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Based on observation and interview, the facility did not construct, install, and maintain the building systems to ensure the life safety to patients. The facility did not have a facility free of life safety deficiencies which could affect all patients, staff, and visitors in 4 of 4 smoke compartments during the survey conducted July 14 to July 16th, 2014.

42 CFR 485.623: Condition of Participation: Physical Plant is NOT MET.

Findings Include:
K-34: Utilities in an exit stair not serving the enclosure
K-56: Sprinkler system not installed per NFPA 13
K-130: Toilet Dispensers within ANSI clear spaces.
Please refer to the specific K-tags for additional details.

The cumulative effects of these environmental deficiencies resulted in the hospital's inability to ensure a safe environment to all occupants, patients, and staff of this facility.

Based on record review, observation and interview, the facility staff failed to follow policy regarding monitoring temperatures of 1 of 1 blanket warmer located in the emergency department. This could potentially affect all the patients receiving care in the emergency department.

Findings include:

Per review of facility policy on 7/15/14 at 12:00 pm, titled Heating IV Fluids, Blood Warmers, and Blankets, policy # 902 & 902E, dated 2/14, stated in part under, 3. Blanket warming cabinets temperatures should not exceed 130 degrees Fahrenheit.

Per observation on 7/14/14 at 2:15 pm in the Emergency Department, in the clean supply room, was a blanket warmer. Note on the door of the blanket warmer stated, " Temperature should be 120-130 degrees Fahrenheit " . Current temperature on the blanket warmers door was displayed at 135 degrees Fahrenheit and a daily temperature log hanging on door recorded the daily temperatures of the blanket warmer. Dates 7/1/14 - 7/14/14 were listed with temperatures ranging from 133-139 degrees Fahrenheit.

Per interview on 7/14/14 at 2:15 pm, PCM D stated that the current temperature and the temperatures listed on the blanket warmer daily temperature log for the month were out of acceptable parameters.

Based on observation and interview, the facility did not construct, install, and maintain the building systems to ensure the life safety to patients. The facility did not have a facility free of life safety deficiencies which could affect all patients, staff, and visitors in 4 of 4 smoke compartments during the survey conducted July 14 to July 16th, 2014.

42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is NOT MET.

Findings Include:
K-34: Utilities in an exit stair not serving the enclosure
K-56: Sprinkler system not installed per NFPA 13
K-130: Toilet Dispensers within ANSI clear spaces.
Please refer to the specific K-tags for additional details.

The cumulative effects of these environmental deficiencies resulted in the hospital's inability to ensure a safe environment to all occupants, patients, and staff of this facility.

Based on observation and interview the facility failed to ensure that medications were secured and stored properly in 1 of 3 areas where emergency carts are stored (nursing unit) and 2 of 8 pt. care rooms in ED. This deficiency potentially affects all patients and visitors at this facility.

Findings include:

On 7/15/2014 at 2:40 PM noted an emergency cart containing medications stored in an alcove/hallway connecting the two patient wings. This emergency cart has a breakaway lock. Per interview with Patient Care Manager B staff are not always in view to observe the integrity of the cart contents potentially leaving patients and visitors with unauthorized access to medications.

On 7/15/14 at 1:45 pm during a tour of the emergency department the following opened and undated supplies were found in room 6; 1 container of 1000 ml of sterile water, 1-4 oz. bottle of hydrogen peroxide, 2-4 oz. containers of prep solution. In room 5 the following supplies were found opened and undated; 3-4 oz. containers of prep solution and 1 container of 500 mls. of Sodium Chloride. Per interview with PCM D staff are to discard containers of unused supplies or the containers should be dated.

Based on record review, observation, and interview, the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection in 4 of 4 pt. care observations (pt. #7, 9, 12, and 13) and 2 of 8 pt. care areas observed (surgical department and ED). This failure had the potential to affect all pt's treated at the facility during this survey, 7-14-2014 (10) and 7-15-2014 (7).

Findings include:
Per review of facility policy on 7/15/14 at 12:00 pm, titled Hand Hygiene Requirements, policy # S 509, dated 9/13, the policy stated in part," 2. Decontaminate hands with an alcohol based hand rub before having direct contact with patients, before putting on gloves to perform invasive procedures, after contact with a patient ' s skin, and after gloves are removed."

Per review of facility policy on 7-15-2014 at 2:50 pm, the policy titled, Point of Care Testing for Glucose with the Nova Statstrip, #POC-1 dated 5-23-2013 states in part, (pg 5) " a) Cleaning and disinfecting the exterior surface is performed after each patient and is documented within the meter before accepting a patient result."

Per observation on 7/14/14 at 2:20 pm, PCM D was observed attempting to place an IV in pt. #13. PCM D removed gloves and left room without performing hand hygiene. Then PCM D re-entered room and put on gloves without performing hand hygiene before putting on gloves to attempt procedure again. Findings were shared with DPC A on 7/15/14 at 4:00 pm.

During an interview with Infection Control (IC) RN I on 7/15/14 at 1:45 pm, IC RN I stated that it is expected that staff clean supplies between patient use and the staff are also expected to complete hand hygiene upon entering and exiting patient care rooms and when removing gloves. IC RN I stated that APIC and CDC guidelines are followed for infection prevention.


26390

On 7-15-2014 at 11:15 am RN L was observed in pt. #12's room performing a blood glucose check. RN L entered the room and put on a pair of gloves without performing HH. After checking pt. #12's blood glucose RN L removed gloves, took the meter and went to the nurse's station and then to room #121 with the meter, put on gloves and proceeded to check pt. #9's blood glucose. No HH or cleaning of the glucose meter was performed.

During an interview with FM C on 7/15/14 at 8:15 am, FM C stated the 3M twist and fill automated dispenser is used to mix cleaning chemicals. FM C stated that chemical indicator strips are available to test the concentration of the cleaning chemical, however this facility has not incorporated the use of the strips.
On 7-15-2014 at 12:10 pm RN K was observed in pt. #7's room performing a dressing change. RN K put on gloves to remove the soiled dressing, removed gloves and disposed of soiled dressing and gloves, put on clean gloves without performing HH. RN K cleansed the wound and removed gloves then disposed of gloves and put on a clean pair without performing HH.


32670

On 7/14/2014 at 1:45 pm during a observation of the surgical department, clean scopes are stored in a vented cabinet inside the dirty utility room. Per interview with Manager of Surgical Services E, agreed the current placement of the scope storage cabinet does not provide separation of clean items from dirty items and would need to be moved. Per Dir of Pt Care and Operations A, this facility does not have a policy on scope storage.

Based on observation and record review the hospital failed to follow proper food storage precautions in 1 of 1 kitchen observation and 1 of 1 policy review. This failure has the potential to affect all inpatients at the hospital during the survey, 7-14-2014 (10) and 7-15-2014 (7).

Findings include:

On 7-15-2014 at 1:30 pm a review of the policy titled Food and Nutrition Services, dated 1/01 was completed. The policy states in part, "Dry Storage: 2. All opened foods will be kept in containers that prevent contamination and absorption of humidity. Such containers will be clearly labeled with common name of food, date opened, and use by date."

On 7-14-2014 at 1:45 pm a observation of the dry storage area of the kitchen was completed with DL M. Ten pre-made pie crusts were observed in a box with the wrapping torn open, 2 open bags of pasta with no date, a bag of potato chips open with no date or outer wrapping and a bag of open chips dated 3-11.

Based on record review the facility failed to ensure all verbal orders (VO) and telephone orders (TO) are signed, dated by physician within 48 hours in 2 of 20 records reviewed (pt. #3 & 11). This failure has the potential to affect all inpatients at the hospital during the survey, 7-14-2014 (10) and 7-15-2014 (7).

Findings include:

On 7-14-2014 at 3:00 pm a review of the Bylaws of The Medical Staff, dated revised 6/13/14 was completed. Page 5 states in part, "Verbal orders Telephone orders - Completion time - within 48 hours after order. Components required - legible, signed, dated and timed."

On 7-15-2014 at 10:45 am a review of pt. #3's record was completed. VO's dated 7-10-2014 at 9:00 am and 7-10-2014 at 9:20 am are without physician signatures. TO's dated 7-9-2014 at 9:50 am and 5:50 pm are signed with no date or time next to physicians signature.


32670

Per review of Pt # 11's MR on 7/15/2014 at 1:30 pm accompanied by Case Manager G, noted telephone orders dated 7/6/14 at 11:55 pm that were not authenticated by the physician. A second order dated 7/12/2014 at 6:30 pm was not authenticated by the physician.

Based on record review and interview, the facility staff failed to complete a physical assessment in 1 of 2 sexual assault patient's record (pt. #4) reviewed in a total of 20 records reviewed. This deficiency has the potential to affect all patients treated in the emergency department.
Findings include:
Per review of facility policy on 7/15/14 at 12:00 pm, titled Emergency Department Unit Standards, policy # 1.01E, dated 5/14, stated in part under, II. It is our goal that patients entering the Emergency Department shall have an accurate and ongoing assessment of physical and psychosocial needs.
Per review of pt. #4's MR with CAA H on 7/15/14 at 10:00 am indicated a 15 year old who presented to ED for an exam following a sexual assault. Documentation indicated physician orders for tests to be performed, medications and discharge orders. Physician documentation does not indicate a physical exam.
During an interview with DPC A on 7/15/14 at 2:20 pm, DPC A stated that a medical exam was not present in pt. #4 ' s MR and that physicians are expected to complete a physical exam of all patients.

Based on record review and interview, the facility failed to document swing bed patients' attendance, interventions and response to swing bed activities program in 3 of 3 swing bed records reviewed (# 10, 11, 12) out of a total of 20 records reviewed. This deficiency has the potential to affect all three swing bed patients receiving care at this facility during this survey.

Findings include:

Per review on 7/15/2014 at 10:00 AM of facility policy titled "Recreational Activities - - Swing Bed it states "Activities will be documented daily by all staff. Documentation will be in the interdisciplinary care plan and in progress notes."

Per review of Swing Bed Pt # 10's MR on 7/15/2014 at 2:00 PM accompanied by Case Manager G, the MR does not contain documentation of activities attended or offered to Pt #10 or any response to activity interventions.

Per review of Swing Bed Pt #11's MR on 7/15/2014 at 1:30 PM accompanied by Case Manger G, the MR does not contain documentation of activities attended or offered to Pt #11 or any response to activity interventions.

Per review of Swing Bed Pt #12's MR on 7/15/2014 at 1:00 PM accompanied by Case Manger G, the MR does not contain documentation of activities attended or offered to Pt #12 or any response to activity interventions.

Per interview on 7/15/2014 at 11:00 AM with Case Manager G, each patient is given an activities list during the initial activities assessment. At this time staff do not chart activities attended, the patients response or outcomes to activities in the MR.