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Based on observations and documentation reviews as referenced in the Life Safety Report of Survey completed 01/05/2010 the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital failed to develop and maintain a safe physical plant and overall safe environment by failing to ensure wood fences were flame retardant, maintained flame retardant, and exit access were complaint with code.

~Cross-refer to 485.623(a) Physical Plant and Environment Standard Tag C0221

2. The hospital failed to ensure fire drills were conducted at unexpected times.

~Cross-refer to 485.623(c)(1) Physical Plant and Environment Standard Tag C0227

3. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 485.623(d)(1) Physical Plant and Environment Standard Tag C0231

4. The hospital failed to ensure exit discharge illumination was compliant with code.

~Cross-refer to 485.623(d)(5) Physical Plant and Environment Standard Tag C0235

Based on observations as referenced in the Life Safety Report of Survey completed January 5, 2010, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Building 01:
1. Based on observation on 01/05/2010 there were wood fences under canopies in the area around the generator and the 02 storage tank. These fences must be rendered flame retardant and maintained flame retardant. 42 CFR 483.70 (a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 012

2. Based on observation on 1/5/2010 the following exit access were observed as noncompliant: specific findings include exit access was not a solid path (easily maintained in inclement weather) to a public way (exit from PCU staircase door 146 also joined with physical therapy exit). 42 CFR 483.70(a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 038

Based on observations and fire drill record reviews as referenced in the Life Safety Report of Survey completed January 5, 2010, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Building 01:
Based on observation on 1/5/02010 and review of fire drill records, determined that the third shift drills were held between 5:00 am and 6:30 am only. Fire drills are to be held at unexpected times.

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 050

Based on observations as referenced in the Life Safety Report of Survey completed January 5, 2010, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Building 01:
1. Based on observation on 01/05/2010 the following corridor doors were non-compliant, specific findings include:

A. There were deadbolts on the following corridor doors that require a multiple range of motion to exit the room: Pharmacy (room 240), shower room next to room 232, rooms 143, 101 to 105, 107, 109, clean utility (room 149G), nourishment room (149F), lab (62F), clean utility (151), nourishment room (150), surgical services manager's office. 42 CFR 483.70(a)

B. The positive latching device on the nurses lounge across from room 117 did not function properly. 42 CFR 483.70(a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 018

2. Based on observation on 01/05/2010 there was storage blocking the sprinkler heads in the Med. Supply Room and the closet in the conference room on the second floor. 42 CFR 483.70 (a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 056

3. A) Based on observation on 01/05/2010 there were wall mounted charting cabinets on the 100 hall that did not retract. 42 CFR 483.70 (a)

B) Based on observation on 01/05/2010 there was a temporary dust wall in the corridor on the second floor. This temp. wall had reduced the width of the egress corridor from eight (8) feet to four feet six inches(4 feet-6 inches). This wall is approximately thirty (30) feet long. 42 CFR 483.70 (a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 072

4. Based on observation on 01/05/2010 there were unsecured 02 cylinders in the 02 storage room near the ambulance entrance. 42 CFR 483.70 (a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 076

5. Based on observation on 01/05/2010 the 02 alarm on the second floor could not be tested (shut off valve could not be located). 42 CFR 483.70 (a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 077

Based on observations as referenced in the Life Safety Report of Survey completed January 5, 2010, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Building 01:
Based on observation on 1/5/2010 at approximately noon the following exit discharge illumination was observed as noncompliant: specific findings include only one bulb fixtures at the east exit near the equipment room. 42 CFR 483.70(a)

~ Cross refer to NFPA 101 Life Safety Code Standard - Tag K 045

Based on review of hospital policy, observations, and staff interview the hospital failed to ensure appropriate food handling procedures were followed.

Findings include:

Hospital policy which is undated, entitled "Cooked Leftovers & Partially Used and/or Opened Food Items" states under II. Procedure: ...2. "Proper storage of leftovers is essential and shall be performed as follows:" "a. Label/Date all leftovers. b. All partially used and/or opened Food Items will be labeled with an Opened Date and a Use By Date." Under "Storage of Perishable Food Items" 5. "Left over foods should not be mixed with fresh foods. Left over foods are dated and labeled and discarded after 3 days."

During the Dietary Department tour on 1/5/2010 at 1130 it was observed that in Refrigerator #2 opened containers of Pineapple topping, chicken, cherries, beets, chocolate pudding, and jello were present with no opened date or use by date on the containers. Refrigerator #1 was observed to have open containers of Fresh Salad, Potatoes Salad, Turkey lunch meat, cole slaw, Dill Relish, Mayonnaise, Dill Pickles, Ham lunch meat dated 12/8/2009, and Cubed Cheese dated 12/18/2009.

During this tour on 1/5/2010 at 1200, the Dietary Department manager confirmed these findings and indicated these items had not been dated per policy and were removed for disposal at the time of the tour.

Based on review of facility policies and procedures, closed medical record reviews and staff interviews, the facility nursing staff failed to ensure ongoing reassessments of patients following pharmaceutical (medication) interventions for: pain in 3 of 6 surgical patients (#14, #15, #11), and pain and blood pressure control in 1 of 6 emergency department patients reviewed (#1).

The findings include:

Review of the facilities "Pain Management" policy, effective 11/08, revealed, that "If the patient has pain, additional assessment data will be obtained." The policy stated that the assessment data will include, "intensity (0-10) utilizing the appropriate age specific pain scale and "an ongoing evaluation will occur with each separate pain complaint." Further review of the pain policy revealed "Evaluation: 1. Assess/document the effectiveness of specific intervention. ..." Continued review of the pain policy revealed that the nurse will "reassess the effectiveness of intervention: a.30 minutes after non-pharmacological interventions, b. 60 minutes after po (by mouth) analgesic/narcotic given, c. 30 minutes after IM (intramuscular) analgesic/narcotic given, d. 15-30 minutes after IV (intravenous) analgesic/narcotic given". The policy further indicated that the evaluation will include documentation of the effectiveness of the pain management intervention.

1. Closed record review of Patient #14 revealed a 49 year-old female admitted to the facility on 12/7/2009 for a hysterectomy (surgical removal of uterus). Record review revealed the administration of two Percocet (narcotic pain medication) tablets by mouth at 2215 on 12/7/2009. Review of the post-operative order revealed that one Percocet tablet was ordered every 6 hours by mouth as needed for mild pain and two Percocet tablets were ordered every 6 hours by mouth as needed for moderate to severe pain. Further examination of the record revealed the nurse did not document a pain score for this patient either before or after the administration of the medication in the nursing notes or the pain-assessment section of the record. Review of the nurse's documentation did not identify the patient's level of pain to indicate the need for 2 tablets versus the need for 1 tablet. Record review also revealed the administration of 1 Percocet tablet by mouth at 0945 on 12/8/2009. Further review of the nurse's notes dated 12/08/2009 at 0750 and 1130 revealed the nurse failed to document that the patient complained of pain, was assessed for pain prior to the administration of medication or that the patient was reassessed after the administration of pain medication.

Interview on 1/7/2010 at 0935 with administrative nursing staff revealed that the "Pain Management" policy required the use of a scale, stating, "...you have to define the patient's complaint." Interview confirmed the nurse "did not use the scale."

Interview on 01/07/2010 at 0935 with administrative nursing staff revealed the nurse should reassess the patient's pain level within 1 hour after administration of an oral pain medication. Interview confirmed Patient #14 received 1 Percocet on 12/08/2009 at 0945 and the nurse did not reassess the patient's pain level. Interview revealed the nurse did not follow the hospital's policy for reassessment of pain.


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2. Closed record review of Patient #15 revealed a 37 year-old admitted 12/21/2009 with abdominal pain. Record review revealed Patient #15 had an appendectomy on 12/22/2009. Review of the physician's orders dated 12/22/2009 at 1200 revealed "...Morphine Sulfate 6 mg (milligrams) IVP (intravenous push) every 2 hrs (hours) prn (as needed) pain...". Review of the medication administration record revealed Patient #15 was administered Morphine Sulfate 6 mg IVP at 1545 on 12/22/2009. Record review revealed no documentation that the patient's pain level was reassessed following the pain medication intervention.

Interview on 01/07/2010 at 0935 with administrative nursing staff revealed the nurse should reassess the patient's pain level within 30 minutes after administration of an intravenous pain medication. Interview confirmed Patient #15 received Morphine Sulfate 6 mg IV on 12/22/2009 at 1545 and the nurse did not reassess the patient's pain level. Interview revealed the nurse did not follow the hospital's policy for reassessment of pain.

3. Closed record review of Patient #11 revealed a 27 year-old admitted with an ectopic pregnancy on 07/30/2009. Record review revealed the patient had a left partial salpingectomy (removal of fallopian tube). Record review revealed a physician's order dated 07/31/2009 at 0735 "...Percocet 1 tablet PO (by mouth) q (every) 6 hours PRN (as needed) Mild Pain...Percocet 2 tablets PO q 6 hours PRN Moderate-Severe Pain...". Record review revealed Patient #11 received Percocet 2 tablets at 1100 on 07/31/2009. Record review revealed no assessment of the patient's pain level prior to the administration of the medication and no reassessment of the patient's pain level following the pain medication intervention.

Interview on 01/07/2010 at 0935 with administrative nursing staff revealed the nurse should assess the patient's pain level using the pain scale prior to the administration of pain medication and should reassess the patient's pain level within one hour after administration of an oral pain medication. Interview confirmed Patient #11 received two Percocet tablets on 07/31/2009 at 1100 and the nurse did not assess the patient's pain level prior to the administration of the medication and did not reassess the patient's pain level. Interview revealed the nurse did not follow the hospital's policy for pain assessment/reassessment.



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4. Medical record review of patient #1 revealed a 30 year-old that presented to the emergency department (ED) on 01/01/2010 at 1756 with a chief complaint of "headache" at a pain level of 10/10, with 10 being the strongest. Record review revealed documentation of blood pressure in triage as 167/105. Record review revealed a prior medical history of hypertension. Record review revealed the ED provider ordered Labetalol (anti-hypertensive medication) 100 mg (milligrams) by mouth at 1859 for elevated blood pressure. Record review revealed the patient was discharged 6 minutes later at 1905 in "stable" condition. Record review revealed no reassessment of headache pain or response from the Labetalol prior to discharge. Record review revealed the patient's blood pressure at discharge was 188/103 (higher than triage B/P).

Interview with ED nursing management on 01/07/2010 at 0915 revealed, it is the expectation for the nursing staff to re-evaluate abnormal vital signs (temperature, pulse, respiration, and blood pressure). Interview revealed it is the expectation for patients to be reassessed for vital signs and pain level prior to/or at the time of discharge. Interview revealed it is the expectation of the nursing staff to re-evaluate patients after the administration of medications for effectiveness. Interview revealed patient #1's blood pressure was elevated at triage. Further interview revealed the patients blood pressure was reassessed at discharge. Interview revealed the patients blood pressure was higher at discharge, than upon arrival. Interview revealed the nurse should have notified the physician of the increased blood pressure. Interview revealed the patient was administered Labetalol at 1859. Interview revealed the patient was discharged 6 minutes later at 1905. Interview revealed the patient should have been reassessed for effectiveness of the medication prior to being discharged. Interview revealed 6 minutes is not an acceptable time period for reassessment for effectiveness of an oral medication. Interview revealed "the nurse should have waited at a minimum of 20 minutes." Further interview revealed no available documentation of a pain reassessment performed at the time of discharge. Interview confirmed the nursing staff failed to reassess a patient for pain and the effectiveness of a medication before discharge.