HospitalInspections.org

A. Based on review of Medical Staff Bylaws, clinical record review and staff interview, it was determined for 1 of 3 (Pt. #7) clinical record reviewed on 4 East, the Hospital failed to ensure that all patients were seen and evaluated by the admitting physician or consultant within 24 hours.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/5/10 at 11:30 AM. The Bylaws included "...2. Daily Visits: a. All patients will be seen by the attending physician within 24 hours of admission and such visit shall be documented in the progress notes. A progress note must be written every day by the attending physician or his alternate. ... 6. Consultation. b. Consultants are expected to see and examine all patients referred to them and to prepare and sign a formal consultation records of their findings...to be done within 24 hours of consultation".

2. The clinical record of Pt. # 7 was reviewed on 4/5/10 at 9:35 AM. Pt. #7 was a 53 year old female admitted on 4/2/10 at 8:10 PM with the diagnosis of Left Calf Swelling, Rule Out Deep Vein Thrombosis. The clinical record of Pt. #7 lacked a daily progress note from the attending physician or his alternate from 4/2/10 to 4/5/10 at 9:35 AM (61 hours after admission) .

The clinical record of Pt. #7 contained an order dated 4/2/10 at 8:10 PM for a consultation with an Orthopedic physician. The clinical record lacked a consultation report or progress note from the consultant as of 4/5/10 at 9:35 AM (61 hours after consult order written).

3. The above finding was verified with the Nurse Manager of 4 East on 4/5/10 at 11:00 AM, during an interview.

A. Based on review of Hospital policy, observation, clinical record review and staff interview, it was determined that in 1 of 3 (Pt. #1) records reviewed on restraints in 3 East, the Hospital failed to ensure the order for restraints was not written on an as needed basis.

Findings include:

1. The Hospital policy titled "Use of Restraint Policy & Procedure" was reviewed on 4/5/10 at 12:00 PM. The policy required, "PRN/standing orders are not acceptable and are not used to authorize the use of restraints."

2. The 3 East unit was toured on 4/5/10, at approximately 9:00 AM to 9:45 AM. Pt. #1 was observed in room 312-1 wearing mittens around each hand and bilateral soft wrist restraints.

3. The clinical record of Pt. #1 was reviewed on 4/5/10 at approximately 9:45 AM. Pt. #1 was an 85 year old female admitted on 4/1/10 with diagnoses of Chest Pain and Abdominal wall Pain. The clinical record contained an untimed physician order dated 4/3/10 for "Mittens &/or restraints as needed."

4. The above findings were confirmed with the Nurse Manager of 3 East during an interview on 4/5/10 at approximately 10:10 AM.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 3 (Pt. #1) records reviewed, for restraints, the Hospital failed to ensure restraints orders were limited to 24 hours and a renewal was obtained each calendar day.

Findings include:

1. The Hospital policy titled "Use of Restraint Policy & Procedure" was reviewed on 4/5/10 at 12:00 PM. The policy required, "Orders for restraints...are time limited to 24 hours... A renewal order must be obtained each calendar day and entered in the patient's medical record."

2. The 3 East unit was toured on 4/5/10, at approximately 9:00 AM to 9:45 AM. At 9:20 AM, Pt. #1 was observed in room 312-1 wearing mittens around each hand and bilateral soft wrist restraints.

3. The clinical record of Pt. #1 was reviewed on 4/5/10 at approximately 9:45 AM. Pt. #1 was an 85 year old female admitted on 4/1/10 with diagnoses of Chest Pain and Abdominal wall Pain. The clinical record contained an untimed physician order dated 4/3/10 for "Mittens &/or restraints as needed." As of survey date 4/5/10 at 9:45 AM, the record lacked renewal orders for the use of the bilateral wrist restraints after the initial order and application on 4/3/10 at 6:49 PM, a total of 39 hours.

4. The above findings were confirmed with the Nurse Manager of 3 East during an interview on 4/5/10 at approximately 10:10 AM.

A. Based on review of Hospital policy, observation,clinical record review and staff interview, it was determined that in 1 of 3 (Pt. #1) records reviewed for restraints, the Hospital failed to ensure patients in restraints were assessed every 2 hours as required by policy.

Findings include:

1. The Hospital policy titled "Use of Restraint Policy & Procedure" was reviewed on 4/5/10 at 12:00 PM. The policy required, "Procedure...restraint for the physical safety of a non-violent or non self-destructive patient: c. The patient is assessed every two hours while in restraints with attention to patient safety, elimination/hydration/nourishment needs, orientation repositioning...potential for early removal of restraints..."

2. The clinical record of Pt. #1 was reviewed on 4/5/10 at approximately 9:45 AM. Pt. #1 was an 85 year old female admitted on 4/1/10 with diagnoses of Chest Pain and Abdominal wall Pain. The clinical record contained an untimed physician order dated 4/3/10 for "Mittens &/or restraints as needed." The Nursing documentation included initiation of wrist restraints at 6:49 PM and an assessment at 6:50 PM on 4/3/10. The next every 2 hour assessment was at 8:50 AM on 4/4/10 a total of 14 hours without a documented assessment.

3. The above findings were confirmed with the Nurse Manager of 3 East during an interview on 4/5/10 at approximately 10:10 AM.

A. Based on review of the Operator's Guide, observation, a review of the crash cart checklist, and staff interview it was determined that for 3 of 3 (E#s 2, 3 and 4) staff observed on the 5 East Unit, the Hospital failed to ensure staff were knowledgeable concerning the proper procedure for checking the defibrillator.

Findings include:

1. The Zoll PD 1400 Pacemaker/Defibrillator Operator's Guide was reviewed on 4/5/10 at approximately 1:00 P.M. The guide required, "Delivered Energy and Discharge Buttons Check... Turn the selector switch to DEFIB ON. Set the defibrillator energy level to 100 joules... Verify that the adult paddle... is installed... leaving the paddles in their holders... press either charge button. Wait for the charge ready tone to sound and verify that the energy ready value displayed on the monitor registers 100 joules..."

2. On 4/5/10 from approximately 9:00-10:00 A.M. a tour of the 5 East Unit was conducted. Three staff were observed performing the defibrillator check using the adult paddles. Staff #s 3 and 4 required verbal cueing/instruction from E#2. In addition, all three (E#s 2, 3, and 4) failed to perform the defibrillator check in accordance with the operator's guide. Examples included: they failed to ensure the adult paddles were properly installed, hence they could not get the defibrillator to discharge; they failed to leave the paddles in their holders when attempting to discharge them, but rather held them up in the air (potential safety hazard).

3. On 4/5/10 at approximately 10:00 A.M. the crash cart checklist was reviewed. The defibrillator check strip dated 4/5/10 at 6:03 A.M. indicated that the defibrillator was set at 30 joules instead of 100 joules as required by the operator's guide.

4. The above findings were confirmed by the 5 East Nurse Manager, on 4/5/10 at .approximately 10:00 A.M.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that 4 of 6 (Pt. #1, 2, 6, and 8) clinical records reviewed the Hospital failed to ensure Care plans were updated and individualized, as required by Hospital policy.

Findings include:

1. The Hospital policy titled "Admissions Assessment" was reviewed on 4/5/10 at 12:30 PM. The policy required, "Process Plans...in this screen is where you pull over the care plans. Delete any problems that your patient is not having at time of admission...Add additional problems that may not be on the list. Update care plans as patients condition warrants...."

2. The clinical record of Pt. #1 was reviewed on 4/5/10 at approximately 9:45 AM. Pt. #1 was an 85 year old female admitted on 4/1/10 with diagnoses of Chest Pain and Abdominal wall Pain. The Nursing Care Plan (NCP) included "arrythmia" in the problem list. The clinical record contained a physician order dated 4/3/10 (no time recorded) for an NG (nasogastric) tube, and mittens and/or restraints as needed." The nursing documentation dated 4/3/10 at 6:43 PM indicated an NG tube was inserted and that Pt. #1 was in restraints and mittens due to agitation. The nursing care plan was not updated to include the use of restraints and insertion of the NG tube.

3. The clinical record of Pt. #2 was reviewed on 4/5/10 at approximately 10:25 AM. Pt. #2 was an 85 year old female admitted on 3/15/10 with diagnoses of Fever, and Change in Mental Status. The NCP problem list addressed the infection that resulted in the UTI and Electrolyte imbalance. On 3/27/10 at 7:00 AM, a positive C-diff stool was identified, and Pt. #2 was documented as being on contact precaution at 9:00 AM. The NCP was not updated to include the C-diff infection.

4. The above findings were confirmed with the Nurse Manager of 3 East during an interview on 4/5/10 at approximately 11:20 AM.




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5. The clinical record of Pt. #6 was reviewed on 4/5/10 at 10:00 AM. Pt. #6 was a 38 year old male admitted on 4/1/10 with the diagnosis of Dislodged Gastrostomy Tube. The clinical record included a nurses note dated 4/5/10 that indicated Pt. #6 was bed bound, non verbal with a tracheostomy (requiring intermittent suctioning) and on Parental Nutrition. The Plan of Care dated 4/5/10 lacked inclusion of Pt. #6's tracheostomy care and requirements or Parental Nutrition needs.

6. The clinical record of Pt. #8 was reviewed on 4/5/10 at 10:45 AM. Pt. #8 was a 60 year old female admitted on 4/1/10 with diagnoses of Cerebral Vascular Accident (CVA) and Decubitus ulcer. The clinical record included a nurses note dated 4/2/10 that indicated Pt. #8 was admitted with a sacral decubitus (bed sore). The Plan of Care dated 4/2/10 lacked inclusion of the decubitus ulcer or treatment.

7. The above findings were confirmed with the Nurse Manager of 4 East on 4/5/10 at 11:00 AM, during an interview.

A. Based on clinical record review and staff interview, it was determined that for 1 of 2 (Pt. #4) on 5 East unit and 1 of 2 (Pt. #13) on the Intensive care unit, clinical records reviewed, the Hospital failed to ensure medications were administered in accordance with the physicians's orders.

Findings include:

1. The clinical record for Pt. #4 was reviewed on 4/5/10 at approximately 10:05 A.M. This was a 62-year-old female admitted 3/27/10 with a diagnosis of Neuralgia, Infected Wound Secondary to Herpes Zoster. The record included documentation of a physician's order dated 4/1/10 for Vancomycin 1000 mg IV every 12 hours. The record included documentation of the following administrations:

* 4/1/10 at 7:51 P.M. and 9:49 P.M. (less than 2 hours later)
* 4/2/10 at 10:58 P.M. (more than 24 hours after last documented dose).

2. The above findings were confirmed by the 5 East Nurse Manager, on 4/5/10 at approximately 10:15 A.M.

3. The clinical record for Pt. #13 was reviewed on 4/6/10 at approximately 12:40 P.M. This was a 51-year-old female admitted 3/9/10 with a diagnosis of Respiratory Abnormality. The record included documentation of a physician's order dated 4/1/10 for Vancomycin 1000 mg IV every 48 hours. The record also included documentation of a physician's order dated 4/1/10 at 11:48 A.M. for, "Vancomycin trough before dose tonight; If Vancomycin trough is > 20 then hold dose per... protocol." The record included documentation that the Vancomycin trough for Pt. #13 was 27.8 (goal trough was 15-20) on 4/1/10 at 8:00 P.M. The record also included documentation that the Vancomycin was administered on 4/1/10 at 8:45 P.M.

4. The above findings were confirmed by the Intensive Care Unit Manager, on 4/6/10 at approximately 1:00 P.M.

A. Based on a review of the Hospital's Medical Staff Bylaws, a review of an attestation from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Bylaws were reviewed on 4/7/10 at 2:15 P.M. The Bylaws included, "If, for any reason, the medical record is not complete at the time of discharge, the attending physician will have a grace period, not exceeding thirty (30) days from the date of discharge, to complete the record."

2. The attestation letter from the Manager of Health Information Management was reviewed on 4/7/10 at 2:45 P.M. The letter included that as of survey date 4/7/10, there were 62 incomplete charts greater than 30 days post discharge.

3. The above finding was confirmed with the Manager of Health Information Management during an interview on 4/7/10 at 2:45 P.M.

A. Based on review of Hospital policy, review of the clinical records, and staff interview, it was determined that for 1 of 3 (Pt. #5) clinical records reviewed , the Hospital failed to ensure medications orders were reviewed to ensure completeness and appropriateness of the order.

Findings include:

1. The Hospital's Department of Pharmacy policy titled "Physician Order Review" was reviewed on 4/7/10 at 1:15 PM. The policy required, "The Pharmacist will review the patient profile...The medication order will be reviewed to ensure the order is complete and appropriate... medication order will be reviewed against the patient's medication profile to ensure: -no therapy duplication exist.. IV ...if a problem exists, the pharmacist will initiate an order clarification...."

2. The clinical record of Pt, #5 was reviewed on 4/5/10 at approximately 1:50 PM. Pt. #5 was a 57 year female admitted on 3/31/10, with diagnoses of Chronic Obstructive Pulmonary Disease Exacerbation, Chest Pain, Diabetes, old Hypertension. The clinical record contained an undated, untimed Physician's order with the following: "Admit telemetry...chest pain protocol...Nitrodur 0.4 mg..1/hr & patch daily." On 3/31/10 at 2:20 PM, a second physician order via telephone with the following order: "Nitroglycerin '1"' patch q shift..."

The Medication Administration Record (MAR) included the the following medications:
Nitroglycerin (nitrodur) 0.4 mg/hr patch, QDay
Nitroglycerin (nitrobid) 2% ointment packet, Q 8H

Pharmacy failed to clarify the order with the physician to ascertain which nitroglycerine order to implement (the Patch versus the ointment). As a result nitroglycerin medication therapy was duplicated and was documented as both being given daily from 4/1/10 at 5:00 AM-4/5/10 at 9:00 AM.

3. The Manager of the 3 East Unit was interviewed on 4/5/10 at 2:20 PM. The Manager stated that the orders for medication are read by the pharmacist as written, and are responsible for putting the orders in the computerized MAR. The findings were confirmed by the Manager during the interview.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on April 6 - 7, 2010, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on April 6 - 7, 2010, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 7, 2010.

A. Based on a review of the Medical Equipment Inventory Log and staff interview, it was determined that for 8 of 8 defibrillators (Control #s N 298121, N 308057, N 308058, N 308379, N 298407, N 308378, N 308149, and N 308148), the Hospital failed to ensure performance inspections were performed as required.

Findings include:

1. The Medical Equipment Inventory Log was reviewed on 4/6/10 at approximately 2:30 P.M. The Log included a list of status code definitions, " 12D... Full service 8 hours per day, 5 days per week, with semi-annual PM and Safety Inspections. Includes 100% parts... 14D... Full service 8 hours per day, 5 days per week, with PM and Safety Inspections performed quarterly. Includes 100% parts."

2. The "Schedule A Equipment List" dated 2/4/10 was reviewed on 4/6/10 at approximately 2:30 P.M. The list included documentation that defibrillators have a status of 14D except N 298407 (12D).

3. For 8 of 8 defibrillators, the preventive maintenance Log lacked documentation that the PM and safety inspections were performed as required in 2009.

4. For 3 of 8 defibrillators (N 308379, N 298407, and N 308378) the Log lacked documentation of any PM and safety checks for the defibrillators.

5. The above findings were confirmed with the Director of Quality 4/7/10 at approximately 3:00 P.M.

A. Based on review of Hospital policy, observation, and staff interview, it was determined that in 1 of 2 (E. #1) staff observed in contact precaution rooms, the Hospital failed to ensure adherence to the use of personal protective equipment upon entering the room of a patient on contact precaution, as required by policy.

Findings include:

1. The Hospital policy titled "Isolation Precaution Policy" was reviewed on 4/5/10 at 1:00 PM. The policy required, "Gowns: 1. Contact Precautions-A gown is put on prior to entering the room of a patient on contact precaution."

2. The 3 East unit was toured on 4/5/10, between 9:00 AM and 9:45 AM. At approximately 9:40 AM, an EKG Technician ( E #1) was observed in room 320 preparing to performs an EKG test. The patient in Room 320 was identified as C-diff positive (by the Nurse Manager) and a contact precaution sign was posted at the door. The EKG Technician donned on mask and gloves but did not wear a required gown.

3. The above finding was confirmed with the Nurse Manager of 3 East during an interview on 4/5/10 at approximately 11:20 AM






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B. Based on a review of Hospital policy, observation, clinical record review, and staff interview, it was determined that for 1 of 3 isolation patients on the 5 East Unit, the Hospital failed to ensure an isolation sign was affixed to the door of the patient's room.

Findings include:

1. Hospital policy entitled, "Isolation Precaution Policy," was reviewed on 4/5/10 at approximately 1:00 P.M. The policy requires, "Procedure For Isolation of Patients... A sign is affixed to the door of the patient's room and on the front of the patient's chart."

2. On 4/5/10 from approximately 9:00-10:00 A.M. a tour of the 5 East Unit was conducted. Room 519-1 was identified as having a patient on Contact Isolation, and included an isolation cart outside of the room. There was no Contact Isolation/Precaution sign affixed to the door of the patient's room.

3. On 4/5/10 at approximately 10:05 A.M., the clinical record for Pt. #4 was reviewed. This was a 62-year-old female admitted 3/27/10 with a diagnosis of Neuralgia, Infected Wound Secondary to Herpes Zoster. The record included documentation that the patient
was placed on Contact Isolation on 3/27/10. The record also included in the physician's history and physical exam dated 3/27/10, that Pt. #4 had Herpes Zoster in February 2010.

4. The above findings were confirmed by the 5 East Nurse Manager, on 4/5/10 at approximately 10:15 A.M.


C. Based on a review of Hospital policy, observation and staff interview, it was determined for 1 of 5 (E#9)staff observed in the Intensive Care Unit (ICU) the Hospital failed to ensure staff adherence to the isolation precaution policy.

Findings include:

1. Hospital policy entitled, "Isolation Precaution Policy," was reviewed on 4/5/10 at approximately 1:00 P.M. The policy requires, "A gown is put on prior to entering the room of a patient on Contact Precautions... Gloves are removed .... and discarded in the appropriate trash container... Hands are washed immediately..."

2. On 4/6/10 at approximately 1:30 P.M., E#9 donned a gown, a mask, and gloves and entered ICU-3 (Contact Isolation affixed to the door) to examine the patient. After a period of time, E#9 exited the room wearing the above personal protective equipment, and proceeded to walk around the unit to the front of ICU-7 requesting staff assistance. E#9 then walked into the nursing station and placed the flashlight onto the nursing station desk without first disinfecting the flashlight.

3. The above findings were confirmed by the Intensive Care Unit Manager, on 4/6/10 at approximately 1:30 P.M.


D. Based on a review of manufacturer's directions for use, observation, and staff interview, it was determined that for 2 of 2 staff interviewed, (E#5 and E#11), the Hospital failed to ensure cleaning/disinfecting products were used in accordance with the manufacturer's directions.

Findings include:

1. On 4/6/10 at approximately 8:45 A.M. a tour of the Clean Up Room ( surgical instruments precleaned room) was conducted. The MetriClean 2 (multipurpose instrument cleaner) included manufacturer's directions for use that required 1 ounce to 1 gallon of water for manual cleaning of instruments.

2. No measuring devices were available for 1 ounce or 1 gallon measuring the solution or the water.

3. On 4/6/10 at approximately 8:52 A.M. in an interview with E#5 (surgical tech), E#5 stated that he adds "3 pumps of MetriClean 2 to this much water". E#5 pointed to a position inside the sink, although there was no marked level. E#5 confirmed that he does not use measuring devices.

4. The above findings were confirmed and discussed with E#7 (Nurse Manager of Surgery) on 4/6/10 at approximately 11:00 A.M.

5. On 4/7/10 at approximately 12:45 P.M., the mammography room in the Radiology Department was toured. M-Spray 2000 (neutral disinfectant) was available for use. The manufacturer's directions required that the equipment surface be sprayed, and a wet contact time of 10 minutes be maintained.

6. An interview was conducted on 4/7/10 at approximately 12:45 P.M. with E#11 (mammographer) who stated that she uses M-Spray 2000 when patients have infections and open wounds. E#11 stated that she does not spray the equipment but sprays the disinfectant on a cloth and wipes it dry. E#11 further stated that there is no particular wet contact time required.

7. The above findings were confirmed with the Director of Radiology on 4/7/10 at approximately 12:45 P.M.

A. Based on a review of Hospital policy clinical record review and staff interview, it was determined that for 2 of 2 (Pt. #4 and #12) clinical records reviewed on th 5 East Unit the Hospital failed to ensure the Functional Assessment was completed during the admission process.

Findings include:

1. Hospital policy entitled, "Discharge Planning," was reviewed on 4/5/10 at approximately 1:45 P.M. The policy requires "The Functional Assessment Form is completed during the admission process which includes Discharge planning."

2. The clinical record for Pt. #4 was reviewed on 4/5/10 at approximately 10:05 A.M. This was a 62-year-old female admitted 3/27/10 with a diagnosis of Neuralgia, Infected Wound Secondary to Herpes Zoster. The admission assessment dated 3/27/10 failed to include documentation of a completed functional assessment for: physical therapy, speech therapy, social service needs and potential resources which triggers appropriate disciplines/departments for discharge planning.

3. The clinical record for Pt. #12 was reviewed on 4/5/10 at approximately 2:20 P.M. This was an 89-year-old female admitted 4/3/10 with diagnoses of Dysphasia/Dehydration. The admission assessment dated 4/3/10 at 5:10 P.M. failed to include documentation of a completed functional assessment for: physical therapy, speech therapy, social service needs and potential resources which triggers appropriate disciplines/departments for discharge planning.

4. The above findings were confirmed by the Intensive Care Unit Manager, on 4/6/10 at approximately 1:00 P.M.

A. Based on a review of Hospital policy, a review of sterilizer logs, and staff interview, it was determined that for 2 of 2 (Sterilizer A and Sterilizer B) sterilizers in Surgery, the Hospital failed to ensure that quality control parameters for the sterilizers included performance of the Bowie Dick type test for residual air.

Findings include:

1. Hospital policy entitled, "Recommend Practices for Steam Sterilization," was reviewed on 4/6/10 at approximately 11:30 A.M. The policy requires, "Quality control parameters for the sterilization process should include... Residual - air (Bowie Dick type) testing of pre vacuum sterilizers."

2. Hospital policy entitled, "Sterilization Assurance For O.R.," was reviewed on 4/6/10 at approximately 11:30 A.M. The policy requires, "Temperature wheels are changed at 7 am daily and kept in a file with the results of the A time and temperature strip must be run with each flash sterilization load, and checked for a uniform color change when the cycle is finished."

3. The sterilizer logs were reviewed on 4/6/10 at approximately 11:00 A.M., for October 2009-March 2010. The logs lacked documentation that the Bowie Dick type test for residual air, the temperature wheel, and time and temperature slip had been performed on Sterilizers A & B.

4. The log for sterilizer A included documentation that a load was sterilized on 11/23/09 and included a laparoscopy camera. The log lacked documentation that the appropriate temperature and time ranges for the sterilizer had been achieved for sterilization of the load.

5. In an interview with E#8 (surgery tech), E#8 stated that the recorders (records exposure temperature and time) are broken on both of the sterilizers (Sterilizer A since since 10/8/09, and Sterilizer B since 3/3/10) . E#8 also stated that the Bowie Dick tests are not being performed .

6. The above findings were confirmed with E#7 (Nurse Manager of Surgery) on 4/6/10 at approximately 11:30 A.M.

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 1 ventilators that the Hospital failed to ensure equipment were labeled for appropriate disinfection.

Findings include:

1. The Hospital policy titled "Infection Control for Aids Patient" was reviewed on 4/7/10 at 1:50 PM. The policy required, Ventilator circuits and other disposable equipment should be bagged before leaving the room... all reusable items should be washed separately...rinsed thoroughly-soaked in bleach for 20 minutes...."

2. The Respiratory services was toured on 4/7/10 between 1:00 PM and 2:00 PM. The dirty utility room, an area used to clean equipment such as ventilators, was inspected at 1:15 PM. A ventilator with a label "isolation 4/7/10" was identified (by the Director of Respiratory) as a ventilator used by a patient in ICU room 2, and awaiting cleaning and disinfection. The ventilator was not labeled as having been used by a patient with HIV.

3. The respiratory care record for Pt. #25 was reviewed on 4/7/10 at 1:40 PM. Pt. #25 was a 51 year old female, admitted on 3/9/10 with diagnoses of Respiratory Failure, Pneumonia, and HIV.

4. The Respiratory Care Director was interviewed on 4/7/10 during the tour between 1:00 and 2:00 PM. The Director stated that the ventilator cleaning process for normal use, is different from isolation use which require a 2 process cleaning and 24 hours, and use with HIV patient, which requires use of bleach washing. The Director confirmed the ventilator was not labeled appropriately for cleaning. The above findings were confirmed with the Director during interview.