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Based on medical record reviews, hospital documents reviewed, staff interviews and observations, the hospital's governing body failed to ensure that the patients' right to be provided care in a safe setting was protected, failed to ensure adequate nursing supervision and hall monitoring was provided according to the hospital's plan to prevent the sexual assault of patients, failed to ensure each medical record was completed within thirty days of discharge as required by the hospital's policy, failed to ensure that emergency medical services were appropriately provided to pediatric patients presenting to the emergency room and failed to approve the hospital's policy regarding transfer of pediatric patients in need of emergency medical treatment, failed to ensure that the fire safety requirements were met in regard to vertical opening doors located in smoke compartment barriers latched, failed to ensure there were no penetrations in the smoke compartment barriers, failed to ensure the doors on soiled utility rooms would resist the passage of smoke, failed to ensure exit access doors were readily accessible, failed to ensure the facility failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness, failed to ensure the appropriate fire extinguisher was readily available in a food prep area, failed to ensure the proper usage of portable space heating devices, failed to ensure the trash chute was not blocked with trash in a trash chute discharge room, exit stairways, and exit discharge to the public way.


Findings include:

The governing body did not ensure that that each patient was provided care in a safe setting and protected at all times from sexual assault based on the 12/08/2010 substantial allegation complaint (OH00058367) survey.

The governing body did not ensure adequate nursing supervision and hall monitoring was provided in accordance with the hospital's action plan to prevent the sexual assault of patients developed in response to the 01/03/2011 substantial allegation complaint (OH00058969) survey. This affected 1 Patient (#67) from the total of 67 patients reviewed. The patient census was 393.
Please refer to A063.

The governing body failed to ensure each medical record was completed within thirty days of discharge as required by the hospital's policy. As of 03/04/2011 there were 3,008 incomplete medical records. Please refer to A063.

The governing body failed to ensure emergency services were organized in such a manner as to provide care to all patients presenting to the emergency department.
Please refer to A091.

The governing body failed to ensure that the fire safety requirements were met in regard to vertical opening doors located in smoke compartment barriers latched, failed to ensure there were no penetrations in the smoke compartment barriers, failed to ensure the doors on soiled utility rooms would resist the passage of smoke, failed to ensure exit access doors were readily accessible, failed to ensure the facility failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness, failed to ensure the appropriate fire extinguisher was readily available in a food prep area, failed to ensure the proper usage of portable space heating devices, failed to ensure the trash chute was not blocked with trash in a trash chute discharge room, exit stairways, and exit discharge to the public way.

Findings include:

A tour was conducted between 03/01/11 and 04/04/11 with Staff WW and YY. Vertical opening doors and fire doors were tested which failed to close into the frame as follows:

a) Stair door 7-7 on the seventh floor did not latch when tested on 03/01/11 at 2:05 PM.

b) Stair door 6-4 on the 4 North unit did not latch on 03/02/11 at 2:03 PM.

c) A set of fire doors outside the cafeteria and elevators, on the 1st floor, did not latch when released from the hold open device on 03/03/11 at 10:51 PM.

The failure of these doors to latch properly was verified with Staff WW and YY during the tour. Each of these doors were equipped with positive latching hardware.

The following four smoke compartment barriers were observed with penetrations:

a) The smoke compartment barrier on the 6th floor, leading into the cardiac telemetry unit, had penetrations in the barrier (approximately 1 and 1/2 inches ) around a water sprinkler pipe, a 6-8 inch high by 1/2 inch penetration along a beam in the corner of the barrier by room 6204.

b) The smoke compartment barrier leading into the medical progressive unit, by room 7218, contained eight penetrations around pipes. These penetrations were 1/2 to 2 inches each in size.

c) The smoke compartment barrier on the 5th floor trauma unit (leading into the Burns Special Care Unit) was observed with a penetration around a rigid conduit.

d) The smoke barrier on the 2nd floor by room 2110 was observed with two penetrations around a conduit. These penetrations measured approximately 1 inch each in size.

These penetrations in the smoke compartment barriers were verified with the aforementioned staff during the tour.

The following soiled utility doors (equipped with positive latching hardware) were observed and and determined the openings around the doors would fail to resist the passage of smoke:

a) On 03/02/11 at 10:39 AM, Room 5522 was observed with a 1/4 inch or greater opening at the top right side of the door when in the closed position.


b) On 03/02/11 at 1:50 PM, Room 4421 was observed with a gap exceeding 1/8 inch at the top of the right side of the door.

c) On 03/03/11 at 9:40 AM, the door to Room 2418 (on the endoscopy unit) failed to latch into the frame when tested.

d) On 03/03/11 at 10:10 AM, the door to Room 2240 was not equipped with an automatic self-closing device and had to be manually closed into the frame. Two biohazard containers were observed in this room at the time of tour.

At the time of tour, the aforementioned staff verified these doors did not resist the passage of smoke.

Three sets of sliding glass exit access doors were observed in the Admitting area (west end of the building). These inner access doors were equipped with deadbolt locks that could be locked against egress and required a key to unlock the doors. Each of these sets of doors led to an acceptable exit discharge door.

Observation in the Wall Street Deli revealed an exit door in the food prep area which opened into the main corridor. These doors were blocked with cardboard boxes and a tray with breads.

During tour, Staff WW, XX, and YY verified these doors were not readily accessible.

The exit discharge lighting fixture, located between the gift shop storage room and the chapel, was observed with one single light bulb. A sidewalk, approximately 30 feet in length, led to the public way that contained additional lighting.

A second exit on the ground floor north side of the building (used by several hospital buildings) was equipped with a single light fixture at the exit discharge. At least 100 feet of sidewalk was observed outside this exit discharge was noted without adequate lighting. This was verified with Staff WW at that time.

Based on medical record reviews, hospital documents reviewed, staff interviews and observations, the hospital's governing body failed to ensure that the patients' right to be provided care in a safe setting was protected for one (Patient #67) of 67 patients reviewed, failed to ensure adequate nursing supervision and hall monitoring was provided according to the hospital's plan to prevent the sexual assault of one (Patient #67) of 67 patients reviewed, failed to ensure the parent of a ten year old patient were asked to give consent for the child to be transferred by a priest to another hospital emergency department. This affected one (Patient #54) of six medical records for pediatric patients admitted to the hospital in 2011, failed to ensure that emergency medical services were appropriately provided to pediatric patients presenting to the emergency room for two (Patient #54 and #52) of six pediatric patients reviewed that presented to the emergency department in 2011), failed to approve the hospital's policy regarding transfer of pediatric patients in need of emergency medical treatment, failed to ensure that the fire safety requirements were met in regard to vertical opening doors located in smoke compartment barriers latched, failed to ensure there were no penetrations in the smoke compartment barriers, failed to ensure the doors on soiled utility rooms would resist the passage of smoke, failed to ensure exit access doors were readily accessible, failed to ensure the facility failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness, failed to ensure the appropriate fire extinguisher was readily available in a food prep area, failed to ensure the proper usage of portable space heating devices, failed to ensure the trash chute was not blocked with trash in a trash chute discharge room, exit stairways, and exit discharge to the public way.


Findings included:

The governing body failed to ensure all patients were given the right to receive care in a safe setting. This affected 1 Patient (#67) from the total of 67 patients reviewed. The patient census was 393.
Please refer to A144.

The governing body failed to ensure adequate nursing supervision and hall monitoring was provided according to the hospital's plan to prevent the sexual assault of patients. This affected 1 Patient (#67) from the total of 67 patients reviewed.
Please refer to A144.


The governing body failed to ensure the parent of a ten year old patient were asked to give consent for the child to be transferred by a priest to another hospital emergency department. This affected one (Patient #54) of six medical records for pediatric patients admitted to the hospital in 2011.
Please refer to A131.


The governing body failed to ensure emergency services were organized in such a manner as to provide care to all patients presenting to the emergency department. This affected two of six pediatric patients reviewed that presented to the emergency department in 2011 (Patient #54 and #52).
Please refer to A1102.

The governing body failed to failed to ensure that the fire safety requirements were met in regard to vertical opening doors located in smoke compartment barriers latched, failed to ensure there were no penetrations in the smoke compartment barriers, failed to ensure the doors on soiled utility rooms would resist the passage of smoke, failed to ensure exit access doors were readily accessible, failed to ensure the facility failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness, failed to ensure the appropriate fire extinguisher was readily available in a food prep area, failed to ensure the proper usage of portable space heating devices, failed to ensure the trash chute was not blocked with trash in a trash chute discharge room, exit stairways, and exit discharge to the public way.

Findings include:

A tour was conducted between 03/01/11 and 04/04/11 with Staff WW and YY. Vertical opening doors and fire doors were tested which failed to close into the frame as follows:

a) Stair door 7-7 on the seventh floor did not latch when tested on 03/01/11 at 2:05 PM.

b) Stair door 6-4 on the 4 North unit did not latch on 03/02/11 at 2:03 PM.

c) A set of fire doors outside the cafeteria and elevators, on the 1st floor, did not latch when released from the hold open device on 03/03/11 at 10:51 PM.

The failure of these doors to latch properly was verified with Staff WW and YY during the tour. Each of these doors were equipped with positive latching hardware.

The following four smoke compartment barriers were observed with penetrations:

a) The smoke compartment barrier on the 6th floor, leading into the cardiac telemetry unit, had penetrations in the barrier (approximately 1 and 1/2 inches ) around a water sprinkler pipe, a 6-8 inch high by 1/2 inch penetration along a beam in the corner of the barrier by room 6204.

b) The smoke compartment barrier leading into the medical progressive unit, by room 7218, contained eight penetrations around pipes. These penetrations were 1/2 to 2 inches each in size.

c) The smoke compartment barrier on the 5th floor trauma unit (leading into the Burns Special Care Unit) was observed with a penetration around a rigid conduit.

d) The smoke barrier on the 2nd floor by room 2110 was observed with two penetrations around a conduit. These penetrations measured approximately 1 inch each in size.

These penetrations in the smoke compartment barriers were verified with the aforementioned staff during the tour.

The following soiled utility doors (equipped with positive latching hardware) were observed and and determined the openings around the doors would fail to resist the passage of smoke:

a) On 03/02/11 at 10:39 AM, Room 5522 was observed with a 1/4 inch or greater opening at the top right side of the door when in the closed position.


b) On 03/02/11 at 1:50 PM, Room 4421 was observed with a gap exceeding 1/8 inch at the top of the right side of the door.

c) On 03/03/11 at 9:40 AM, the door to Room 2418 (on the endoscopy unit) failed to latch into the frame when tested.

d) On 03/03/11 at 10:10 AM, the door to Room 2240 was not equipped with an automatic self-closing device and had to be manually closed into the frame. Two biohazard containers were observed in this room at the time of tour.

At the time of tour, the aforementioned staff verified these doors did not resist the passage of smoke.

Three sets of sliding glass exit access doors were observed in the Admitting area (west end of the building). These inner access doors were equipped with deadbolt locks that could be locked against egress and required a key to unlock the doors. Each of these sets of doors led to an acceptable exit discharge door.

Observation in the Wall Street Deli revealed an exit door in the food prep area which opened into the main corridor. These doors were blocked with cardboard boxes and a tray with breads.

During tour, Staff WW, XX, and YY verified these doors were not readily accessible.

The exit discharge lighting fixture, located between the gift shop storage room and the chapel, was observed with one single light bulb. A sidewalk, approximately 30 feet in length, led to the public way that contained additional lighting.

A second exit on the ground floor north side of the building (used by several hospital buildings) was equipped with a single light fixture at the exit discharge. At least 100 feet of sidewalk was observed outside this exit discharge was noted without adequate lighting. This was verified with Staff WW at that time.

Based on medical record and hospital policy review and staff interview, the hospital failed to ensure that emergency medical services were provided appropriately to pediatric patients presenting to the emergency room and failed to ensure the hospital's policy regarding transfer of pediatric patients in need of emergency medical treatment had been approved by the medical staff in accordance with hospital policy..

Findings included:

The hospital failed to ensure emergency services were organized in such a manner as to provide care to all patients presenting to the emergency department. This affected two of six pediatric patients presenting to the emergency department in 2011 (Patient #54 and #52).
Please refer to A1102.

The hospital staff failed to ensure the hospital's policy regarding transfer of pediatric patients that needed emergency medical treatment had been approved by the medical staff in accordance with hospital policy.
Please refer to A1104.

Based on medical record review and staff interview, the hospital failed to ensure the parent of a ten year old patient was asked to give consent for the child to be transferred to another hospital emergency department in the care of a priest . This affected one (Patient #54) of six medical records for pediatric patients admitted to the hospital in 2011.

Findings included;

The medical record for Patient #54 was reviewed on 03/03/11. The ten year old patient, brought to the emergency department by a priest, was admitted to the emergency department on 01/21/11, with burns of the right leg. The parents were not present with the patient. The medical record revealed the patient had first and second degree burns to the right thigh which measured 10 cm. by 20 cm. The patient arrived at the emergency department at 8:44 A.M. The patient was examined by the emergency department physician, but no time the examination was conducted was documented. The examination included a history of present illness, vital signs and a description of the wound. The review of systems on the assessment form stated "not done". The emergency department course section of the assessment form stated the wounds were cleaned and a dressing applied and "we will transfer the patient to the Children's Hospital Medical Center for evaluation and particularly for follow of this pediatric burn." "I spoke with Dr. (name) from the Children's Hospital Medical Center, who has accepted the transfer." The medical record contained evidence the patient's father was contacted by phone and gave verbal consent for treatment at 9:03 A.M. The medical record lacked documentation of any discussion with the patient's father regarding a need to transfer the patient to the emergency department of another hospital. The medical record lacked documentation the patient's father had given consent for the patient to be transferred to the emergency department of another hospital. A nursing note at 9:10 A.M. revealed the patient was sent to Cincinnati Children's Hospital with "priest via private car. Wrapped in warm blanket. To car via w/c (wheelchair)." The medical record lacked documentation of any instructions to the priest regarding care of the patient during transfer. The medical record lacked documentation the priest was qualified to care for the child during transfer. The medical record lacked documentation copies of the patient's medical record were sent to the receiving facility for continuity of care purposes.

These findings were confirmed with hospital Administrative staff at the time of exit on 03/04/11 at 3:45 P.M.

Based on staff interview and record review, the hospital failed to ensure all patients were provided care in a safe setting. This affected 1 Patient (#67) from the total of 67 patients reviewed. The patient census was 393.

Findings include:

The clinical record review for Patient #67 was completed on 03/04/11. The Patient was admitted to the hospital on 12/27/10 with a principal diagnosis of Right Breast Carcinoma for the last round of chemotherapy. The patient had become lethargic and had a seizure (status epilepticus) and was intubation after she stopped breathing . The patient had a prolonged stay in the Neurosurgical Care Unit and was extubated on 01/10/11. Patient #67 had been drowsy and delirious at times throughout admission. Social issues had been identified with husband as he was not allowed to be with patient alone.

On 12/27/10 the social worker documented " social worker not able to completed psycho social assessment due to patient very groggy. Patient #67 was asked by social worker is she feels safe to go home with husband and she did not answer Patient did shake her heard yes that she would prefer Social worker come back when husband is not in the hospital . Husband was outside of room during our conversation. Social worker will meet with patient in the morning."

The initial social work psychosocial assessment was documented as completed on 12/31/10. This assessment stated "met with family. Patient currently intubated. Concern has been voiced that patient is the victim of domestic violence at home and confusion about who is nok/hcpoa (next of kin/health care power of attorney). Located hcpoa forms in Access/Anywhere and met with son. Updated contact information with admitting. Located ER (Emergency Room ) note from 12/26/10 that indicated that patient did fear for her safety at home and had made plans to go to a shelter but changes her mind and returned home."

A "memo" was documented on 01/03/11 by the Neuroscience ICU Clinical Manager that stated " I received notification that the patient had been given oral sex while unconscious in another unit. I investigated it with the UC (University of Cincinnati) police and was informed that charges couldn't be filed. for the safety of this patient I informed the charge nurse that husband was not allowed to visit unsupervised by our staff or the son. The charge nurse then passed that information to the next charge nurse and so on. I also informed the patient's nurse who passed the information on to the next charge nurse and so on. I also informed the patient's nurse who passed the information on to the next shift. With the physician I explained the situation and they were in support of the visiting restrictions."

A police information report reference for "inappropriate behavior" was dated 01/03/1011 for the incident of 01/01/2010 to patient #67. This report stated Staff L ( nurse on the unit) "is a nurse on the 7th floor MICU (Medical Intensive Care Unit) walked into patient's room (Patient #67) and observed her husband performing oral sex on her. The patient is currently in a comatose state on 01/01/11 when the incident occurred. The patient has since been moved to the 4 th floor room #17. Staff L advised the patient's husband the visiting hours were over and that he would have to keep the curtains open when visiting his wife. Spoke to the nursing manager for NICU (Neuro Intensive Care Unit) and all information was previously listed on chart."

The Condition of Nursing Services remains cited as noted in the 01/03/2011 substantial allegation Complaint (OHOOO58367) survey.

Based on staff interview, review of hospital's Medical Staff Policy and Procedure (#5 Delinquency) and review of the hospital's medical record's statistics form, it was determined the hospital failed to ensure each medical record was completed. This affected 3008.25 medical records not completed. The total census was 396.

Findings include:

The hospital medical record's statistical information reported a delinquency rate of medical records of 3008.25. Refer to A 438, 482.24 (b) Form and Retention of Record.

Based on staff interview, review of hospital's Medical Staff Policy and Procedure (#5 Delinquency) and review of the hospital's medical record's statistics form, the hospital failed to ensure each medical record was completed within 30 calendar days of discharge. This affected 3008.25 medical records not completed. The total census was 396.

Findings include:

Interview with Staff H (medical records department head) on 03/02/11 in the afternoon hours revealed the number of delinquent medical records was 3008.25. Staff H stated there had been a "glitch" in the system that occurred in December, 2010 with the hospital's vendor for computerized medical records. Due to this "glitch", Staff H stated, the physician's were not aware of the medical record delinquency.

Review of the hospital's medical records statistical information for the calendar year of 2010, revealed documentation of an average monthly discharge rate of 10,313. The monthly delinquency rates were as follows: January, 2010 was 2351, February, 2010 was 2605, March, 2010 was 2530, April, 2010 was 2164, May, 2010 was 2143, June, 2010 was 1893, July, 2010 was 1245, August, 2010 was 5070, September, 2010 was 4748, October, 2010 was 4932 and November, 2010 was 2550.


Review of the hospital's Medical Staff Policy and Procedure #5 Delinquency revealed, "The attending physician is responsible for completing the medical records within 30 calendar days of discharge. The attending physician will receive notification from the medical records department regarding incomplete or delinquent medical records as follows: 1. Primary notification- initial log-in Access Anywhere. Physician is responsible to log in and check for delinquencies on a regular basis. 2. Secondary notification-medical reds will send a reminder notification at 15 day delinquency by electronic mail. 3. Warning-medical records will send a pending suspension notification at 23 days delinquent by electronic mail notifying the physician that they have 7 days to completed their records or they will be placed on suspension. 4. Suspension -any physician that has not completed their records by day 30 will be placed on suspension.). The current list of suspended physicians was 21 from August, 2010 to March 1, 2011.

Based on observations and staff interviews, the hospital failed to ensure that the kitchen hood filters were maintained and cleaned as needed, failed to ensure a set of smoke barrier doors and two stair way doors closed tightly when tested; 4 smoke barriers were free from penetrations; soiled utility rooms resisted the passage of smoke or were self-closing; exit access doors were readily accessible; exit discharges contained adequate lighting; food prep areas contained the appropriate fire extinguishers; portable space heaters were not used in patient sleeping areas, or when used in office areas, failed to ensure these devices did not exceed 212 degrees Fahrenheit; one trash chute discharge was not blocked with trash; and one stairwell was in accordance with the code, and failed to ensure one exit discharge contained a continuous surface to the public way. This could affect all 396 patients in the facility. The hospital failed to ensure patient cots and chairs in the psychiatric emergency services department were maintained in a clean manner. This affected three of four quiet rooms in the unit. The unit contained a total of 15 beds.



Findings include:

The hospital failed to ensure that the kitchen hood filters were maintained and cleaned as needed.
Please refer to A701.

The hospital failed to ensure fire safety requirements were met related to a set of smoke barrier doors and two stair doors did not close when tested, smoke barriers were observed with penetrations, soiled utility room doors either did not resist the passage of smoke or lacked an automatic closing device, exit access doors contained deadbolts or were blocked, exit discharge lighting for two exits contained only a single bulb, a food prep area lacked the appropriate fire extinguisher, usage of portable space heaters, and one trash chute discharge room.
Please refer to A710.

The hospital failed to ensure a set of smoke barrier doors and two stair way doors closed tightly when tested; 4 smoke compartments barriers were free from penetrations; soiled utility rooms resisted the passage of smoke or were self-closing; exit access doors were readily accessible; exit discharges contained adequate lighting; food prep areas contained the appropriate fire extinguishers; portable space heaters were not used in patient sleeping areas, or when used in office areas, failed to ensure these devices did not exceed 212 degrees Fahrenheit; one trash chute discharge was not blocked with trash; and one stairwell was in accordance with the code, and failed to ensure one exit discharge contained a continuous surface to the public way.
Please refer to A710.

The hospital failed to ensure patient cots and chairs in the psychiatric emergency services department were maintained in a clean manner.
Please refer to A724.

Based on observation and staff interview the hospital failed to ensure that the kitchen hood filters were cleaned in a manner to ensure adequate sanitation was maintained in food preparation areas for the health and safety of the patients. This had the potential to affect all 396 patients currently in the hospital.

Findings included:

A tour of the kitchen on 03/03/11 at 10:17 AM revealed a hood filter system over a hot food prep area. Three metal filters in this hood were observed heavily coated with grease and dirt. Although not as heavily coated, five additional filters were observed to be in need of cleaning due to an accumulation of grease and dust. An interview with the dietary manager revealed the identified filters are only cleaned quarterly, and verified they were in need of cleaning.

Based on observations and staff interviews, the hospital failed to ensure that the fire safety requirements were met in regard to vertical opening doors located in smoke compartment barriers latched, failed to ensure there were no penetrations in the smoke compartment barriers, failed to ensure the doors on soiled utility rooms would resist the passage of smoke, failed to ensure exit access doors were readily accessible, failed to ensure the facility failed to ensure two exit discharges were equipped with more than a single lighting fixture to prevent the failure of any single lighting fixture leaving the area in darkness, failed to ensure the appropriate fire extinguisher was readily available in a food prep area, failed to ensure the proper usage of portable space heating devices, failed to ensure the trash chute was not blocked with trash in a trash chute discharge room, exit stairways, and exit discharge to the public way.

Findings include:

The hospital failed to ensure a set of smoke compartment barrier doors and two stair way doors closed tightly when tested. Refer to K21.

The hospital failed to ensure 4 smoke compartment barriers were free from penetrations. Refer to K25.

The hospital failed to ensure the doors to soiled utility rooms resisted the passage of smoke or were self-closing. (Refer to K29).

The hospital failed to ensure exit access doors were not blocked or locked. Refer to K38.

The hospital failed to ensure exit discharges contained adequate lighting. Refer to K45.

The hospital failed to ensure food prep areas contained the appropriate fire extinguishers. Refer to K64.

The hospital failed to ensure portable space heaters were not used in patient sleeping areas, or when used in office areas, failed to ensure these devices did not exceed 212 degrees Fahrenheit. Refer to K70.

The hospital failed to ensure one trash chute discharge was not blocked with trash. Refer to K71.

The hospital failed to ensure that two of five exits from the facility had a hard or paved surface from the exit discharge to the common way and the path of egress travel from one of five exits did not require a change from downward travel to upward travel. Refer to K130.

Based on direct observation and staff interview, the facility failed to ensure patient cots and chairs in the psychiatric emergency services department were maintained in a clean manner to ensure patient safety in preventing the spread of pathogens through unclean surfaces. This affected three of four quiet rooms in the unit. The unit contained a total of 15 beds.

Findings included;

A tour of the psychiatric emergency services unit was conducted on 03/03/11 at 9:50 A.M. The unit contained four rooms identified as quiet rooms to be used by patients experiencing psychiatric emergencies and who needed a quiet environment. Three of the four rooms were observed during tour. A patient was occupying room 1 and no observations could be made of that room. Rooms 2, 3 and 4 each contained a heavy plastic chair for patient use. The chairs in Rooms 2, 3 and 4 contained a heavy buildup of a black substance covering the entire surface of each chair. The chair in room two contained dried orange marks down the side of the chair which were easily removable when tested by the surveyor with a disposable disinfectant wipe. The floor in room 3 contained various small items of paper trash and dust. The cot in room three contained a heavy buildup of a black substance on the solid plastic shelf underneath the bed portion of the cot. The cot in room 4 contained three packs of saltine crackers on the solid plastic shelf underneath the bed portion of the cot. The heavy plastic chair located in room four also had white colored spill marks on the side of the chair. Two of the heavy plastic chairs were located in the hallway between rooms 2 and 3. These chairs also contained a heavy buildup of a black substance.

These findings were confirmed by Employees G, I and K at the time of tour, 03/03/11 at 9:50 A.M.

Based on medical record review, policy review and staff interview, the hospital failed to ensure emergency services were provided to all patients presenting to the emergency department in accordance with the hospital's policy. This affected two of six pediatric patients presenting to the emergency department in 2011 (Patient #54 and #52).

Findings included:

Review of the medical records and hospital policies and staff interview, revealed the hospital failed to ensure emergency services were provided to all patients presenting to the emergency department in accordance with the hospital's policy. This affected two of six pediatric patients review who presented to the emergency department in 2011 (Patient #54 and #52).
Please refer to A1102.

Review of the hospital's policies and interview with hospital staff revealed the hospital failed to ensure the emergency services policy specific to pediatric patients presenting to the emergency department was reviewed and approved. This had the potential to affect all pediatric patients who presented to the emergency room for treatment.
Please refer to A1104.

Based on medical record review, policy review and staff interview, the hospital failed to ensure emergency services were provided to all patients who presented to the emergency department, hospital failed to ensure the hospital emergency department policy titled: Procedure for Caring for Children Less than Fourteen Years of Age" had been reviewed by the Medical Staff. This affected two of six pediatric patients review that presented to the emergency department in 2011 (Patient #54 and #52).

Findings included:

The medical record for Patient #54 was reviewed on 03/03/11. The patient was a ten year old that arrived at the emergency department at 8:44 A.M on 01/21/11 with burns to the right leg. A priest brought this patient to the emergency room and the parents were not present with the patient.

Review of the medical record revealed the patient had first and second degree burns of the right thigh which measured 10cm by 20cm . The patient was examined by the emergency department physician, but there was no time documented for when the examination was conducted. The examination included a history of the patient's present illness, vital signs and a description of the wound. The review of systems was documented as "not done" on the assessment form. The emergency department's medical record, in the treatment course section, documented the wounds were cleaned and a dressing was applied and "we will transfer the patient to the Children's Hospital Medical Center for evaluation and particularly for follow of this pediatric burn...I spoke with Dr. (name) from the Children's Hospital Medical Center, who has accepted the transfer."

The medical record revealed documentation the patient's father was contacted by phone and gave verbal consent for treatment at 9:03 A.M. The medical record did not have documentation that a discussion with the patient's father occurred regarding a need to transfer the patient nor that the patient's father gave consent for the patient to be transferred.

A nursing note documented at 9:10 A.M. revealed the patient was sent to Cincinnati Children's Hospital with the "priest via private car. Wrapped in warm blanket. To car via w/c (wheelchair)." The medical record did not have documentation that the priest was given instructions regarding the care of the patient during transfer or evidence the priest was qualified to care for the child during transfer. There was no documentation in the medical record a copy of the patient's medical record was sent to the receiving hospital for continuity of care.

The medical record for Patient #52 was reviewed on 03/03/11. The patient was a 22 month old that arrived to the emergency department by ambulance on 02/22/11 after a motor vehicle accident. The medical record revealed the patient arrived at 11:58 A.M. with no signs of distress.

The emergency department physician documented an assessment of the patient which included a history of the present illness, past medical history, allergies, medications, social history, review of systems and a physical examination. The medical record lacked documentation of the time the patient was examined. The physician's plan was documented as "The patient will be asked to be taken to Cincinnati Children's Hospital Medical Center for further comprehensive pediatric evaluation." The plan further stated; "I have identified no emergency medical condition during my examination Patient has received emergent medical _____ and discharged." The medical record did not have documentation as to the rationale for referring the patient to another hospital's emergency department if no emergency medical condition existed. The discharge instructions to the patient's parents included "Go to Cincinnati Children's Hospital". The patient was discharged at 2:30 P.M.

An interview was conducted with the Assistant Medical Director of the Emergency Department, (an Emergency Department physician), Employee F on 03/01/11 at 11:00 A.M. Employee F stated the emergency department would treat pediatric patients with minor care needs, such as a sore throat or ear ache and discharge them to home. Pediatric patients in need of resuscitation would be treated and stabilized then transferred. Any patients with pneumonia or a similar illness would be discharged with the parents and instructed to go to Children's hospital. Employee F stated the emergency department physician would check the lungs, eyes ears and nose. No lab tests, x-rays or similar tests would be conducted, despite having this capability. Employee F stated the emergency department would contact a physician at Children's hospital as a courtesy.

The hospital's policy titled: Procedure for Caring for Children Less than Fourteen Years of Age" was presented on 03/02/11. The policy lacked a policy number. The policy indicated it had been reviewed in February, 2010. The policy lacked evidence this policy had been reviewed by the medical staff. The bottom of the policy contained lines for signatures of the Medical Director of the center for emergency care and the acting nursing director of the center for emergency care. Both signature lines were unsigned.

The policy stated a medical screening exam must be completed and documented by an emergency attending physician. If there is no emergency medical condition identified, the patient may be discharged and referred to CHMC (Children's Hospital Medical Center) for definitive care. A copy of the discharge instructions will be given to patient and family. The policy does not state if the referral should be for emergency care or for follow up care at a later time and date. The policy further lacked instructions for what is to be included in the medical screening exam, or any definition or guidance regarding the completeness of the exam to include laboratory tests and/or radiology tests as appropriate.

Based on medical record review, policy review and staff interview, the hospital failed to ensure emergency services policy specific to pediatric patients who presented to the emergency department was reviewed and had been approved by the medical staff in accordance with hospital policy. This had the potential to affect all pediatric patients who presented to the emergency room for treatment.

Findings included:

The hospital policy titled: Procedure for Caring for Children Less than Fourteen Years of Age" was presented on 03/02/11. The policy lacked a policy number. The policy indicated it had been reviewed in February, 2010. The policy lacked evidence this policy had been reviewed by the medical staff. The bottom of the policy contained spots for signatures of the Medical Director of the center for emergency care and the acting nursing director of the center for emergency care. Both signature lines were unsigned. The policy stated a medical screening exam must be completed and documented by an emergency attending physician. If there is no emergency medical condition identified, the patient may be discharged and referred to CHMC (Children's Hospital Medical Center) for definitive care. A copy of the discharge instructions will be given to patient and family. The policy does not state if the referral should be for emergency care or follow up care at a later time and date. The policy further lacked instructions for what is to be included in the medical screening exam, or any definition or guidance regarding the completion of the exam to include laboratory tests and/or radiology tests as appropriate.

An interview of the Assistant Medical Director of the Emergency Department, (an Emergency Department physician), Employee F on 03/01/11 at 11:00 A.M. Employee F stated the emergency department would treat pediatric patients with minor care needs, such as a sore throat or ear ache and discharge them to home. Pediatric patients in need of resuscitation would be treated and stabilized then transferred. Any patients with pneumonia or a similar illness would be discharged with the parents and instructed to go to Children's hospital. Employee F stated the emergency department physician would check the lungs, eyes ears and nose. No lab tests, x-rays or similar tests would be conducted, despite having this capability. Employee F stated the emergency department would contact a physician at Children's hospital as a courtesy.