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Based on observations as referenced in the Life Safety Report of Survey completed 02/10/2012, 2004 ANSI/AAMI standards for hemodialysis, hemodialysis logs, observations during tour, patient grievance file review, review of policy and procedures, medical records, manufacturer's guidelines, the Center's for Disease Control (CDC) documents review, review of family education information and staff interviews, the hospital failed to have an effective governing body responsible for the functions of the hospital.

Findings include:

1. The hospital failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross-refer to 482.41 Physical Environment - Condition Tag A0700.

2. The hospital failed to protect and promote patients' rights.

~cross-refer to 482.13 Patient Rights - Condition Tag A0115.

3. The hospital failed to provide an organized nursing service.

~cross-refer to 482.23 Nursing Services - Condition Tag A0385.

3. The hospital failed to provide a sanitary environment to avoid sources and potential transmission of infections and communicable diseases.

~cross-refer to 482.42 Infection Control - Condition Tag A0747.

Based on review of facility policies and procedures, 2004 ANSI/AAMI standards for hemodialysis, hemodialysis logs, observations during tour , patient grievance file review and staff interview the hospital failed to protect and promote patients' rights.

Findings include:

1. Hospital staff failed to ensure provision of a safe environment of care by failing to ensure: A. water testing for chlorine and chloramine levels in hemodialysis was per the manufacturer's specifications; B. patients during the hemodialysis treatment were in view of staff; C. dialysate modified from the original concentration per physician's order was labeled with the patient identifiers; D. policies for water culture action levels were per standards of practice; and, E. a schematic of normal operating valve positions was posted in the water treatment room.

~cross-refer to 482.13(c)(2) Patient Rights: Care in Safe Setting - Standard Tag A0144.

2. Hospital nursing staff failed to monitor a patient for a chemical restraint every 15 minutes in 2 of 3 patients chemically restrained ( #12 and #13).

~cross-refer to 482.13(e)(1)(i)(B) Patient Rights: Restraint or Seclusion - Standard Tag A0160.

3. Hospital nursing staff failed to use the least restrictive intervention in 1 of 3 patients chemically restrained ( #11).

~cross-refer to 482.13(e)(3) Patient Rights: Restraint or Seclusion - Standard Tag A0165.

4. Hospital staff failed to provide written notice in its resolution, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in 1 of 2 grievance files reviewed (Grievance file #52).

~cross-refer to 482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision - Standard Tag A0123.

Based on policy and procedure review, patient grievance file review and staff interview the hospital staff failed to provide written notice in its resolution, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in 1 of 2 grievance files reviewed (Grievance file #52).

Findings include:

Review of policy 127.00 reviewed 1/12 by hospital staff entitled "Complaint Management System" revealed "Grievances ...The Grievance Committee will send a " second Written Response to the complainant, setting forth the steps taken to investigate the grievance, the results of the grievance process and the date of completion. The second written response will normally be sent within twenty-one (21) days of receiving the grievance. For grievances referred to Legal services, the second written response may be withheld or delayed, based on advice of counsel.

Review of Grievance file #52 reveled a patient filed a complaint on 10/18/2011. Review of the file revealed the concerns were related to care received after admission to the hospital on 10/12/2011. File review revealed written documentation on 10/21/2011 of a letter to the patient " response to the concern about your care ...follow up with conclusions " . Review of the letter revealed no documentation of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

Interview with Critical Care Director and Risk Management/Patient Safety administrative staff on 2/9/2012 at 1205 revealed the written resolution response to the complainant for Grievance file #52 did not contain all the elements as required per regulation and the hospital policy. The interview revealed the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion were not contained in the letter to the complainant.

Based on review of facility policies and procedures, 2004 ANSI/AAMI standards for hemodialysis, hemodialysis logs, observations during tour and staff interviews, staff failed to ensure provision of a safe environment of care by failing to ensure: A. water testing for chlorine and chloramine levels in hemodialysis was per the manufacturer's specifications; B. patients during the hemodialysis treatment were in view of staff; C. dialysate modified from the original concentration per physician's order was labeled with the patient identifiers; D. policies for water culture action levels were per standards of practice; and, E. a schematic of normal operating valve positions was posted in the water treatment room.

Findings include:

A. Review on 02/08/2012 of "K100-0118 and K100-0118F Ultra-Low Total Chlorine Test Strips Instructions for Use" (no date) revealed "WARNING - Levels of chloramines and free chlorine in dialysis water greater than the AAMI/ANSI maximum allowable levels...may cause severe injury or death to dialysis patients. Failure to follow instructions for use...may result in inaccurate test results. Important Tips for Using the E-Z Chek Sensitive and Ultra-Low Total Chlorine Test Strips...2) For every test, use a stop watch or second hand of a clock/watch to make sure the dip/swish time and wait time called for in the IFUs (instructions for use) is correct..." Further review revealed "Test Procedure...2) Remove one test strip from its foil package and dip it in the sample for 20 seconds. Important Note: The 20 second dip time is for a test sample at approximate room temperature 72-80 (degrees Fahrenheit) or warmer (93 degrees Fahrenheit max)...While dipping the strip, move it back and forth...3) Remove the strip and shake once, briskly, to remove excess water. 4) Wait 20 seconds for the test strip color to develop..."
Observation during tour on 02/08/2012 at 1045 of the water treatment area of the facility's hemodialysis (HD) unit revealed the HD staff member collected a water sample for chlorine and chloramine testing, dipped the strip in the water sample and moved the strip back and forth in the sample took the strip out of the sample and took a reading immediately after one brisk shake of the strip. Observation revealed no timer or clock with a second-hand in the area during the performance of the test. Interview during the observation revealed the staff member was counting to herself and had no timer in the area. Further interview revealed the staff member always took the reading immediately after and did not wait the 20 second wait period. Interview revealed staff failed to follow manufacturer's specifications by failing to use a timer during the performance of the test and failed to wait the specified amount of time before reading the result of the chlorine/chloramine level. Observation revealed by not waiting the specified amount of time for the color to develop with the strips, the readings of the chlorine/chloramine levels could potentially be falsely negative.
B. Review on 02/08/2012 of facility policy "Hemodialysis Plan for Providing Care/Services" dated 05/2010 revealed "III. Care Delivery - A. Modality...The RN (Registered Nurse) will remain in visual contact with the patients at all times."
Observation during tour of the facility's hemodialysis unit on 02/08/2012 at 1155 revealed there were three patients present in the 7-bay unit with one staff present, a RN. Observation revealed Patient #4 requested a medication for pain. Observation revealed the RN went into the medication room, behind a closed door and out of sight of the patients, to retrieve the medication. Interview with the RN at 1205 revealed the staff is by herself "most of the time" and has to leave the patients unattended and out of visual sight to retrieve medications and to perform water testing. Observation revealed the water room was within the unit, but away from the treatment area and out of visual and auditory sight of the patients.
Interview on 02/08/2012 at 1235 with an HD RN during observation of a portable HD treatment in the CCU revealed the staff will on occasion dialyze two patients at a time in the critical care areas. Interview revealed "the patients are not always in my sight, we try to put them in rooms close together".
Interview with administrative staff on 02/08/2012 at 1300 revealed the staff had not recognized the visualization of the patients as a safety issue. Interview revealed "We need to take a look at how we can fix this".
C. Review on 02/08/2012 of "American National Standard for Dialysate in Hemodialysis" (ANSI) dated 2004 by the Association for the Advancement of Medical Instrumentation (AAMI) revealed "6.4.2 Additives...When additives are prescribed for a specific patient, the container holding the prescribed acid concentrate should be labeled with the name of the patient, the final concentration of the added electrolyte, the date on which the prescribed concentrate was made, and the name of the person who mixed the additive."
Review on 02/08/2012 of facility policy "Potassium Additives to Increase the Dialysate Bath Concentration Procedure" dated 05/2011 revealed "1. Adjusting Potassium Bath...C. Procedure...4) Place patient ID label on container."
Observation during tour of HD unit on 02/08/2012 at 1210 revealed the patient in Bay #4 had a dialysate fluid with a label indicating the original fluid in the jug had an additive mixed in to modify the concentration per a physician's order. Interview with the HD RN during the observation revealed the patient in Bay #4 had a physician's order for a dialysate fluid which was not standard. Interview revealed the HD RN had to "spike" the jug with an additive to make the dialysate ordered by the physician for the patient. Observation of the jug failed to reveal any label identifying the jug with the additive was for the Patient in Bay #4. Interview revealed "I should have put the patient's label on the jug, I forgot."
D. Review on 02/09/2012 of facility policy "Culturing the R.O. Water, Dialysate and Portable R.O. Water Systems Procedure" dated 06/2011 revealed "4. a maximum of 100 cfu/ml of bacteria is allowed in the dialysate..."
Review on 02/08/2012 of "ANSI" standards dated 2004 by the AAMI revealed "6 Monitoring - 6.1 General...Table 4-Monitoring guidelines for water purification equipment and distribution systems and dialysate...Water distribution and piping system...Bacterial count (less than or equal to) 50 cfu/ml (colony forming units per milliliter)...Dialysate...Bacterial growth (less than or equal to) 50 cfu/ml..."

Review of the facility's HD Unit central water culture reports dated 07/22/2011 revealed "...Return Loop...Colony Count, Water, 48 HR (hours) - 60 CFU/ml" Review of logs failed to reveal any action taken for the bacterial count above 50 CFU/ml.

Interview with Infection Control staff on 02/09/2012 at 1340 revealed the facility's policy for water culture action levels did not match up with AAMI standards. Interview revealed since the result of 60 CFU/ml on the water culture result dated 7/22/2012 was not an action level according to facility policy, there was no action taken. Interview revealed "We need to modify our policy to meet the current standards."

E. Review on 02/08/2012 of "ANSI" standards dated 2004 by the AAMI revealed "8 Environment...Water systems should include schematic diagrams that identify...valves..."

Observation during tour of the HD Unit's central water treatment area on 02/08/2012 at 1050 failed to reveal a schematic diagram of the normal operating positions of the central water treatment system.

Based on policy review, medical record reviews and staff interview, the nursing staff failed to monitor a patient for a chemical restraint every 15 minutes in 2 of 3 patients chemically restrained ( #12 and #13).

Findings include:

Review of policy"Restraint Management Patient Care Policy Number: Administrative Manual #409 & II-R-1 effective date: 07/2010" revealed "Chemical restraints is a medication used to control the behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition. In the rare instance that chemical restraint may be necessary to control unexpected physically violent behavior the patient will be monitored per behavioral restraint procedure...Emergency Behavioral Restraint: (Any Setting): Applying a restraint in an emergency situation in which the patient's behavior is violent, aggressive or destructive, posing an imminent danger to the patient or others...Emergency Behavioral Restraint or Seclusion Flowsheet...Every 15 MINUTE OBSERVATION NOTES Include: description of behavior, signs of injury, any interventions tried and their effectiveness".

1. Medical record review of patient #12 revealed on 11/2/2011 the patient was "fighting, kicking, spitting". Record review revealed the patient was given per physician's order on 11/2/2011, at 1645 Haldol (central nervous system medication used to more quickly (IM) to control behavior of patient) 5 mg IM "Now", at 1747 Geodon (antipsychotic) 40 mg IM "stat" (1 hour 2 minutes after Haldol), and at 1905 Ativan (central nervous system medication used to more quickly (IM) to control anxiety of patient) 1 mg IM "x 1 now" ( 1 hour 18 minutes after Geodon) Record review revealed the patient was "agitated". Record review did not reveal any documentation of every 15 minute monitoring of the patient. Record review revealed documentation the patient was monitored at 2030 after the patient was placed in 4-point physical restraints.

Interview with administrative nursing staff on 2/10/2012 at 1030 revealed there was no documentation of monitoring every 15 minutes after the patient was administered the Haldol, Geodon and Ativan.

2. Medical record review of patient #13 revealed on 1/21/2012 the patient was physically restrained with bilateral wrist restraints at 0115. Record review revealed the patient was "agitated". Record review revealed the patient was administered Haldol (central nervous system medication used to more quickly (IM) to control behavior of patient) 5 mg IV and Valium (central nervous system medication used to more quickly control anxiety) 2 mg IV stat per physician's orders for agitation. Record review revealed no documentation of every 15 minute monitoring after the administration of the medication.

Interview with administrative nursing staff on 2/10/2012 at 1030 revealed there was no documentation of monitoring every 15 minutes after the patient was administered the Haldol and Valium.

Based on policy review, medical record reviews and staff interview, the nursing staff failed to use the least restrictive intervention in 1 of 3 patients chemically restrained ( #11).

Findings include:

Review of policy"Restraint Management Patient Care Policy Number: Administrative Manual #409 & II-R-1 effective date: 07/2010" revealed "The RN should consider the following and intervene with least restrictive measures to reduce the need for restraints".

Medical record review of patient # 11 revealed the patient became "agitated, combative and threatening" on 2/3/2012. Record review revealed the patient was administered Haldol (central nervous system medication used to more quickly (IM) to control behavior of patient) 5 mg Intramuscular (IM) at 1142. Record review revealed the patient received a second dose of Haldol 5 mg IM and Ativan (central nervous system medication used to more quickly (IM) to control anxiety of patient) 2 mg IM at 1202 (20 minutes after first dose of Haldol). Record review revealed the staff placed the patient in "four-point" physical restraints at 1150. Record review revealed the patient was documented at 1200 "pt (patient) is asleep, at 1215 "Pt is awake in bed", at 1230 pt laying in bed with eyes closed, at 1245 pt is asleep". Record review did not reveal why the patient was placed in physical restraints after administration of 2 doses of Haldol 5 mg IM and Ativan 2 mg IM.

Interview with administrative nursing staff on 2/10/2012 at 1030 revealed the four-point restraints were not the least restrictive after the patient received medication.

Based on review of policy and procedures, medical records, manufacturer's guidelines, family education information and staff interview, the hospital failed to provide an organized nursing service.

Findings include:

1. Hospital nursing staff failed to assess a patient's complaint of pain for intervention and failed to monitor after implementing an intervention for pain in 1 of 4 patients observed in the Emergency Department (ED) (#8).

~cross-refer to 482.23(b)(3) RN Supervision of Nursing Care - Standard Tag A0395.

2. Hospital nursing staff failed to rotate injection sites per the hospital's guidelines for 4 of 6 records reviewed of patients receiving Lovenox. (#55, 54, 50, and 60).

~cross-refer to 482.23(c) Administration of Drugs - Standard Tag A0404.

Based on policy and procedure review, medical record review and staff interview, the nursing staff failed to assess a patient's complaint of pain for intervention and failed to monitor after implementing an intervention for pain in 1 of 4 patients observed in the Emergency Department (ED) (#8).

Findings include:

Review of policy "Medication Follow-Up Policy Nursing Practice Guide" effective 5/09 revealed Intravenous (IV) route of administration had a time limit for follow up of "15-30 minutes".

Review of policy "Assessment of the Emergency Department Patient Policy Patient Care Practice Guide" effective 3/11 revealed Vital signs are documented:...C. If stable, every 2 hours and PRN based on patient condition and therapeutic interventions initiated. D. After administration of medications with potential side effects".

Open medical record review of patient #8 revealed a 23 year old presenting to the ED on 2/8/2012 at 1021 with a chief complaint of abscess, increased facial and nasal swelling, pain and increased redness. Record review revealed the patient had been seen at the ED the day before and the abscess was opened. Record review revealed the patient complained the pain medication given "isn't helping pain". Record review revealed the patient arrived at 1021. Review revealed at 1034 during triage the patient complained of pain at a level of 10 out of 10 on a 10 point scale with 10 being the worst pain. Record review revealed no documentation of an intervention for the patient's complaint of pain. Record review revealed the patient complained of pain at 1220 at 10 out of 10 and at 1229 the patient complained of pain and the nurse documented "waiting for the MD to arrive." Record review revealed at 1303 the patient continued to complain of pain and "Dr. (Name of physician) aware that pt (patient) is in pain". Record review revealed at 1340 "Notified ED physician of pt's (patient's) pain. Dr. (name of physician) hasn't ordered anything for him". Record review revealed at 1345 the patient continued to complain of pain at a level of 10 out of 10. Record review revealed the patient was administered Toradol (nonsteriod noninflammatory) 30 mg IVP (intravenous push) at 1422, (3 hours 52 minutes) after initial complaint of pain at 10 out of 10. Record review revealed no further documentation of reassessment until 1530 (1 hour 8 minutes) when the patient was administered Dilaudid (narcotic pain medication) 2 mg IVP. Record review revealed the patient was reassessed at 1545 with a pain level at 6 out of 10.

Interview with administrative ED staff on 2/8/2012 at 1100 revealed the staff did not follow the hospital policy. The interview revealed they did not know why the patient waited 3 hours 52 minutes before an intervention was completed. The interview revealed the patient should have been reassessed for vital signs every 2 hours and after pain medication within 30 minutes. The interview revealed there was no further documentation of assessment or reassessment for patient #8.

Based on review of manufacturer's guidelines, policy review, family education information review, medical record review and staff interview, the hospital nursing staff failed to rotate injection sites per the hospital's guidelines for 4 of 6 records reviewed of patients receiving Lovenox. (#55, 54, 50, and 60).

Findings include:

Review of the insert in the Lovenox package revealed, "... Administration should be alternated between the left and right anterolateral and left and right posterolateral abdominal wall. ..."

Review of "Clinical Nursing Skills", page 620 states, " ...Administering Subcutaneous Anticoagulants ...Rationale: Injections should be rotated to prevent local post-injection complications. ..."

Review of the hospital booklet used to teach patients or family members to give the Lovenox injections states under Treatment Record page 12 ... " It's important to alternate injecting yourself from right to left...Page 13 ...Where to inject Lovenox ... Remember to alternate sides each time. "

1. Open record review of patient #55, a 29 year old, admitted for overdose and Respiratory Arrest on 2/3/2012 at 2010. The Physician wrote an order on 2/4/2011 at 2159 for Lovenox 40 mg subcutaneous Q day (once daily). Review of the record revealed the injections were given on 2/2/2012 in the RLQ (right lower quadrant), 2/6/2012 in the RLQ, 2/7/2012 in the RLQ, 2/8/2012 in the RLQ, and 2/9/2012 in the RLQ.

Interview with the nurse providing care for the patient on 2/9/2012 at 1330 confirmed the sites had not been rotated.

2. Open record review of patient #54, a 63 year old, admitted for Ventilator Dependant Respiratory Failure and decreased level of Consciousness on 2/3/2012 at 1330. The Physician wrote an order on 2/3/2012 at 1255 for Lovenox 40 mg subcutaneous Q day (once daily). Review of the record revealed the injections were given on 2/3/2012 in the LLQ (left lower quadrant), 2/4/2012 in the RLQ (right lower quadrant), on 2/5 in the LLQ, on 2/6/2012 in the LLQ, and on 2/7/2012 in the LLQ.

Interview with the nurse providing care for the patient on 2/8/2012 at 1400 confirmed the sites had not been rotated.

3. Open record review of patient #60, a 58 year old, admitted for Right Hip Fracture, on 2/2/2012 at 1925. The Physician wrote an order for Lovenox subcutaneous Q day (once daily). Review of the record revealed the injections were given on 2/6/2012 in the RLQ (right lower quadrant), on 2/7/2012 in the LLQ (left lower quadrant) and on 2/8/2012 in the LLQ.

4. Open record review of patient #50, a 49 year old, admitted for " not feeling good " on 2/5/2012. The Physician wrote an order on 2/5/2012 at 2304 for Lovenox daily per Lovenox treatment protocol. Review of the record revealed the injections were given on 2/6/2012 in the LLQ (left lower quadrant), on 2/7/2011 in the LLQ, on 2/8/2012 in the RLQ (right lower quadrant), and on 2/9/2012 in the RLQ.

Interview with the unit Nurse manager and the Assistant manager on 2/9/2012 at 1345 indicated the injections should be rotated as such LUQ (left upper quadrant) LLQ (left lower quadrant, RUQ (right upper quadrant) and RLQ (right lower quadrant.) Further interviews with the Hospital Trainers as well as the Pharmacy Director confirmed the injection sites should be rotated per policy and standard guidelines.

Based on facility policy review, observation during tour and staff interview, the hospital's pharmacy staff failed to ensure outdated medications were removed and discarded from a medication box in the Radiology department.

Findings include:

Review of the hospital's Pharmacy Policy and Procedure with an effective date of 7/1/2010 states, "...PROCEDURE: 1. The pharmacy technician will inspect his/her assigned patient care area once during each calendar month. ... 4. ...All stock should be inspected for expired drugs. ...7. Technicians shall return all expired drugs to the pharmacy department for proper disposal after completing their unit inspection ... "

Observation during tour of the Radiology Department on 2/8/2012 at 10:00 revealed a tackle (Medication Storage) box which contained emergency medications. It revealed three (3) vials of Famotidine (Pepsid) 20mg/2ml. One vial had an expiration date of June 2011 (7 months ago), one with an expiration date of December 2011 (2 months ago) and another vial with an expiration date of January 2012 (1 month ago).

Interview with the Radiology manager on 02/08/2012 at 1000 confirmed the medications had expired and were available for patient use.

Based on observations as referenced in the Life Safety Report of Survey completed 02/10/2012, the hospital failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

Findings include:

1. The hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~cross-refer to 482.41(a) Physical Environment: Maintenance of Physical Plant - Standard Tag A0701.

2. The hospital failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~cross-refer to 482.41(a)(1) Physical Environment: Emergency Power and Lighting - Standard Tag A0702.

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.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710.

4. The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients as evidenced by failure to discontinue the usage of roller latches within the hospital.

~cross-refer to 482.41(b)(5) Physical Environment: Roller Latches Prohibited - Standard Tag A0712.

5. The hospital failed to ensure that alcohol based hand rub dispensers were located away from an ignition source.

~cross-refer to 482.41(b)(9) Physical Environment: Alcohol-Based Hand Rub Dispensers - Standard Tag A0716.

6. The hospital failed to ensure the facilities were designed and maintained in accordance with Federal, State and local laws, regulations, and guidelines to ensure patient safety.

~cross-refer to 482.41(c) Physical Environment: Facilities - Standard Tag A0722.

7. The hospital failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms and emergency air handler shutdown switches were installed and operated properly when activated.

~cross-refer to 482.41(c)(4) Physical Environment: Ventilation, Light, Temperature Controls - Standard Tag A0726.

Based on observations as referenced in the Life Safety Report of Survey completed 02/10/2012, the hospital failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is a broken light switch located on basement level corridor wall near female staff room on security corridor.

B. There is no bonding jumper between normal and emergency panelboards serving the same patient vicinity. Panelboards are located in electrical room "E" of the northeast tower.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 02
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The outside cylinders are not protected from extremes of weather and the cylinders are not protected from rusting while the cylinders are sitting on the concrete pad. GMH-outside- Gas manifold area

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

Based on observations as referenced in the Life Safety Report of Survey completed 02/10/2012, the hospital failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Exit egress lighting was switched and could leave the area in darkness. 7th floor group activities rooms, both North and South front halls.

B. Exit egress lighting was switched and could leave the area in darkness. 7th floor exam rooms, both North and South front halls.

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

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no emergency lighting to the public way for courtyard area serving the Chemo & ROC waiting area - located on basement level.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no emergency power system supplying load indicator for generator annunciator serving the main hospital - panels are located in the security room on the basement level.

B. There is no audible signal test switch for generator annunciator panels located within the security room - located on basement level of main hospital.

C. There is no visual indicator & audible signaling device for the low fuel level in the main fuel tank - the system is not arranged to function with a three hour fuel capacity remaining in the main fuel tanks.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

Building 02
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no exit discharge lighting to public way - located in first floor exit passageway for north stairway.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The emergency system supplying load indicator is not functioning on the generator annunciator panel. During loss of normal power to the Life Safety Branch transfer switch there was no visual indicator response.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 145.

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Nurse Call system and key-pad system are wired to the Life Safety Branch of the essential electrical system - located on ground floor of ambulatory surgery center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 05
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no emergency lighting for ground level exit discharge located on north side of facility.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Based on observations as referenced in the Life Safety Report of survey completed 02/10/2012, 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.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is fire protection material missing from structural steel beams in the ROC mechanical room located on basement level.

B. There are penetrations in the ceiling around conduit and sprinkler heads that were not sealed in order to meet the required rating for the area. Basement Loading Dock Area

C. There are penetrations in the ceiling around conduit that were not sealed in order to meet the required rating for the area. 3rd floor mechanical room across from room 3202.

D. Smoke door labeled 20 minutes, not 90 minutes, in a two hour rated wall. 1st floor going into NICU classroom.

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

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no positive latching hardware on exit access doors to SCIU Suite located on the first floor of main hospital.

B. The inactive leaf of exit access doors to operating rooms require greater than a single hand motion to close and latch. The inactive leafs are equipped with manual flush bolt sets. (Located on first floor level)

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

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Facility at the time of the survey could not verify that the door to the Vertical Chase was a 2-hour rated door. Basement EP Storage.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

4. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There are unsealed penetrations in the 1 hour smoke barrier above the cross corridor doors at the family waiting room. Main-4th floor - cross corridor doors at the family waiting room.

B. There are unsealed penetrations in the 1 hour smoke barrier above the cross corridor doors at the entrance of the PICU-S area. Main-4th floor- PICU-S.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025.

5. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The double doors at the smoke barrier leading into the ICU suite on the visitors entrance has a gap grater than 1/8 of an inch. Main 4th floor- ICU Visitors Entrance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 027.

6. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The wall between the bulk storage area and pharmacy area at the double doors was not constructed to meet the one hour fire rated construction requirements for the area. Basement Bulk Storage Area.

B. The maintenance closet is constructed as a two hour fire rated enclosure and is equipped with a ¾ hr rated door and is not sprinkler. Basement - Pharmacy Maintenance Closet.

C. Could not verify the ¾ hour fire resistance rating of the corridor door to the Pharmacy. Basement - Pharmacy.

D. The maintenance closet has two ducts penetrating the rated wall that are not equipped with fire dampers. There are holes in the wall that have not been sealed in order to meet the required fire resistance rating of the wall. Basement - Between Bulk Storage Rooms.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

7. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is an active dead bolt installed on the patient room door, when the dead bolt is engaged it results in more than a one motion of the hand for egress from the room. Main - 6th floor- Patient room 6156.

B. Stairway J exits into unprotected glass and steel passageway without an alternate exit from within glass and frame enclosure. The stair door prevents reentry due to access controlled egress lock assembly. The passageway encloses an interior courtyard on the basement level.

C. Stairway J is equipped with an incomplete access controlled egress lock - the exit door from the stair is not equipped with a release switch. The switch must be not greater than five feet from the door.

D. The delayed egress locks are not equipped with a sign on the door that states "Push, alarm will sound" lock will release in fifteen seconds. The locks are located near the maintenance room and triage area on the basement level.

E. Corridor area of imaging center terminates in a room with less than eight feet clear and obstructed path. The room is a waiting room located off the main corridor on the basement level.

F. There are dead-bolt locks on power operated horizontal exit doors - located on basement level near ROC waiting room.

G. The access controlled egress locks did not release during activation of the fire alarm system - Locks are located on the CT, and Imaging area cross corridor doors.

H. Exit egress door with delayed egress did not release with pull station or smoke detector. Corrected during survey. 3rd floor, peds exit stairwell.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

8. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is a deadbolt lock in addition to other positive latching hardware on doors to CT scan #1, and #2.

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

9. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Additional exit and directional signs are needed in the exit corridor from the kitchen that will lead to the second mean of egress back to the stairwell. Basement Kitchen Exit Corridor.

B. Additional exit and directional signs are needed in the rear exit corridor from the pharmacy. Second means of egress was not marked in the corridor. Basement - Pharmacy rear exit corridor.

C. Exit signage was not provided at exit door to the corridor. Second Floor Scan Center near Locker.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

10. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The closet has a sprinkler head that is rated 200 degree F intermediate temperature rating in place of 155 degree F ordinary temperature rating. Second floor data closet near medical records passage way.

B. The vertical shaft was not equipped sprinkler protection. A, B, C, D, E, F, G and H Vertical Mechanical Chase.

C. The sprinkler system was blocked by a solid shower curtain in rooms 7105 and 7252. 7th floor.

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

11. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The sprinkler head is blocked in the electrical room just off the back of the medication.
Main - 4th floor- Medication room near 4126.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

12. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There are portable space heaters located in the following areas
i. Bio-med room - basement level.
ii. Materials supply office - basement level.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 070.

13. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There are wall-mounted clerical pads that protrude into required corridor width. The pads did not self-close when opened. Pads are located between exam rooms 27 & 28 of the basement level and on 7th near the center hall employee elevators.

B. Door to bathroom protrudes greater than seven inches into required corridor width in the fully open position. Door is located between exam rooms 26 & 25 on the basement level.

C. There are impediments stored in the required egress corridor from operating rooms in the main hospital tower.

D. There are wall-mounted computers, staff identified for doctor's dictation, with flip down keyboards that protrude into required corridor width. The keyboards did not self-close when opened. Computers are located 7th and 5th floors.

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

14. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The storage room was being used for oxygen storage and there was not a No Smoking signage posted on the storage room door. Basement - Advanced Home Health Care Storage.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 141.

Building 02
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There was a gap between the double doors to the small storage room door that was not smoke resistant. Sprinkler coverage could not be obtained due to solid shelves. 4th floor Caremont Surgical Suite.

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

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Fire door to stair did not self latch - located on ground floor at north corridor of surgery center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 033.

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. No sprinkler coverage of shower stalls in ambulatory surgery center located on the ground floor - shower stalls are located in patient rooms similar to room #3.

B. Upper and lower most portion of the stairwell landing not sprinklered in the north stairwell MOB.

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

4. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. North corridor is obstructed by surgical lights and other impediments - located on ground floor of surgery center.

B. Corridor is obstructed by computer on wheels charging and stored in exit egress - located on ground floor of surgery center outside peds.

C. Exit egress to the public way is obstructed by cars in parking spaces located directly in the path of the egress. North side near parking deck.

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

Building 03
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Smoke door labeled 20 minutes, not 45 minutes, in a one hour rated wall. Birth Center, door to triage.

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

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Corridor not smoke tight with louver in door to IT room, Birth Center first floor to the right of the security desk, HUB 62.

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

Building 04
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The supply room, and soiled linen room are not equipped with sprinkler or one hour fire resistive enclosure. The roof ceiling assembly of each room is equipped with non-rated suspended ceiling assembly.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The six sprinkler risers in the riser room are equipped with accelerator that are equipped with gate and ball valves that are not electronically supervised. West Building - Basement Sprinkler riser room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 061.

Building 05
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Fire doors to hyperbaric unit utilize inactive door leaf without self-closing device and automatic flush bolt assembly. Wound Center located on third floor.

B. The roof/ceiling assembly of the hyperbaric unit utilizes a non-rated roof suspended ceiling assembly. There is no one hour fire resistive enclosure at the roof/ceiling assembly.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Fire doors to east stairway, adjacent to lobby, would not latch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 033.

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no exit directional signage leading from the lobby area to the mammography and MRI corridor exits. CIS- Corridors leading to mammography and MRI.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

4. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is a large bulk soiled lined storage cart greater than 32 gallons that was stored in the changing room. Imaging Center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 075.

Based on observations as referenced in the Life Safety Report of Survey completed February 10, 2012, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients as evidenced by failure to discontinue the usage of roller latches within the hospital.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There are roller latches on exit access doors to imaging rooms #3, #4, and #6. Imaging rooms are located on the basement level.

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

Based on observations as referenced in the Life Safety Report of survey completed 02/10/2012, the hospital failed to ensure that alcohol based hand rub dispensers were located away from an ignition source.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The Alcohol Based Hand Rub dispenser is within seven inches of the electrical light switch. Basement - chemical treatment area across from the nurses station.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0211.

Based on observations as referenced in the Life Safety Report of Survey completed 02/10/2012, the hospital failed to ensure the facilities were designed and maintained in accordance with Federal, State and local laws, regulations, and guidelines to ensure patient safety.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Exit access doors from restroom A is twenty-two inches in clear opening. Restroom is located in basement level imaging center.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 040.

2. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. Pull stations located 48" above finished floor at exit near 5th floor D stairwell, 3rd floor E stairwell, 5168, 5216, 5265, 3265, 3240.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

3. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There are oxygen and vacuum system piping supported from mechanical ducts by pipe hangers - pipe hangers must be secure to the structure - located on basement level.

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

4. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The zone control valves serving anesthetizing rooms in ENDO are not arranged to control individual rooms without shutting-off supply in other rooms. Valve box is located on the basement level.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 078.

Building 05
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The circuit breaker and panelboard supplying normal power to fire alarm control panel is not identified on control panel.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Based on observations as referenced in the Life Safety Report of Survey completed February 10, 2012, the hospital failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms and emergency air handler shutdown switches were installed and operated properly when activated.

Findings include:

Building 01
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The relative humidity is 32.6% and 25% respectively as measured by sensors located in operating room #7 of the main hospital tower.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 078.

Building 04
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. The air handling unit did not shut-down with activation of duct-mounted smoke detector.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Building 05
1. Based on observations on February 7, 2012 at approximately 3:00 PM onward, the following items were non-compliant, specific findings include;

A. There is no manual shutdown switch for all air handling units serving hospital based provider facilities within the medical office building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Based on review of facility policies and procedures, observations during tour, the Center's for Disease Control (CDC) documents review, and staff interviews, the hospital failed to provide a sanitary environment to avoid sources and potential transmission of infections and communicable diseases.

Findings include:

The facility failed to ensure a system for infection prevention by failing to ensure: A. staff only touch contaminated surfaces with gloved hands; B. designated clean and dirty areas; C. reusable equipment disinfection procedures are followed; and, D. failed to ensure staff followed facility policy for the infection control policy of Glucose Meter testing.

~cross-refer to 482.42(a)(1) Infection Control Officer Responsibilities - Standard Tag A0749.

Based on review of facility policies and procedures, observations during tour, the Center ' s for Disease Control (CDC) documents review, and staff interviews, the facility failed to ensure a system for infection prevention by failing to ensure: A. staff only touch contaminated surfaces with gloved hands; B. designated clean and dirty areas; C. reusable equipment disinfection procedures are followed; and, D. failed to ensure staff followed facility policy for the infection control policy of Glucose Meter testing.

Findings include:

A. Review on 02/08/2012 of facility policy "Infection Prevention and Control Policy " dated 10/27/2011 revealed " ...Procedure - A. Standard Precautions ...3. Standard Precautions require: ...c. Gloves: clean gloves must be worn when touching ...contaminated items ... "

Review on 02/08/2012 of the CDC document " Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients " dated 4/27/2001 revealed " Infection Control Practices for All Patients ...During the process of hemodialysis, exposure to blood and potentially contaminated items can be routinely anticipated; thus, gloves are required whenever caring for a patient or touching the patient's equipment. "

Observation during tour of the hemodialysis (HD) unit on 02/08/2012 from 1130-1155 revealed three patients present with one staff Registered Nurse (RN) giving care to each patient currently receiving HD treatments during the observation. Observation revealed the RN would go to each station and touch the face of the in use and contaminated HD machine without gloves.

Interview with the HD management administrative staff on 02/08/2012 at 1310 revealed staff should utilize gloves when touching contaminated surfaces. Interview revealed " we did not realize the face of the machine was considered contaminated. "

B. Review on 02/08/2012 of facility policy " policy "Infection Prevention and Control Policy " dated 10/27/2011 revealed " ...Procedure - A. Standard Precautions - 1. All personnel must follow Standard Precautions. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources within the hospital.

Review on 02/08/2012 of the CDC document " Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients " dated 4/27/2001 revealed " Infection Control Practices for All Patients ...Any item taken to a patient's dialysis station could become contaminated with blood and other body fluids and serve as a vehicle of transmission to other patients either directly or by contamination of the hands of personnel. Therefore, items taken to a patient's dialysis station, including those placed on top of dialysis machines, should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients ...Additional measures to prevent contamination of clean or sterile items include ...b) not handling or storing contaminated (i.e., used) supplies, equipment, blood samples, or biohazard containers in areas where medications and clean (i.e., unused) equipment and supplies are handled ... "
Observation during tour of the hemodialysis (HD) unit on 02/08/2012 from 1130-1155 revealed three patients present with each patient currently receiving HD treatments during the observation. Observation revealed a contaminated arm clamp used on an earlier patient in the sink where, during the observation, the HD RN used the same sink for handwashing. Observation revealed there was no designation of clean sinks dedicated to handwashing and dirty sinks dedicated to cleaning soiled, reusable equipment.

Interview with the HD management administrative staff on 02/08/2012 at 1315 revealed contaminated items should not be placed in sinks used for handwashing.

C. Review of manufacturer ' s recommended use of the hospital-approved disinfectant wipes (no date) revealed " Cleaning and Disinfection ...cleaning always precedes disinfection ...Contact or Dwell time - the time required for each disinfectant to kill pathogens ...Surfaces must stay wet for this amount of time in order to be effectively disinfected. " Further review revealed " Clorox Germicidal Wipes ...The contact time for this product is 2 (two) minutes. "

Observation during tour of the hemodialysis (HD) unit on 02/08/2012 from 1130-1155 revealed three patients present with each patient currently receiving HD treatments during the observation. Observation revealed a contaminated hemostasis arm clamp used on an earlier patient in the sink used for handwashing. Observation revealed the staff RN picked the contaminated clamp up out of the sink, wiped the clamp off in less than a one minute period, then ran the clamp under the water in the sink and placed the clamp on a paper towel on the countertop. Observation revealed the staff RN then took the same arm clamp into a patient ' s station for use when the patient ' s treatment was complete.

Interview with Infection Control staff on 02/09/2012 at 1340 revealed contaminated items should be cleaned of blood or debris first, and then disinfected per the manufacturer ' s specifications. Interview revealed the staff RN failed to follow the hospital-approved procedure for disinfection of contaminated and reusable equipment by failing to first clean the arm clamp then wipe the arm clamp with the disinfectant wipe for a contact (wet) time of 2 minutes.



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D. Review on 2/9/12 of facility policy "Glucose Meter (Sure Step) Nursing Practice Guide" revealed "The glucose meter is cleaned with an alcohol or bleach wipe between patients and rinsed with a paper towel moistened with waster to remove residual bleach. The test strip holder is cleaned weekly."

Observation during tour of the Birthing Center on 2/9/12 at 12:50 PM revealed a nurse performing a blood glucose test in Room 3343. The nurse donned gloves and removed the glucose meter from the plastic tote box and performed the glucose test. Then, the nurse entered the glucose test results into the computer and placed the glucose meter back into the plastic tote box. The nurse failed to clean the glucose meter prior to placing the meter into the tote box with clean supplies.

Interview with the Birthing Center's Clinical Manager on 2/9/12 at 12:55 PM revealed dirty glucose meters are placed in the tote box with clean supplies prior to being cleaned. The CM confirmed the nurses should clean the dirty glucose meters prior to placing into the tote box with clean supplies.

Based on hospital policy review, observation and staff interview, the hospital failed to A. ensure a malignant hyperthermia cart was immediately available to surgical patients in the Birthing Center; B. ensure safe transport of soiled endoscopes; and C. ensure safe transport of soiled surgical instruments.

Findings include:

A. Review on 2/9/12 of facility policy "Malignant Hyperthermia Patient Management Protocol" effective 1/12 revealed "This protocol is utilized by the RN for the management of Malignant Hyperthermia (MH) in the post op patient. . . Most cases of Malignant Hyperthermia occur during general anesthesia, but the 12 hour period immediately following surgery is also critical time . . . Equipment: Treatment protocol kept on top of and in the MH cart ...MH cart located in the sterile core . . . "

Observation during tour of the Birthing Center (BC) on 2/9/12 at 11:30 AM revealed Cesarean Sections are performed in the Birthing Center. Interview with the Director of Perioperative Services, the Chief Certified Registered Nurse Anesthetist and BC Clinical Manager revealed General Anesthesia is administered in the Birthing Center for surgical procedures.

Interview with the CRNA who was assigned to do a C/Section in the Birthing Center at the time of the tour indicated the Malignant Hyperthermia Cart was in the clean supply room. Observation revealed no MH cart in the department. The CRNA stated she would obtain the MH cart from the Main OR. The Main OR is located in another building which is connected by an enclosed walkway. The distant is not readily available to the Birthing Center.

Interview with the Director Perioperative Service and Chief CRNA on 2/9/12 at 11:45 AM revealed there is only one MH cart in the Main Operating Room. The Perioperative Director confirmed the MH cart was not readily available to the BC.

Interview with the Birthing Center Director on 2/9/12 at 3:20 PM revealed that Anesthesia would notify the Main Operating Room to bring the Malignant Hyperthermia Cart if there was a need for the cart.

B. Review on 2/9/12 of policy "Reprocessing of Endoscopes and Accessories" revealed "Upon removal of the endoscope from the patient, . . . Transport towel wrapped scope to cleaning room in container. "

Observation during tour of the Endoscopy/Bronchoscopy Unit on 2/8/12 at 12:15 PM revealed the endoscopy tech placing an endoscope in a white plastic bag and proceeding to the soiled work room.

Interview with the Endoscope Technician on 2/8/12 at 12:20 PM in the soiled worked room revealed the techs are to place the dirty endoscopes in the plastic bag for transport to the soiled work room.

Interview with the Endo Director on 2/8/12 at 12:20 PM revealed the bags are patient belonging bags. The director confirmed there was no evidence the plastic bag had been approved as a safe container to transport soiled endoscopes.

Interview with the Director of Perioperative Services and Director of Material Processing on 2/9/12 at 3:30 PM confirmed the plastic bag observed in the endoscopy department had not been approved as a safe container to transport endoscopes.

C. Review on 2/8/12 of facility policy "Traffic Patterns in the Perioperative Practice Setting revealed "Soiled supplies, instruments, and equipment should not re-enter the clean core area. They should be contained in closed container or cart and /or properly covered for transport to a designated decontamination area."

Observation during tour of the Outpatient Surgical Center (OPS) on 2/8/12 at 1:15 PM revealed a surgical staff member removing the instruments from the operating room, the instruments were only covered with a towel and transported in the semi-restricted area to the soiled work room.

Interview with the Clinical Manager (CM) on 2/8/12 at 1:30 PM revealed the Outpatient Surgical Center does not utilize the closed container or cart system. The manager revealed the OSC did not have room for "storage" of the carts. Interview with the CM confirmed the OSC had not following policy for containment of soiled instruments.