained.

2. An interview with the Cardio-Pulmonary Manager (E22) was conducted during the tour. E22 stated "I don't think they (equipment) have to be inspected."

3. An interview was conducted 4/10/14 at 2:00 PM with E1. E21 stated "biomed does not have the treadmills or bicycles on their log."

A. Based on observational tour and interview, it was determined, for 5 patients undergoing surgical procedures in operating room suite 21 on 4/9/14 and for more than 100 patients seen in the emergency department on 4/9/14, the hospital failed to ensure equipment was thoroughly disinfected prior to patient use.

Findings include:

1. On 4/9/14, between 7:15 AM and 10:15 AM, an observational tour was conducted in the preoperative area. In surgical suite 21 the following was found:

- tape residue was on both arm boards and 1 arm board was torn, reducing the potential for through disinfection.

- wall tile was cracked and chipped, reducing the potential for thorough disinfection.

2. On 4/9/14 at 10:13 AM, an interview was conducted with the executive director of cardiovascular and integrated services at the time of the observation. The director wrote a note but did not make a statement.

3. On 4/9/14 between 1:00 PM and 2:00 PM, an observational tour was conducted in the emergency department. Three of 3 cart/gurney mattresses in rooms 15, 17 & 21 contained tape and tape residue, reducing the potential for thorough disinfection. Two of the 3 cart side rails (rooms 17 & 21) also contained tape residue.

4. On 4/9/14 at approximately 1:30 PM, during the tour, an interview was conducted with the emergency department director. The director stated the tape residue would be removed from the carts.


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B. Based on document review, observation and interview, it was determined that in the Interventional Radiology Department, the Atrium outpatient rehabilitation services area, and the OB Surgery Suite, the Hospital failed to ensure infection control practices were maintained. This potentially affected all patients receiving services in theses areas.
Findings include:
1. The policy titled "Central Venous Catheters (Non-Valved/Open Ended Catheters)" (revised 3/14) was reviewed 4/8/14 at 2:00 PM. The policy stated to set up a sterile field and cleanse skin with the 2% chlorhexidine for 30 seconds and dry for 30 seconds. The policy stated when the injection caps are changed not to contaminate the luer lock end.
2. The policy titled "Standard Infection Prevention and Control Practices" (revised 6/13) was reviewed 4/11/14 at 8:45 AM. The policy stated to perform hand hygiene after gloves are removed and to change gloves between procedures.
3. The policy titled "Aseptic Technique" (revised 11/13) was reviewed 4/11/14 at 8:40 AM. The policy stated it pertains to areas of x ray and other areas where invasive procedures or surgical interventions may be performed. The policy stated head and facial hair shall be contained within protective covering and doors to procedure/operating rooms are kept closed.
4. Pt #10 was admitted 4/9/14 with the diagnosis of a renal mass. A tour of the Interventional Radiology Department with the Director of Imaging (E19), the Medical Imaging Operations Manager (E20) and E21 on 4/9/14 at 12:40 PM. Pt #10 was observed to have a CT (computerized tomography) guided needle biopsy of a transplanted kidney. The following was observed: the sterile instrument table was moved to allow passage 3 times while bending over the sterile field by the Radiology Technician (E18) who did not don a hair covering or mask; the room door was open during the procedure; no hand sanitizer was available in the procedure room.
5. An interview was conducted with E20 and E21 during the observation of Pt #10's procedure. E20 stated "we don't have to follow the same rules (referring to infection control) since it is a needle biopsy." When asked about infection control practices and maintaining a sterile field, E21 stated "it should be the same practice for all sterile procedures."
6. Pt #30 was admitted on 4/3/14 with a diagnosis of weakness and dehydration. During an observation of a central line dressing change conducted on Pt #30 by a Registered Nurse (E23) on 4/8/14 at 11:30 AM, the following was observed: during the preparation of the central line dressing change kit, E23 reached in to pull out a sterile towel and contaminated the inside contents; no hand hygiene was performed after glove removal; while opening sterile glove packaging, E23's non gloved hand hit the sterile chlorhexidine applicator; the chlorhexadine skin cleanse and dry time was 19 seconds total; during the cap change, hand hygiene was not conducted and gloves were not removed after dressing change; the uncapped luer lock touched the patients bed sheet.
7. An interview was conducted with the Nurse Systems Manager (E21) and the 7C Nurse Manager (E24) 4/8/14 at 11:30 AM after observing Pt #1's dressing change. After discussing the above observations E21 stated "I saw that too. I think our Nurse Educator will be doing some follow with staff about these issues."
8. A tour of the Atrium outpatient rehabilitation services was conducted 4/10/14 at 10:00 AM with the Outpatient Rehabilitation Site Manager (E26) and the Director of Outpatient Rehabilitation Services (E27). The following was identified: no hand hygiene supplies were available in treatment room # 5 , #7 or the therapy gym; in the therapy gym supply closet, 2 pair of crutches with cracked/broken arm pads were available for patient use; in the therapy gym, a wall mount pulley had soiled white silk tape on the handle pieces; two opened 16 ounce soda bottles (one labeled as diet coke, the other as cherry coke) filled with a clear fluid were stored on a shelf with patient equipment and available for patient use.
9. An interview was conducted with E26 and E27 during the tour of the outpatient rehabilitation services 4/10/14 at 10:00 AM. E26 stated "we have new alcohol containers that don't fit the old brackets so they haven't been filled... sometimes people donate used equipment (referring to the crutches) to us and it sits in the storage closet...we taped the stoppers on the handles so they don't slide around." Upon inquiry, E26 agreed by nodding yes that the tape cannot be cleaned. E26 stated "we use the bottles as hand weights." Upon inquiry, E26 agreed by nodding yes that the bottles were not marked as non consumable and could be accessed by children.


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10. During a tour of OB surgery suite #2 on 4/9/14 at 10:50 AM with E2 and E30, one 10 ml (milliliter) empty syringe with a needle attached and labeled as 50 mg/ml Ephedrine label and one open 7.0 endotracheal tube, with stylet in it and a 10 ml syringe attached were observed in the top drawer of the locked anesthesia cart.

11. An interview was conducted with E2 on 4/9/14 at 11:00 AM. E2 stated the labeled syringe with needle and the open 7.0 endotracheal tube with stylet and 10 ml syringe attached should not have been in the top drawer of the locked anesthesia cart.

A. Based on document review, observational tour, and interview, it was determined, for 1 of 1 patient (Pt. #33) observed undergoing a surgical skin preparation, the hospital failed to ensure surgical skin preparations were performed according to policy.

Findings include:

1. Hospital policy #GG-16, titled, "Skin Preparation of Patients", revised by the hospital on 2/14, was reviewed on 4/9/14 at 11:00 AM. "V. F. 5. Application of the skin antiseptic should progress from the actual procedure site to the periphery. This prevents reintroduction of microorganisms into the surgical site."

2. On 4/9/14, between 7:15 AM and 10:15 AM, an observational tour was conducted in the preoperative area. At 10:12 AM, in surgical suite 21, Pt. #33 was being prepared for a left carotid endarterectomy. An anesthesiologist (MD #1), using an antiseptic sponge applicator, moved the applicator back and forth from procedure site (neck) to periphery (shoulder) four times while performing the skin antiseptic cleaning.

3. On 4/9/14 at 10:13 AM, an interview was conducted with the executive director of cardiovascular and integrated services at the time of the observation. The director wrote a note but did not make a statement.


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B. Based on document review, observation, and interview, it was determined that for 3 of 3 staff (E #4, E #5, and E #6) observed in the Surgical Department, the Hospital failed to ensure adherence to dress code.

Findings include:

1. Hospital policy titled "Surgical Attire," (review date 4/24/13) required, "V. Procedure:...C. All hair including sideburns, beard, moustache, and/or neckline must be covered completely by a hat and/or hood in the restricted area."

2. On 4/8/14 between 7:15 AM and 9:30 AM an observation tour was conducted in the Hospital's Surgical Department.

The following were identified during the tour:

In room 10:

* E #4, the Certified Registered Nurse Anesthetist (CRNA) had approximately 2 inches of hair exposed from the back of his surgical cap.

* E #5 the Certified Surgical Tech had approximately 2 inches of hair exposed from the back of his surgical cap.

Outside room #22 at wash station:

* E #6 the CRNA was wearing a surgical cap that did not enclose his beard.

3. The Director or Surgical Services stated during the tour of the surgical department on 4/9/14 at approximately 9:30 AM, that all hair should be covered.