HospitalInspections.org

Based on medical record review, facility policy and staff interview, the hospital failed to ensure that physician orders for medically necessary restraints were written according to hospital policy for 1 of 2 patients (Patient #23) restrained during their ICU (intensive care unit) hospital stay.

Findings include:

The 5/26/10 review of the clinical manual reflects a policy and procedure called "Restraints" with an effective date of 8/07. On page 6 of 12, under "IV. Procedure. B. Medical Restraint Procedures, 1. Initiation and Renewal of Restraint Orders" states:
"a. A restraint order must be obtained for each restraint episode documenting on the "restraint order sticker"..."All orders are to include the following:
1) Date and time restraint was initiated.
2) Reason or clinical justification for restraint.
3) Type of restraint.
4) Number and type of limb(s) to be restrained.
5) Length of time restraint is to be utilized."

The 5/26/10 review of Patient #23's "Emergency Care Center Physician Record" shows a 5/24/10 -10:55 p.m. physician's order for a "full 4-point restraint" for "safety of pt (patient) and staff". The duration of the restraint was not documented on the physician's "restraint order".

The 5/26/10 review of Patient #23's "Physician Orders" shows a 5/25- 2 a.m. physician's order for a "soft wrist and ankle restraints". The reason for the restraint was not documented for this order. The duration of the restraint was not documented on the physician's "restraint order".

The 5/26/10 review of Patient #23's "Physician Orders" shows a "restraint order" to "protect tubes" for "soft wrist restraints" bilaterally. This order was neither timed or dated, and the duration of the restraint was not documented on this physician's "restraint order". This restraint order sticker was found on a page of physician's orders dated 5/25/10.

This was verified by Director of Patient Services K and Director of Quality A on 5/27/10 at approximately 12:30 p.m.

Based on medical record review and staff interview, the hospital failed to ensure that 1 of 6 patients (Patient #23), receiving care in the ED (Emergency Room), received a skilled nursing evaluation of their chief complaint or presenting complications. This occurred in a total sample of 30 patients.

Findings include:

The 5/26/10 review of Patient #23's Emergency Department clinical record (ECC Quick Report) dated 5/25/10 for the time period of 11:23 a.m. through 1:42 p.m. reflects that Patient #23's blood pressure was abnormally high (normal reference blood pressure is 120/80). The blood pressure during this period are: (Blood pressure were taken by an automatic machine)
11:23 a.m. - 271/130
11:30 a.m. - 280/164
11:45 a.m. - 240/108
11:47 a.m. - 281/148
11:48 a.m. - 281/148
11:55 a.m. - 285/152
11:56 a.m. - 285/152
12:09 p.m. - 274/179
12:11 p.m. - 274/179
12:14 p.m. - 277/150
12:15 p.m. - 177/163
12:32 p.m. - 254/145
12:37 p.m. - 267/147
12:42 pm. - 273/155
12:46 p.m. - 258/138
12:47 p.m. - 281/153
12:52 p.m. - 255/147
12:57 p.m. - 260/148
1:02 p m. - 252/158
1:07 p.m. - 282/152
1:12 p.m. - 263/152
1:17 p.m. - 278/151
1:22 p.m.- 278/150
1:25 p.m. - 247/156
1:27 p.m. - 234/107
1:32 p.m. - 223/132
1:37 p.m. - 194/109
1:42 p.m. -157/113
There was no documented evidence that the assigned RN (Registered Nurse) documented a skilled nursing assessment for the signs or symptoms of Hypertension or performed a nursing neurological exam to rule out hypertensive complications of Stroke or Transient Ischemic Attack (stroke -like changes that resolve themselves).

This was verified by ED RN M on 5/26/10 at 10:50 a.m. and by Director of Patient Services K and Director of Quality A on 5/27/10 at approximately 12:30 p.m.

Based on 9 of 9 (pt. # 6, 8, 11, 12, 13, 14, 15, 16 and 17) observations and interview with facility staff the hospital failed to ensure confidentiality of patient records on treatment units.

Findings include:

During a tour of the hospital with Director of Patient Care Services K on 05/25/2010 at 1:30 PM the following patient's records were observed to be kept in unlocked drawers in an alcove outside their rooms. Pt. #6 in room 3207, pt. #8 in room 3405, pt. #11 in room 3310, pt. #12 in room 3210, pt. #13 in room 2304, pt. #14 in room 2306, pt. #15 in room 2408, pt. #16 in room 2410, and pt. #17 in room 2504.

The following observations were confirmed per interview with K on 05/25/2010 at 2:30 PM.

Based on 12 of 30 medical records reviewed (#4, 5, 6, 7, 8, 9, 10, 12, 19, 20, 22 and 23,), staff interview and facility policy, the hospital failed to assure medical records were complete.

Hospital "Rules and Regulations; Part VII" state; "Every medical record entry must be authenticated and dated promptly by the person (identified by name and discipline) responsible for ordering, providing, or evaluating the service provided."

Findings include:

Findings by Surveyor #26711:

A medical record review was completed on 5/25/10 at 7:30 a.m. on Patient #4's closed medical record. Patient #4 was hospitalized with Congestive Heart Failure (the heart no longer pumps effectively) between 5/9/10 and 5/11/10. Patient #4's medical record contained three physician orders that were not timed, and two progress notes that were not timed.

These finding were confirmed by Quality Improvement (QI) staff E on 5/25/10 at 2:45 p.m.

A medical record review was completed on 5/25/10 at 8:00 a.m. on Patient #5's closed medical record. Patient #5 was hospitalized for a ruptured appendix (the appendix became swollen and burst) between 5/22/10 and 5/24/10. Patient #5's medical record contained one physician order that was not timed and one physician order that did not include the year for the date.

These finding were confirmed by QI staff E on 5/25/10 at 2:45 p.m.

A medical record review was completed on 5/25/10 at 9:50 a.m. on Patient #6's open medical record. Patient #6 was hospitalized on 5/23/10 after re-fracturing the right ankle and breaking the screw that was holding the bones in place. Patient #6's medical record contained one physician order that was not timed and two progress notes that were not timed.

These findings were confirmed by QI staff E on 5/25/10 at 10:10 a.m.

A medical record review was completed on 5/25/10 at 10:20 a.m. on Patient #7's open medical record. Patient #7 was hospitalized on 5/23/10 with a bowel obstruction (the intestines were blocked and not working). Patient #7's medical record contained three physician orders that did not include the year on the dated orders.

These findings were confirmed by QI staff E on 5/25/10 at 10:30 a.m.

A medical record review was completed on 5/25/10 at 10:50 a.m. on Patient #8's open medical record. Patient #8 was hospitalized on 5/4/10 with an infected gallbladder and has had a declining health status since the admission. Patient #8's medical record contained 14 physician orders that were not timed, and one that was not timed or dated. There were 32 progress notes that were not timed, 9 that did not include a year with the date, and 1 that was not dated at all.

These findings were confirmed by QI staff E on 5/25/10 at 11:00 a.m.

A medical record review was completed on 5/26/10 at 8:00 a.m. on Patient #10's closed medical record. Patient #10 was hospitalized between 5/21/10 - 5/22/10 after surgical removal of an ovarian cyst. Patient #10's medical record indicates a surgical "time-out" was performed and that the alcohol based skin prep was dry. The only skin prep documented as being used was Betadine, which is not alcohol based. After a discussion with Surgery Supervisor C on 5/26/10 at 9:40 a.m., and investigation on C's part with the surgery staff, it was determined that documentation of the use of Chloroprep (an alcohol based skin prep) for the abdomen was not completed.

These findings were confirmed by Surgery Supervisor C on 5/26/10 at 10:30 a.m.

A medical record review was completed on 5/26/10 at 7:20 a.m. on Patient #9's closed outpatient medical record. Patient #9 had same day surgery for the removal of a bladder tumor. Patient #9's medical record contained intraoperative orders and post-operative orders that were not timed by the physician.

These findings were confirmed by QI staff E on 5/26/10 at 10:05 a.m.

A medical record review was completed on 5/26/10 at 10:50 a.m. on Patient #12's open medical record. Patient #12 was hospitalized on 5/20/10 with severe asthma and pneumonia. Patient #12 came in through the Emergency Room (ER). The ER physician note/order sheet is missing dates and times for orders, and the disposition of the patient from the ER. The form is incomplete.
Patient #12's medical record contains one physician order that is not timed, and one physician order that is not timed or dated. There is one order that is written by a pharmacist that is not timed or dated. There are four progress notes that are not timed, and seven progress notes that do not include a year with the date.

These findings were confirmed by QI staff E on 5/26 at 11:13 a.m.


Findings by surveyor #20878:

Hospital "Rules and Regulations; part V" indicate; "An appropriate medical record shall be kept for every patient receiving emergency services...The record shall include: Time of treatment and time of physician notification."

Patient #20's medical record was reviewed on 05/26/2010 at 2:00 PM. The record contained documentation of an emergency room visit. The transfer form was missing various times and the "Continual Care" order sheet is lacking the time of authentication.

Patient #19's medical record was reviewed on 05/26/2010 at 2:00 PM. The record contained documentation of an emergency room visit. The transfer form was missing various times.

These findings were confirmed by QI staff E on 5/26/10 at 3:00 PM.


Findings by Surveyor 09948:

Hospital "Rules and Regulations; Part VII" state; "Every medical record entry must be authenticated and dated promptly by the person (identified by name and discipline) responsible for ordering, providing, or evaluating the service provided."

The 5/26/10 review of Patient #22's "Emergency Care Center Physician Record" for the 5/25/10 ED (emergency room) visit, has no date on it to reflect the day that care was initiated. This record has no date nor time for medical orders written for laboratory and radiology tests that were ordered for Patient #22. A timeline of care could not be established to determine when medical orders were written, and when these orders were completed by the responsible staff in order to ensure timely treatment and care.

The 5/26/10 review of Patient #23's "Emergency Care Center Physician Record" for the 5/24/10 ED (emergency room) visit, has no date on it to reflect the day that care was initiated. This record has no date nor time for medical orders written for laboratory and radiology tests that were ordered for Patient #23. A timeline of care could not be established to determine when medical orders were written, and when these orders were completed by the responsible staff in order to ensure timely treatment and care.

Patient #'s 22 and 23's findings were verified with Director of Patient Services K and Director of Quality A on 5/27/10 at approximately 12:30 p.m.

Based on 6 of 30 medical records reviewed (#1, 3, 4, 7, 8, and 12) , interview with staff and review of facility policy, the hospital failed to assure authentication of verbal orders in a timely manner.

The hospital's "Rules and Regulations part V" dictates; "All verbal and telephone orders shall be signed and dated by the individual giving the order within 48 hours."


Findings by Surveyor #26711:

A medical record review was completed on 5/25/10 at 7:30 a.m. on Patient #4's closed medical record. Patient #4 was hospitalized with Congestive Heart Failure (the heart no longer pumps effectively) between 5/9/10 and 5/11/10. Patient #4's medical record contained one physician verbal order that was not authenticated by the physician within 48 hours.

These finding were confirmed by Quality Improvement (QI) staff E on 5/25/10 at 2:45 p.m.

A medical record review was completed on 5/25/10 at 10:20 a.m. on Patient #7's open medical record. Patient #7 was hospitalized on 5/23/10 with a bowel obstruction (the intestines were blocked and not working). Patient #7's medical record contained three physician verbal orders that were not properly authenticated with a year and a time.

These findings were confirmed by QI staff E on 5/25/10 at 10:30 a.m.

A medical record review was completed on 5/25/10 at 10:50 a.m. on Patient #8's open medical record. Patient #8 was hospitalized on 5/4/10 with an infected gallbladder and has had a declining health status since the admission. Patient #8's medical record contained 5 physician verbal orders that were not properly authenticated.

These findings were confirmed by QI staff E on 5/25/10 at 11:00 a.m.

A medical record review was completed on 5/26/10 at 10:50 a.m. on Patient #12's open medical record. Patient #12 was hospitalized on 5/20/10 with severe asthma and pneumonia. Patient #12's medical record contains one pharmacist order that is not authenticated by a physician.

These findings were confirmed by QI staff E on 5/26 at 11:13 a.m.


Findings by surveyor #20878:

Patient #1's medical record was reviewed on 05/25/2010 at 1:00 PM. The record contained two telephone orders which were taken on 10/20/2009 and not countersigned by the physician until 11/12/2009. There was also one telephone order taken on 10/23/2009 which was not countersigned until 11/11/2009.

Patient #3's medical record was reviewed on 05/25/2010 at 11:00 AM. The record contained six telephone orders which were taken between the dates of 05/04 and 05/07/2010 and were not countersigned by the physician.

These findings were confirmed by QI staff E on 5/26/10 at 2:00 PM

Based on observation, staff interview and review of maintenance records between 5/24-6/08/2010, the facility failed to construct, install, and maintain the building system due to (i) lack of positive latching hardware on exit access doors in four locations; (ii) lack of astragals in smoke doors in four locations; (iii) one non-latching corridor door to hazardous area; (iv) more than two delayed egress locked doors in an egress path from two suites; (v) one means of egress corridor not kept clear and unobstructed; (vi) one means of egress in a suite not arranged in accordance with NFPA 101 18.2.5; (vii) lack of double lamp lighting fixture above one exit door; (viii) lack of sprinkler protection or alternative fire extinguishing system in five telecommunication rooms; (ix) two corridors in patient sleeping areas used as return air plenums; (x) trash receptacles not stored in a room protected as a hazardous area in two locations; (xi) store one empty oxygen cylinder separate from full cylinder; (xii) lack of remote emergency manual stop for the emergency generator of the essential electrical system; (xiii) failure to label emergency electrical wall outlets, and maintain working clearance in front of electrical switches; and (xiv) failure to maintain four clean spaces under positive pressure and two dirty spaces under negative pressure; and provide ventilation in a closet within one sterile storage in the Surgical suite.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to tags K-18, K-27, K-29, K-38, K-39, K-41, K-45, K-56, K-67, K-75, K-76, K-106, K-147, A-701 and A-709 for detail.

Based on observation and interview, the facility failed to (i) maintain required negative/positive pressure in 5 spaces in accordance with the recommendations in CDC and the American Institute of Architects (AIA) guidelines; (ii) store a housekeeping equipment in a separate housekeeping facility; (iii) replace one stained ceiling tile, and maintain one radiology room clean, and one janitor closet wall smooth. This had a potential of affecting indeterminable number of patients.

Findings include

During a tour of the facility with Staff N (facilities management director), and Staff P (facilities management supervisor) between 5/26-5/28/2010, Surveyor 12316 observed spaces in the following locations that were either not maintained clean, or did not either have properly maintained positive or negative pressure to cause airflow in right direction from clean to dirty spaces

Item 1. On 5/24/2010 at 3 pm, one housekeeping equipment -floor buffer- was stored in a closet within the Sterile Storage Room 1145 and not in a closet or room outside of the Sterile Storage that is directly accessible from the Surgical Suite. The closet within the Sterile Storage did not have any air supply and/or return/exhaust to provide some air changes.

Item 2. On 5/24/2010 at 3:16 pm, the sterilizer service side Room 1153 was not under negative pressure with respect to corridor. Instead, it was under positive pressure causing airflow into corridor.

Item 3. On 5/24/2010 at 3:22 pm, the Sterile Supply Room 1152 was not under positive pressure relative to the Decontamination Room 1150.

Item 4. On 5/24/2010 at 3:26 pm, the Soiled Utility Room 1151 located across the Operation Room (OR) 1 was not under negative pressure relative to the adjacent corridor. The room was under positive pressure causing airflow in a wrong direction toward corridor.

Item 5. On 5/24/2010 at 3:53 pm, one ceiling tile in the Recovery Room 1112 in the Day Surgery on the 1st Floor was stained and not clean.

Item 6. On 5/25/2010 at 1:30 pm, the Clean Storage Room 2317 on the 2nd Floor across Stair 1 was not under positive pressure relative to the corridor. Instead, it was under negative pressure. Based on review of the 2nd Floor Plan of the hospital, the room was designed as a soiled utility room that requires a negative pressure.

Item 7. On 5/25/2010 at 2:38 pm, the Clean Utility Room 1701 was not under positive pressure relative to the corridor. The room is located adjacent to the nurse station of the Intensive Care Unit (ICU) on the 1st Floor.

Item 8. On 5/25/2010 at 3 pm, the Clean Utility/Supply Room 1812 was not under positive pressure relative to the corridor. Instead, it was under negative pressure. The room is located across the Trauma Room #4 in the Emergency Department on the 1st Floor.

Item 9. On 5/26/2010 at 10:11 am, there were some dust and lint deposit on the blue sheathing of electrical wires of the radiology equipment in the Radiology Room 1503, and one wall corner adjacent to equipment was partly damaged. The Room 1503 is located in the 1st Floor.

Item 10. On 5/26/2010 at 4:38 pm, one wall of the Janitor Closet G116E in the Kitchen on the Garden Level was not smooth and clean due to chipped off drywall and lack of interior finish on the chipped off surfaces.

The above deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection.

The above observation was acknowledged by the facility management director, and facility management supervisor at the time of discovery, and confirmed with both staff at the exit conference on 5/27/2010 at 11:50 am.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

1. Failed to protect the life safety of patients from fire due to lack of positive latching hardware on exit access doors in four locations;
2. Failed to protect the life safety of patients from fire due to lack of astragals in smoke doors in four locations;
3. Failed to protect the life safety of patients from fire due to one non-latching corridor door to hazardous area;
4. Failed to protect the life safety of patients from fire due to more than two delayed egress locked doors in an egress path from the Emergency Department and Intensive Care Unit suites;
5. Failed to protect the life safety of patients from fire due to one corridor not kept clear and unobstructed in accordance with NFPA 101 18.2.3.3;
6. Failed to protect the life safety of patients from fire due to more than 50 ft travel distance from one interior room to exit access door in the Lab Suite;
7. Failed to protect the life safety of patients from fire due to lack of double bulb lighting fixture above one exit door for illumination of the means of egress;
8. Failed to protect the life safety of patients from fire due to lack of sprinkler protection or alternative fire extinguishing system in five telecommunication rooms;
9. Failed to protect the life safety of patients from fire due to two corridors used as return air plenums;
10. Failed to protect the life safety of patients from fire due to trash receptacles not stored in a room protected as a hazardous area in two locations;
11. Failed to protect the life safety of patients from fire due to failure to store one empty oxygen cylinder separate from full cylinder;
12. Failed to protect the life safety of patients from fire due to lack of remote emergency manual stop for the emergency generator of the essential electrical system; and
13. Failed to protect the life safety of patients from fire due to failure (i) to label some emergency electrical wall outlets in the post anesthesia care unit, intensive care unit and emergency department in accordance with NFPA 70 517-19(a), and (ii) to provide working space in front of electrical switches in two locations in accordance with NFPA 70 110-26.

Refer to K-tags K-18, K-27, K-29, K-38, K-39, K-41, K-45, K-56, K-67, K-75, K-76, K-106, K-147 for detail.

Based on observations in 4 out of 10 hospital departments, policy and procedure review, and staff interviews, this hospital failed to ensure patients (Patient #9 and #21) and visitors were protected from the spread of potential sources of infections.

Findings include:

Hospital policy titled, "Hand Hygiene," effective date 1/20/10 (policy does not have a numerical identifier), was reviewed by Surveyor #26711 on 5/25/10 at approximately 3:15 p.m. The policy states on page 2 of 5, in section C., "Use the alcohol-based hand rub: 1. Before and after providing care to any patient. 2. Before and after contact with a patient's skin (e.g., taking vital signs, lifting a patient). 3. After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, as long as hands are not visibly soiled. 4. After removal of gloves. 5. Before donning [applying] gloves. 6. After contact with the patient's environment and medical equipment. 7. Between moving from a contaminated body site to a clean body site while providing patient care. 8. Before using the computer in patient rooms."

Hospital policy titled, "Personal Protective Equipment (PPE)," effective date 3/19/10 (policy does not have a numerical identifier), was reviewed by Surveyor #26711 on 5/26/10 at 9:40 a.m. The policy states on page 2 of 8, in section F., "Use of Gloves: 1. At a minimum, gloves will be worn when there is reasonable anticipation of employee hand contact with blood and other potential infectious material (OPIM), with sputum, pus, urine, feces, saliva, wound drainage, etc., and non-intact skin or mucous membranes, and when the employee has non-intact skin. 2. Disposable gloves (single use only) can be latex, vinyl, or nitrile. Gloves are to be replaced as soon as practical when visibly soiled, torn, punctured or when the barrier is compromised. They will not be washed or disinfected for reuse."

Per interview with Infection Control Practitioner (ICP) G on 5/26/10 at 1:10 p.m., "The PPE policy needs to be more specific," to address when gloves are to be used and/or changed during the course of patient care.

In an interview with ICP G on 5/24/10 at 12:55 p.m., ICP G stated that the expectation within the hospital for a dressing change protocol is: wash hands before applying gloves, put on clean gloves, remove dressing, remove gloves, wash hands, put on clean gloves, apply dressing, remove gloves, wash hands.

On 5/24/10 at 2:35 p.m. Surveyor #26711 toured the Surgery area accompanied by Surgery Manager B and Surgery Supervisor C. The following infection control breaches were noted in this area and confirmed by B and C at the time of discovery:
1. Physician D was observed to be administering an Intravenous (IV-through the vein) medication to Patient #9 and was not wearing gloves. Supervisor C commented, "I'm surprised he didn't have them on , he usually does." Both B and C confirmed gloves are to be worn during IV medication administration.
2. Clean supplies (boxes of supplies for re-stocking PPE's above the scrub sinks, such as gloves and eye-shields) are being stored in a soiled utility room which holds soiled garbage and linen from surgery. The cabinet doors do not constitute a separation of clean and dirty.
3. In the Central Sterile Supply decontamination room there are gouges in the wall making this a non-intact painted surface and unable to clean.

On 5/25/10 at 12:30 p.m. Surveyor #26711 toured the kitchen area accompanied by Food Service Manager H. The following infection control breaches were noted in this area and were confirmed by H at the time of discovery:
1. A "Janitor closet" is missing areas of paint on the walls exposing the dry wall underneath and causing this to be a non-cleanable surface. A ceiling tile was also loose and mis-aligned in this room.
2. Cardboard shipping boxes with food items are being brought in to the kitchen and stored on shelving near the food preparation area. Cardboard can harbor micro-organisms which can be transferred to people and/or food.
3. Cafeteria staff I was observed coming into the kitchen area with gloves on. Staff I put a bag of buns in a microwave and removed the gloves as Staff I was exiting the kitchen back into the cafeteria and put on a new pair of gloves in the cafeteria. Staff I was not observed to wash hands between glove changes.

On 5/25/10 at 9:10 a.m. Surveyor #26711 observed Physical Therapy (PT) staff F perform wound care on Patient #21. Surveyor #26711 was accompanied by Quality Improvement (QI)staff E.

PT F was gowned and gloved upon Surveyor #26711's arrival to the room. PT F, with gloved hands, was observed to pick up a piece of trash from the floor. With these same gloves on PT F filled the clean portable whirlpool tank with water and plugged the machine into the wall. PT F then removed the gloves, did not wash hands, and left the room to get towels from the nurse server (cupboards outside the room). Without washing hands, PT F put on new gloves, removed the old dressing from Patient #21's right foot which contained dark reddish brown drainage. PT F discarded the dressing but did not remove gloves or wash hands and continued with care by placing a clean towel under Patient #21's right leg which was in the whirlpool tank. PT F then removed the gown and gloves, did not wash hands and touched another clean towel and PT F's own face before washing hands. After the whirlpool treatment was completed, PT F washed hands, touched PT F's own face, and put on gloves to finish the cares.

Per interview with ICP G on 5/26/10 at 1:10 p.m. when the above observation was discussed, ICP G confirmed this practice is not the expectation of the hospital. Policy and hospital expectations were not followed.

During a tour of the Medical/Surgical third floor on 5/25/10 at 9:50 a.m., Surveyor #26711, accompanied by QI E, discovered two single serving containers of Italian Ice in the refrigerator. The manufacturer packaged dates on the lids of these items were 2008 and 2005.

On 5/26/10 at 1:20 p.m., Food Service Manager H confirmed to Surveyor #26711 that the manufacturer recommendation for this frozen food item would be one year from the date stamp. Both items were out dated.

During a tour of the maternity unit on 05/25/2010 at 1:30 PM, Surveyor #20878, accompanied by the Director of Patient Care Services K, discovered that the filter on a "Giraffe Incubator" (isolette) had no indication of when it had last been changed. The manufacturers manual specified that the filter should be changed every three months, this was confirmed per K at the time of the tour. Per interview with K on 05/26/2010 at 1:00 PM the hospital had no record of filter changes on the isolette nor was there a policy dictating how frequently they should be done.