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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K25: smoke barrier walls,
K29 hazardous areas,
K48 training of staff for fire,
K56 sprinklers,
K62 sprinkler maintenance,
K67 HVAC system,
K72 obstructions in the corridor, and
K147 extension cords.
Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 485.623. The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K25: smoke barrier walls,
K29 hazardous areas,
K48 training of staff for fire,
K56 sprinklers,
K62 sprinkler maintenance,
K67 HVAC system,
K72 obstructions in the corridor, and
K147 extension cords.
Please Refer to the full description at the cited K-tags: This observed situation was not compliant with CFR 485.623. The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility. This deficiency was confirmed at the time of discovery in an interview with Staff A (Maintenance Director) .

Based on observations and interviews with facility staff, the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment for the prevention of potential contamination or infection.


Findings include:

Surveyor 20878

1) During a tour of the kitchen on 04/07/2010 at 8:15 AM with Dietary Manager C it was observed that the Hobart meat slicer had bits of meat stuck to its undercarriage despite having been cleaned, this was confirmed by C.

Surveyor 12187

Findings include:

2) During a tour of therapy services on 4/5/2010 at 1:35 PM with staff A, it was observed that Staff B was drinking soda from a can and reading magazines in the exam room. The soda and magazines were located on the exam table which was covered with a sheet. Staff B was on a chair and leaning over the exam table. This was confirmed by staff A.

3) During the observation of the Operating room on 4/62010 at 2 PM, it was observed that a suction canister ready to be used in the operating room was being stored in the " back of the sterilizer ' room which is not a clean area. This was confirmed by staff A.

4) During the observation of the sterilization room (next to general supply room) on 4/6/2010 at 2:15 PM, dirty and (water) stained ceiling tile where observed in this ' clean ' room. Clean supplies are being stored in this room. This was confirmed by staff A

5) During the observation of the main air handler unit on 4/6/2010 at 2:30 PM, it was observed that there was black material on the bottom of the floor of the air handler beyond the heating and cooling coil. It was theorized that this material could be black rubber from a near by tire recapping plant or mold from stagnant water from the cooling coil pan. Because the air handler could not be shut down at the time of investigation and a sample taken, determination of the substance is on going.

6) During the observation of the procedure clean up room on 4/5/2010, at 3:35 PM, it was observed that paint was peeling off of the walls, there were air gaps around pipe penetrations and the ceiling tile was ripped and had holes in them. These surfaces are not cleanable. This was confirmed by staff A.

7) During the observation of the SC utility room on 4/6/2010, at 11:55 AM it was observed that there was were not smooth and washable, ( the walls had ripped wall board), and the ceiling had ripped ceiling tiles. The room could not be properly cleaned. This was confirmed by staff A.

Based on review of 10 of 30 records (# 1 through #10 ), interview with staff and review of facility policies and procedures the hospital failed to assure entries were properly timed and dated.

Findings include:

The following records were reviewed over the course of the survey on 04/05/2010,04/062010 and 04/07/2010

The hospital's policy on medical records states; "All entries in medical records by medical staff or other Hospital staff shall be legible, permanently recorded, dated and authenticated with the name (and title) of the person making the entry.

Patient (pt.) #1's medical record contained 7 telephone orders written from 01/02 through 01/04/2010 which were co-signed by the physician but the signature was not timed or dated.

Pt. #2's medical record contained 12 verbal and telephone orders written between the dates of 11/13 and 11/16/2009 which were co-signed by the physician who failed to time and date the signature.

Pt. #3's medical record contained 3 telephone orders written on 01/26/2010 which were not co-signed by the nurse practicer, 3 telephone orders written on 01/27/2010 were co-signed by the nurse practitioner who failed to time and date the signature.

Pt. #4's medical record contained a telephone order written on 01/06/2010 which was co-signed by the physician who failed to time and date the signature.

Pt. #5's medical record contained 2 telephone orders written on 01/16/2010 which were co-signed by the nurse practitioner who failed to time and date the signature.

Pt. #6's medical record contained 7 telephone orders written on between the dates of 01/28 and 01/29/2010 which were co-signed by the nurse practitioner who failed to time and date the signature.

Pt. #7's medical record contained 2 telephone orders written on 03/05/2010 which were co-signed by the physician who failed to time and date the signature.

Pt. #8's medical record contained a telephone order written on 12/06/2009 which was co-signed by the physician who failed to time and date the signature.

Pt. #9's medical record contained 4 verbal and telephone orders written between the dates of 11/16 and 11/20/2009 which were co-signed by the physician who failed to time and date the signature.

Pt. #10's medical record contained 4 verbal and telephone orders written between the dates of 10/13 and 10/15/2009 which were co-signed by the physician and the nurse practitioner who both failed to time and date their signatures.

These findings were confirmed per interview with director of nursing G on 04/07/2010 at 11:00 AM.

Based on observation and interview with staff the facility failed to provide safeguards against unauthorized use.

Findings include:

During an interview with Director of Housekeeping E on 04/07/2010 at 9:00 AM it was revealed that housekeeping staff routinely clean the medical records department in the early morning when medical records staff are not present.

During a tour of the therapy department on 04/07/2010 at 10:15 AM with Physical Therapy director F it was observed that medical records were kept in an unlocked file cabinet. This cabinet was accessible to housekeeping staff when they cleaned the area without therapy staff present.

During a tour of the respiratory therapy office on 04/07/2010 at 10:55 AM it was observed that patient records are kept in an unlocked file cabinet. Housekeeping has access to this room when staff are not present.