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Based on observation and interview, it was determined 15 of 30 pieces of patient care equipment were overdue for preventative maintenance. The failed practice had the potential to affect all patients admitted for surgery because the safe condition and operation of the equipment was not assured. The findings follow:

A. On a tour of the Surgery Department and Ambulatory Surgery Center on 06/24/14 at 1300 the following pieces of patient care equipment were observed with overdue inspection stickers:
1) Equipment ID# 8916, due April 2014.
2) Equipment ID# 9249, due April 2014.
3) Equipment ID# 6978, due April 2014.
4) Equipment ID# 6327, due April 2014.
5) Equipment ID# 3124, due April 2014.
B. On a building tour on 06/25/14 at 0930 with the Plant Operations Director, the following pieces of patient care equipment were observed with overdue inspection stickers:
1) Equipment ID# 6412, due January 2013.
2) Equipment ID# 1617, due January 2013.
3) Equipment ID# 1460, due January 2013.
4) Equipment ID# 6588, inspection sticker could not be located.
5) Equipment ID# 1758, due April 2014.
6) Equipment ID# 21893 due April 2014.
7) Equipment ID# 8231, due April 2014.
8) Equipment ID# 9127, due January 2014.
9) Equipment ID# 41824, due January 2014.
10) Equipment ID# 2892, due January 2014.
C. In an interview on 06/25/14 at 0930, the Biomedical Director verified the pieces of equipment were overdue for preventative maintenance and he was behind in the inspection schedule for some departments.

Based on observations and interview, it was determined the facility failed to ensure two of two infant warmers were kept in good repair in that the covering was ripped exposing the cushion underneath. Failure to ensure patient care equipment was not torn or ripped did not allow the facility to ensure the cleanliness of the equipment. The failed practice affected any patient utilizing the equipment. Findings follow:

A. During a tour of the Obstetrics (OB)/Operating Room (OR) on 06/25/14 at 0845, an infant warmer was observed to have three of four corners of the cushion ripped. The findings were verified by the OB Clinical Manager at 0845 on 06/25/14.
B. During the tour of the Isolation Nursery Room on 06/25/14 at 0900, an infant warmer was observed to have three of four corners of the cushion ripped. The findings were verified by the OB Manager at 0900 on 06/25/14.


30634

Based on observation and interview, it was determined the facility failed to ensure six (Orange 1, Orange 2, Green 1, Green 2, Blue 1 and Blue 2) of seven microwaves located in patient nourishment areas were free of stains and residue. The failed practice created the potential for food items to become contaminated and could affect any patient receiving food that had been in the microwave. Findings follow.

A. During a tour of the 4th floor on 06/25/14 from 0940 to 1000, microwaves in the following nourishment areas contained stains, crumbs, and residue: Orange 1, Orange 2, Green 1, Green 2, Blue 1 and Blue 2.
B. Review of policy titled "Cleaning Procedures" was not specific as to who was responsible for cleaning the microwaves. When asked who was responsible, the Medical/Surgical Director stated "housekeeping."
C. Findings were confirmed by the Medical/Surgical Director and the Food and Nutrition Services Director at the time of the tour.


31039

Based on observation, review of policies, review of cleaning lists for the hydrocollators and interview, it was determined the facility failed to clean the hydrocollators on a monthly basis (per policy) in two (inpatient and outpatient) of two rehabilitation gyms toured and had torn treatment table mats that were unable to be thoroughly cleaned to prevent cross contamination between patients in one (outpatient) of two (inpatient and outpatient) rehabilitation gyms toured. By not cleaning the hydrocollators per policy and maintaining treatment table mats in a condition that allowed them to be thoroughly cleaned, the facility could not assure a sanitary environment when patients used these items. The failed practice had the likelihood to affect all rehabilitation patients who received therapy on one of the torn treatment table mats or received hot pack therapy. Findings follow:

A. During a tour of the outpatient rehabilitation gym on 6/25/14 between 1230 and 1330, three of the four treatment table mats had tears in them. One table had five rips, one table had two rips and one table had one rip in it.
B. Review of policy titled "Rehabilitation Therapy General Procedures for Infection Control" (same for inpatient and outpatient) revealed the following: "Commercial Hot Packs: The machines are drained and cleaned with cleaner/disinfectant and rinsed every month."
C. Review of cleaning lists revealed the months the hydrocollators missed a cleaning in the previous 12 months (July 2013-May 2014):
1) Outpatient Whitehall Hydrocollator: July, November and December 2013;
2) Outpatient Chattanooga Hydrocollator: July, November, and December 2013 and May 2014; and
3) Inpatient Chattanooga Hydrocollator: June, August, September, November, and December 2013 and March, April and May 2014.
D. Outpatient findings were verified through interview with Outpatient Physical Therapist #1 on 6/25/14 at 1300. Inpatient findings were verified through interview on 6/25/14 at 1445 with the Inpatient Rehabilitation Technician.

Based on review of the Agreement between the (named eye bank) Laboratory and the facility and interview, it was determined the agreement with the named eye bank had expired. By not having a current signed agreement with an eye bank, the facility could not assure that all useable eyes are obtained from potential donors. The failed practice had the likelihood to affect all potential eye donors. Findings follow:

A. Review of the Agreement between the (named eye bank) Laboratory and the facility on 06/25/14 revealed the previous agreement expired on 08/31/2013.
B. Findings were verified through interview, on 06/25/14 at 1418 with the Chief Nursing Officer.

Based on interview and review of the Operating Room (OR) log, it was determined the facility failed to include the required elements in its OR log. Failure to include all required elements in the operating room log did not allow the Facility to track and trend potential problems. Findings follow:

Review of the OR log at 1600 on 06/24/14 revealed the log did not contain the age of the patient. The findings were verified by the OR Meditech Coordinator at 1605 on 06/24/14.

Based on clinical record review and interview, it was determined the opertive report for 12 of 12 ( #4, #7, #21-#26, and #28-#31) did not include the time of the operation. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of the operative report revealed the time of the operation was not documented for the following patients:
1) Patient #4-verified by LPN #1 on 06/27/14 at 1040;
2) Patient #7-verified by the Physician Liaison on 06/26/14 at 1530;
3) Patient #21 and #22-verified by the OR Meditech Coordinator on 06/27/14 at 0945;
4) Patient #23-verified by the OR Meditech Coordinator on 06/27/14 at 0925;
5) Patient #24-verified by the Clinical Informatics Analyst on 06/26/14 at 1515;
6) Patient #25-verified by the Clinical Informatics Analyst on 06/27/14 at 0840;
7) Patient #26-verified by the Clinical Informatics Analyst on 06/27/14 at 0945;
8) Patient #28-verified by the OR Meditech Coordinator on 06/26/14 at 1530;
9) Patient #29-verified by LPN #1 on 06/27/14 at 0835;
10) Patient #30-verified by the OR Meditech Coordinator on 06/26/14 at 1500; and
11) Patient #31-verified by the Clinical Informatics Analyst on 06/27/14 at 1020.

Based on interview and Policy and Procedure Manual review, it was determined the facility failed to develop and implement policy and procedure defining and outlining the actions Respiratory Therapy staff would take in the event of a medication error. The failed practice did not allow staff to be knowledgeable or have protocols available for reference. The failed practice affected all patients receiving Respiratory Therapy services on 06/23/14. Findings follow:

A. Review of the Respiratory Therapy Policy and Procedure Manual at 0900 on 06/26/14 revealed it did not contain a policy or procedure addressing medication errors.
B. During an interview with the Director of Respiratory Therapy at 0945 on 06/26/14 she stated there was not a policy and procedure addressing medication errors for the Respiratory Therapy Department.