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Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented. This occurred in two (Staff B, C and E) of three contract staff personnel files reviewed.

Findings:

Review of the personnel files for Staff B, C and E did not contain documentation of hospital orientation.

The above information was presented to the administrative staff during the exit conference on the afternoon of 09/22/14.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, document review and staff interview, it was determined the hospital failed to ensure:

a. all equipment used in patient care areas was checked for safety before put into use and failed to ensure oxygen tanks were safely secured. The hospital failed to make necessary repairs to damaged walls, trims, floors and work surfaces. See Tag A-0701;

b. biohazardous waste was collected and stored appropriately. See Tag A-0713;

c. the hospital's surgical suite design was maintained to reflect Federal and State regulations and in a manner to provide a level of service according to national standards of practice and failed to provide post-anesthesia care in a location that met the requirements. The hospital also provided laundry services in an area that was not designed for this purpose. See Tag A-0722;

d. medical equipment was inspected, monitored and maintained as required within the biomedical program and failed to ensure equipment and supplies were stored in a safe manner. See Tag A-0724; and

e. the hospital failed to ensure sterile supplies were stored within acceptable ranges for temperature and humidity and that proper ventilation was maintained for clean and dirty areas. See Tag A-0726.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation and staff interview, it was determined the hospital failed to ensure all equipment used in patient care areas was checked for safety before put into use and failed to ensure oxygen tanks were safely secured. The hospital failed to make necessary repairs to damaged walls, trims, floors and work surfaces.

Findings:

1. On 01/07/14, a tour of the hospital was conducted. The surveyors observed multiple standing household fans in patient rooms and in other areas of the hospital. None of the fans had documentation they were checked for electrical safety before they were put into patient use.

2. Portable oxygen tanks were found unsecured in various areas. Large standing oxygen tanks were found unsecured in the oxygen storage room.

3. On 01/08/14, electrical dental equipment that was not hospital property was observed in use in the outpatient surgery department. The equipment had not been inspected by the hospital for safety prior to use on hospital patients.

4. Various walls in the hospital were chipped, gouged and had peeling of paint and/or sheetrock. Baseboards were found separated from the walls. Door frames, doors and other wood surfaces were chipped and scratched.

Areas around decontamination sinks and handwashing sinks were no longer intact and could not be disinfected.

Multiple areas of the physical facility in the main surgery department were in disrepair. There were holes in the OR walls and exposed sheetrock. Many surfaces were no longer intact and could not be disinfected.

A closet in one of the recovery rooms was made of unfinished plywood. Sterile medical supplies, IV fluids and patient linen was stored in this closet.

5. There were no safety electrical outlets found in the surgery decontamination room or the sterile processing room. A household powerstrip was found in the sterile processing room.

6. One side of the surgical scrub sink in the main OR had too little water pressure to be useful and it could not maintain control of water temperature.

Staff confirmed these findings during interview.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to ensure biohazardous waste was collected and stored appropriately.

During tours of the hospital on 01/07/14 and 01/08/14, the surveyors observed there were no soiled utility areas identified as biohazard waste storage areas.

In the main hospital surgery department, a dirty biohazard material collection box was stored in the sterile corridor. A large, plastic sharps collection box was also stored there.

The staff stated the surgery department did not have an identified biohazard waste collection and storage area.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation, document review and staff interview, it was determined the hospital failed to:

a. maintain the hospital's surgical suite design to reflect Federal and State regulations and in a manner to provide a level of service according to national standards of practice;

b. provide post-anesthesia care in a location that met the requirements;

c. identify and appropriately utilize spaces in the off-site surgery location; and

d. the hospital failed to provide laundry services in an area designed for this purpose.

Findings:

1. On 01/07/14, hospital leadership was asked to provide a current floor plan. The surveyors were provided an undated "Fire Policy Floor Plan" that was not current and did not identify all rooms in the hospital.

Leadership was asked to provide original hospital and surgery department floor plans. None were provided. Staff stated parts of the current emergency department were originally part of the surgery department.

A tour of the main surgery department was conducted. The following observations were made:

~ The surgery department did not have a semi-restricted corridor. The only entrance to the department was directly into the sterile core from a public, unrestricted corridor shared with the emergency department.

~ The entrance and exit to the sterile processing area was a split, Dutch door. The door was located in the emergency department public hallway outside of the surgery department.

Surgery staff had to go in and out of the restricted surgical area to access the sterile processing area.

~ The surgery department did not have a staff dressing room, toilet, showers or lockers. The surgery staff obtained surgical attire from a remote, unrestricted staff office (former patient room) and then took them to another converted patient room that had been made into the "bone density examination room."

This room was used for outpatient exams and also for storage of a portable x-ray machine. The room did not have the features of a surgical staff support area, was not located within the surgery department and was not an area restricted to OR personnel.

~ The main surgery department did not have a semi-restricted area designated to unpack shipping boxes that contained sterile surgical supplies.

~ The main decontamination room shared air circulation with the sterile processing room. The decontamination room did not have the physical features required for this area, including separate instrument washing/rinsing sinks and staff handwashing sink, among others.

~ The main surgery department had no sterile surgical supply storage area that met requirements. Sterile surgical supplies were stored cramped in a small closet that had a window with an air-conditioning unit. This room was also used to store other equipment, linen and non-sterile supplies. The closet did not maintain the proper temperature, humidity and air circulation requirements for storage of sterile supplies.

~ The surgery department did not have an equipment storage/holding area. Some clean surgical equipment was stored in the janitor's closet with housekeeping supplies and the janitor's sink. Because the janitor's closet was full of other items, the mop bucket was stored in the sterile corridor.

~ The surgery staff used the surgical scrub sink as a utility sink, rather than utilize the janitor's closet as designed.

~ The main surgery department did not have clean and soiled utility rooms and did not have a biohazard waste collection and storage room.

~ The main surgery department did not have storage for non-sterile supplies.

~ The surgery administrative office was remotely located outside the surgery department in another area of the hospital.

2. During the tour, it was determined the hospital did not have a post-operative care area that was separate from the rest of the hospital.

The nursing staff stated patients were sometimes recovered in patient rooms. The staff identified two regular patient rooms within the med/surg unit used to recover patients. These rooms did not meet the requirements for a post-anesthesia care unit.

One room did not have suction available for patients. The other room had a portable suction machine that could be used on one patient, but the room was set up to receive two patients.

Portable oxygen was provided on the stretchers used to recover surgery patients but two of the tanks were empty. One bed did not have oxygen available.

The staff also said one of the examination/treatment rooms within the emergency department was the "recovery room." This room was not a separate area of the hospital and did not meet the requirements for post-anesthesia care area.

3. On 01/08/14, a tour of the off-site outpatient surgery department was conducted.

~ The restricted endoscopy suite contained rooms that were no longer used as designed and were used to store items for other departments, including medical records.

~ A patient holding room was used to store furniture and supplies for other areas of the outpatient facility.

~ The endoscopy janitor's closet was no longer used to service the endoscopy suite, but was used as a storage room for decorations, paint and other non-departmental items.

~ The surgery department at this location did not have a separate sterile surgical supply storage area within the the sterile core. Some sterile supplies were stored in a semi-restricted hallway outside the sterile core.

A large amount of the department's sterile supplies were stored in the sterile processing room that contained the steam sterilizer. Temperature and humidity could not be controlled in a manner required for the storage of sterile supplies.

Staff walked through the sterile processing area to obtain supplies.

4. At the off-site surgery location, a room was being used as an "urgent care" treatment site. The room contained sutures, intubation supplies and equipment, an electrocautery unit, dressings and supplies to administer IV fluids. The room did not meet the requirements for a hospital emergency room and was not considered a part of the hospital's emergency services.

5. During the initial tour of the main hospital, the surveyors observed a household (non-commercial) washer and dryer in a housekeeping closet. The washer and dryer had patient linen and gowns in them.

The staff stated the only items processed in the washer and dryer were housekeeping rags and mop heads. The washer and dryer did not have the capability to appropriately sanitize these items. In addition, the housekeeping closet did not meet the physical design requirements for a hospital laundry department.

Unable to assess compliance due to on-going construction/renovation.

Original Findings:

Based on observation and staff interview, it was determined the hospital failed to ensure sterile supplies were stored within acceptable ranges for temperature and humidity and that proper ventilation was maintained for clean and dirty areas.

Findings:

On 01/07/14 and 01/08/14, tours were conducted of the hospital's surgical areas. The following observations were made:

1. In the main surgery department, sterile surgical supplies were stored in a small closet that contained a window air-conditioning unit. At the time of the survey, the room was excessively warm. Staff stated they had problems with air circulation and temperature control in this room.

2. At the outpatient surgery department, sterile surgical supplies and equipment were stored in the sterile processing room, exposing them to excessive temperatures and humidity from the steam sterilizer.

3. Observations were made of doors propped open to the soiled storage room and to the sterile processing room at the outpatient site, thus affecting the requirements for special ventilation and airflow in these areas.

Based on review of infection control data, hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) develop a Tuberculosis (TB) risk assessment for the hospital. This was confirmed by Staff D on the afternoon of 09/22/14.

Based on record review and staff interview, it was determined the hospital did not integrate all outpatient services at all locations with hospital inpatient services.

Findings:

Surgical services provided at the off-site location were not consistent with practices at the main hospital.

The off-site location used a room in the clinic area to perform surgical procedures (pain management). This was confirmed by Staff D on the morning of 09/22/14.

The room did not meet the requirements for an operating room.

Based on personnel record review and staff interview, the hospital failed to ensure individuals who had been convicted of abusing, neglecting, or mistreating individuals in a health care setting were not employed. This occurred in three of three (B, C and E) contract employee personnel files reviewed.

Findings:

Review of the personnel files for Staff B, C and E did not contain evidence of a criminal background checks and state nurse aide registry checks.

The above information was presented to the administrative staff during the exit conference on the afternoon of 09/22/14.