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Based on record review and interview with staff, the facility failed to pursue and obtain appropriate informed consents for treatment and care provided for 11 patients (#2, #6, #7, #8, #9, #11, #19, #25, #28, #29 and #35) of the 37 patients in the sample.

Findings are as follows:

Authorization for Treatment

Upon review of clinical records of 10 patients in the sample, (#2, #6, #7, #8, #9, #19, #25, #28, #29 and #35) it was noted that the facility used an Authorization for Treatment form as documentary evidence that the patient or his/her legal representative has been informed of his/her health status and consented to provision of treatment at the facility by facility staff. In all 10 of these records, there was either no signed consent or the consent was signed inappropriately by a person not authorized to make legal decisions for the patient.

These records and the facility's policy were reviewed and discussed with the facility's Risk Management Director and other administrative staff, who acknowledged that appropriate informed consent for treatment had not been obtained.

1. Patient #2 was transferred from the Emergency Department to the Psychiatric Unit on 1/8/10. The nurse on the unit wrote at 6:30 am that the patient was "pleasant but very confused." She also wrote that he was unable to sign any paperwork and that she was unable to do any further assessment. During the day shift, the nurse wrote that the patient was medicated with antipsychotic and anti-anxiety medications simultaneously for violent behavior and disorganized and pressured speech. She noted that he was unable to sign a release form to obtain medical records from another facility. Upon review of the patient's medical record, it was noted that the Authorization for Treatment form was signed by Patient #2 on 1/8/10, the day of admission to the unit when his cognitive and behavioral status were in question. There was no witness to the signature, and no evidence of any attempts to inform the patient of his rights later in his stay when his cognitive and mental status had improved.

2. Patient #6 was admitted on 1/3/10. Review of the Authorization for Treatment form revealed a written notation of "Verbal OK." There was no witness signature, no other signature and no other documentation.

3. Patient #7 was admitted 1/11/10 for a severe headache, and was discharged the next day. The Authorization for Treatment form was signed by the patient's fiance, although that person had no legal authority to do so.

4. Patient #8 was admitted 1/6/10. The Authorization for Treatment form had a written notation that stated "verbal consent patient being treated." There was no evidence that any additional attempt was made to provide the patient with an opportunity to sign for authorization.

5. Patient #9 was admitted 1/9/10. The Authorization for Treatment form had a written notation that the patient was unable to sign due to intoxication. There was no evidence that any other attempts were made to provide information regarding treatment to the patient or a legal representative.

6. Patient #19 was admitted on 1/8/10. Upon review, the Authorization for Treatment form had that date written in with the notation "unable to sign" and an "X" mark. There was no other notation on the form to indicate an explanation for the "X", and there was no other signature or identified witness. Upon review of the patient's record it was noted that the patient had an involved spouse, and that the patient had returned to an improved cognitive status by the fourth day of stay. There was no evidence that any effort had been made to obtain consent from the spouse or to follow-up with the patient.

7. Patient #25 was admitted on 1/7/10 and the Authorization for Treatment form in the record was noted "unable to sign." The record made reference to an identified Health Care Agent for the patient, but there was no evidence that any effort was made to contact the Agent for consent.

8. Patient #28 was admitted on 1/10/10 and the Authorization for Treatment form had a notation that stated "patient unable (OD)." There was no evidence that any other effort was made to inform the patient or a legal representative of his rights.

9. Patient #29 was admitted on 12/27/09 in an unresponsive state and was admitted as unidentified "Jane Doe." This name was written on the Authorization for Treatment form which was not signed. The patient regained consciousness two days after admission, but there was no evidence that any attempt was made to inform the patient of her rights at that time. There was no signature or documentation of a follow-up with the patient or a legal representative before the patient was discharged on 1/13/10.

10. Patient #35 was admitted 12/14/09 and discharged 1/14/10. The patient presented to the Emergency Department with psychotic symptoms and was accompanied by his sister. The Authorization for Treatment form was not signed by the patient or his sister, and had a notation of "Verbal OK Security at Bedside." There was no other information and no witness signature. During the hospital stay, the sister obtained temporary legal guardianship but there was no evidence that any attempt was made to provide information to her or to the patient.

11. Other consent forms were found in the records that were signed inappropriately.
- Patient #11, who had signed other forms and paperwork on admission on 12/8/09, did not sign a required notice of patient's rights form until 12/15/09.
- In the records of Patient #2 and Patient #35 there was a form for a release of medical information which was blank but was already signed by the patient, although by law the patient has to be informed prior to signing what records are to be requested and for what purpose.




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Based on record review and staff interview, the hospital failed to follow its' policy for discharging a mother and her newborn for 1 (#18) of a total sample of 37.

Findings included:

Patient #18 was admitted on 1/12/10, after going into labor at around 12:30 A.M.

The patient's labor and delivery were uncomplicated, and a healthy, newborn girl was delivered at 12:37 A.M. on 1/12/10.

Record review on 1/14/10, revealed that discharge requirements by the hospital included the patient signing a form titled " Parental Discharge Acknowledgement. " Review of the form indicated, "I certify that during the discharge procedure, I checked the Ident-A-Band bracelet on both the baby and myself and found that they contained the correct identification number. I certify that I have received my baby. "

The Parental Discharge Acknowledgement form was not signed by the patient per the hospital ' s policy. The incomplete form contained the date and the signature of one of the hospital staff nurses. The mother's signature acknowledging that she had checked the identification number on both herself and her baby was omitted.

Interview with the nurse manager of the obstetrics/maternity service on 1/15/10 at 10:15 A.M., confirmed that the nurse who discharged the patient and her newborn, failed to follow the hospital's policy on completing the Parental Discharge Acknowledgement process.

Based on clinical record reviews, observations and interviews with nursing staff and nursing administration, hospital staff failed to administer medications to 5 identified patients (#2, 4, 6, 11 & 21) of a sample of 37, in a manner to ensure that the prescribed medications were administered within an acceptable period of time.

The findings are as follows:

1. Patient #11 was admitted to the hospital 12/8/09 with multiple medical diagnoses including acute and chronic renal failure, congestive heart failure and a question of pneumonia.

Over the course of hospitalization the patient had undergone multiple medical procedures. The patient was started on dialysis during this hospitalization. On 12/17/09 the patient had a cardiac arrest, was resuscitated and was transferred to the intensive care unit. According to the medical record the patient developed a right upper extremity deep vein thrombosis. The patient underwent a volar fasciotomy 12/20/09 for compartmental syndrome. While hospitalized the patient had a gastrostomy tube inserted.

On 1/13/10 at 9:30 AM survey staff observed the nurse administer the patient's morning medications. Following the medication administration the nurse asked the patient if she had pain and to designate a number 0 to 10 (0 being no pain and 10 being the worst) related to the degree of pain that she currently was experiencing. The patient indicated that the pain was at a "9" level. The nurse informed the patient that she would bring her some Tylenol for the pain.

At 11 am. the surveyor accompanied the clinical leader to the patient's room. During that visit the surveyor asked the patient if she had received the Tylenol. The patient responded that she had not been medicated with Tylenol.

At 1:15 PM. the surveyor observed the patient's nurse enter her room and inform the patient, "I have some Tylenol for you."

It was noted in the patient's medical record that the nurse had taken a verbal telephone order for Tylenol on 1/13/10 at approximately 1 PM.

The surveyor interviewed the nurse regarding the delay in providing pain medication to this patient. The nurse indicated that the patient did not have a physician order for Tylenol and that there was a delay (approximately 3.5 hours) in contacting the physician to obtain an order. The nurse acknowledged that the patient had a variety of narcotic pain medications ordered; however, the nurse was reluctant to administer them as her opinion was that it was not necessary.

On 1/15/10 the VP of Patient Care Services was interviewed regarding the delay in providing pain medication to this patient. She confirmed that a delay of 3.5 hours to provide pain medication was not acceptable.

2. Patient #2's record and medication administration history as provided by facility staff revealed that on two occasions, a physician had written a medication order with the time to be administered as "now." On both occasions, a substantial amount of time passed before the nurse administered the medication, as follows.

a. During the initial tour of the psychiatric unit on 1/12/2010 at approximately 10:30 AM, the surveyors were approached by patient #2 who was speaking rapidly and insistent on demonstrating how the toilets flushed. The patient began rapidly flushing the toilet while stating "see, see." The nurse intervened and escorted the patient to another room.

Review of the record indicated that approximately 30 minutes after the surveyors' observation, on 1/12/10 at 11:05 AM, the physician wrote an order for patient #2 for the antipsychotic drug Abilify "5 mg orally every morning start now." Medication administration records show that the first dose of this drug was administered at 12:38 PM.

b. During review of the medication orders for Patient #2, it was noted that on 1/11/10 at 11:30 AM the physician wrote orders for three medications to be administered orally "x 1 [one time only] now." These three medications were:
-the anti-anxiety medication, Ativan 1 mg,
-the anti-depressant medication, Celexa 10 mg,
-and the medication Lithium 300 mg., used to prevent and/or control mania.

Documentation could not be found on the current medication administration records for the time of administration of these medications. The nurse practitioner provided an additional medication record which included the specific times the medications were administered. According to this record the medications that were ordered at 11:30 AM. for "now" were administered at 3:00 PM.

During interview with a nurse on the unit, she stated that "now" meant within an hour or two after the order was given, and that this type of order did not mean that the medication needed to be given immediately.

The delay in the administration of these medications was discussed with nursing administration and the Director of Operations for Behavioral Health. They each indicated that an order for "now" administration meant that the medication was to be given at that time. No other information or documentation was provided regarding the delay in the administration of these physician ordered medications.

3. Patient #21 was admitted to the hospital 1/11/10 with medical diagnoses which included ureteral stones, leukocytosis and a history of atrial fibrillation.

Review of the medical record indicated that on 1/12/10 at 9:10 AM there was a physician's order for the nurse to administer 5 mgm. of intravenous Cardizem (a calcium channel blocker) "now" to patient #21. The Cardizem had been ordered as the patient had been identified as having rapid atrial fibrillation.

Review of the electronic medication administration record revealed that the Cardizem was administered on 1/12/10 at 10:37 AM.

On 1/13/10 the nurse manager was asked to print a copy of the patient's pharmacy activity report for the previous 24 hours. This activity report indicated that on 1/12/10 at 10 AM. a nurse removed a vial of Cardizem 25 mgm./5 ml. from the medication system (the secured Pyxis medication station) for this patient. The information provided indicated that nurse did an "override" of the system in order to access the medication.

Review of the information related to the time frame of the administration of this medication failed to provide clear and concise documentation related to the actual time the nurse administered the medication. The physician order was timed at 9:10 AM, the medication was removed from the secured medication unit at 10 AM, administration time was charted as 10:37 AM. The nurse wrote a nursing note at 11:46 AM and acknowledged the administration of the Cardizem, however, there was no actual time of administration included in the note.

On 1/15/10 the VP of Patient Care Service was interviewed regarding the issues related to medication administration. The Hospital administrative staff confirmed that there was no written policy or procedure related to the terminology of "now." The VP of Patient Care Services indicated that when medications were ordered to be administered "now" that they were to be administered "now."

4. Review of Patient #4's clinical record and medication administration records on 1/13/10 revealed the psychiatrist had ordered the antipsychotic medication, Abilify 5 milligrams "now" at 10:35 A.M. on 1/12/10. Medication administration records reviewed noted the medication was administered at 11:39 A.M., over one hour later.

The medication administration records were reviewed with nursing staff on 1/13/10 and with the Director of Operations for Behavioral Health on 1/14/10. The Director confirmed medications ordered "now" should be administered at that time.

5. Review of the Patient #6's record and medication administration history provided by facility staff revealed that on four occasions, a physician had written a medication order with a time to be administered as "now."

- On 1/9/10 at 11 A.M. , the physician had written an order for Klonopin 0.5 milligrams to be administered orally for one dose "now." Medication administration records reviewed noted the dose was given at 11:31 A.M.

- On 1/10/10 at 9:30 A.M., the physician ordered Cardizem 30 milligrams give first dose now. According to the medication administration records reviewed, the medication was administered at 10:18 A.M.

- At 8:30 P.M. on 1/10/10, the nurse obtained a telephone order for Cardizem 30 milligrams for one dose "now." Documentation on the medication administration record noted the medication was given at 9 P.M.

-The physician ordered on 1/11/10 at 8:30 A.M., for the patient to receive Cardizem 30 milligrams orally for one dose "now." Medication administration records reviewed revealed the medication was administered at 8:54 A.M.

These medication records were reviewed on 1/13/10 with the the Unit Clinical Manager and the Nurse Educator for the Medical-Surgical Units who both acknowledged that medications ordered for "now" should be given at that time.

The facility failed to maintain current and accurate records for scheduled drugs in the employee pharmacy.

Findings include:

1. Based upon observation and interview with staff of the employee pharmacy the facility failed to keep a perpetual inventory of each Controlled Substance in Schedule II that is reconciled every ten days. On January 12, 2010 at 10:45 A.M. surveyor observed that the inventory records for four Schedule II Controlled Substances had not been reconciled since 12/30/09 and one Schedule II Controlled Substance had not been reconciled since 12/21/09. Reconcile inventory is required under 247 CMR 9.01: (14) "A pharmacist shall keep a perpetual inventory of each controlled substance in Schedule II which the pharmacist has received, dispensed or disposed of in accordance with the law. This inventory must be reconciled at least once every ten days."

2. Based upon observation and interview with staff of the employee pharmacy, the facility failed to keep a perpetual inventory of each Controlled Substance in Schedule III, IV and V. The hospital pharmacy must maintain a perpetual inventory; and an accountability system must be maintained that would deter and detect diversion of Controlled Substances in Schedule III, IV, and V as required under 105 CMR 700.005.

Based on observations and interview with the Director of Pharmacy, the facility failed to provide drugs and biologicals in accordance with applicable standards.

Findings include:

Observation and interview with pharmacy staff on 1/12/2010 in the Medical Oncology Pharmacy Satellite, the Intravenous Admixture Service is not compliant with the current Standards of the United States Pharmacopoeia Chapter 797. The hospital's pharmacists are not compliant with 247 CMR 9.01 (3) "A pharmacist shall observe the standards of the current United States Pharmacopoeia." The Intravenous Admixture Service area and preparation hoods lack the physical requirements for USP 797 Standards for preparation of sterile intravenous solutions.

The facility failed to ensure that outdated and beyond use medications were removed from patient use.

Findings include:

1. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 9 AM in Nursing Area "ED", the surveyor observed that the Pediatric Code Cart contained an injection of Sodium Bicarbonate Pediatric with an expiration date of January 1, 2010. The injection was out of date.

2. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 9 AM in Nursing Area "ED", the surveyor observed 2 bottles of glucometer Lifescan SureStep Pro Test Strips and one bottle of glucometer Low Control Test Solution that were open and not dated by staff when first used. The manufacturer states that the test strip bottle must be discarded after 120 days after opening, and the low control test solution must be discarded after 90 days. The open and not dated bottles are considered beyond use date (out of date).

3..Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 10:25 AM in Nursing Area "MB5A" the surveyor observed in the medication room cabinet a bottle of MD-Gastroview with an expiration date of JUL 09. The bottle expired the last day of July 2009. The bottle was out of date.

4. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 10:40 AM in Nursing Area "MB4B" the surveyor observed in the medication room refrigerator two vials of Tubersol PPD (Tuberculin Purified Protein Derivative). The manufacturer states in professional literature that once a multi-dose vial is opened the Tuberculin PPD is stable for 30 days and not to be used after 30 days. One opened and dated vial was marked to expire on 1/9/2010; the other open vial was not marked with the date of opening nor the date when to expire. The open and not dated vial is considered beyond use date (out of date) and the expiration dated vial is out of date.

5. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 10:55 AM in Nursing Area "MB4A", the surveyor observed in the medication room refrigerator one vial of Tubersol PPD (Tuberculin Purified Protein Derivative). The manufacturer states in professional literature that once a multi-dose vial is opened, the Tuberculin PPD is stable for 30 days and not to be used after 30 days. The open vial was not marked with the date of opening nor the date when to expire. The open and not dated vial is considered beyond use date (out of date).

6. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 11:15 AM in Nursing Area "MB3B" the surveyor observed in the medication room refrigerator one vial of Tubersol PPD (Tuberculin Purified Protein Derivative). The manufacturer states in professional literature that once a multi-dose vial is opened the Tuberculin PPD is stable for 30 days and not to be used after 30 days. The opened and dated vial was marked to expire on 11/05/2009, this vial is out of date.

7. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 11:20 AM in Nursing Area "MB3A", the surveyor observed 2 bottles of glucometer Lifescan SureStep Pro Test Strips that were open and not dated by staff when first used. The manufacturer states that the test strip bottle must be discarded after 120 days after opening. The open and not dated bottles are considered beyond use date (out of date).

8. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 11:40 AM in Nursing Area "OB", the surveyor observed one open vial of Humulin R Insulin, not dated by staff when opened and one bottle of Novolin N Insulin not dated by staff when opened. The manufacturer states in professional literature that once a multi-dose vial of insulin is opened the bottle should be discarded after 28 days. The open and not dated bottles are considered beyond use date (out of date).

9. Based upon observations and interview with the Director of Pharmacy on 1/13/10 at 11:45 AM in Nursing Area "LD", the surveyor observed that the Pediatric Code Cart contained an injection of Sodium Bicarbonate Pediatric with an expiration date of January 1, 2010 and an injection of Epinephrine Pediatric with an expiration date of January 1, 2010. The injections were out of date.

The facility failed to ensure food service operations adhered to hospital policies and procedures and acceptable standards of practice to ensure proper food handling.

Based on document review, observation and interview, the facility failed to maintain and/or insure sanitary conditions during the preparation, distribution and service of foods. Dietary managers failed to ensure food service handlers adhered to: proper hygienic food handling practices and the timely distribution of meals to maintain palatable foods at proper temperatures. Findings included:

1. Observation of the of the meal tray service line on 1/13/10 from 11:30 A.M. to 11:45 A.M., revealed improper food handling techniques as evidenced by the following:

Staff failed to ensure proper hygienic food handling practices and techniques during the preparation and service of food to prevent potential cross contamination. During observation of the tray line on 1/13/10 from 11:30 A.M. to 11:45 A.M., the surveyor observed food handler #1 handling cooked grilled sandwiches with ungloved hands from the grill area, placing the sandwiches into a container and then into a warming unit. Dietary staff #1 was observed to wipe shelving on carts and handle dirty and clean equipment prior to placing raw hamburgers onto the grill. This dietary employee left the tray line / grill area and returned wearing gloves. Dietary staff #1 proceeded to perform several tasks working with uncooked (raw poultry and vegetables) foods and prepared (already cooked) menu items without proper handwashing and change of gloves. When pieces of poultry fell out of the cooking pan, dietary staff #1 picked up the uncooked meat, discarded it, and then proceeded to handle the hamburgers cooking on the grill. These concerns were shared with the Food Service Director on 1/13/10 at 11:45 A.M.

2. Food service personnel failed to ensure that all exposed hair, including facial hair was properly covered and restrained during the preparation and serving of meal trays . Review of current facility policies for hygiene failed to specify acceptable procedures or protocol to contain facial hair. Standards of practice for food safety protection and employee hygiene includes the use of beard/ facial covering and proper hair restraint usage to avoid contamination of foods / equipment.

Dietary staff #1, #2, #3 and #4 were observed serving the food service tray line on 1/13/10 during the noon meal service serving, cooking and or preparing food items for patient consumption. The employees' either lacked proper hair restraint and/or they wore head wear that did not effectively contain exposed hairs.

On interview, the Food Service Director on 1/19/10 confirmed these findings.

3. During observation of the noon meal on the CPC unit on 1/13/10, a test tray was sampled when the last patient tray was served and revealed unacceptable temperatures. The meal distribution to this patient unit involved transporting meal trays through service corridors to loading dock area, outside of the building and across parking lot area to a separate building. Insulated equipment held hot and cold foods within the same enclosed tray system. The meal trays left the main kitchen at approximately 11:49 A.M. and arrived on the CPC unit at approximately 11:55 A.M. The meal trays were checked by facility personnel for diet accuracy and safety precautions. The insulated meal trays were contained and served to patients as they arrived in the dining area. Several trays sat unserved until 12:20 P.M., and at that time, the sample meal tray was tested. The milk tasted warm at 60.8 degrees Fahrenheit (F); the entree meal and soup were unpalatable and tepid as the chicken soup, meat loaf and mashed potatoes registered 130 (F), 115 (F) and 122 degrees (F) degrees.

Based on record review and staff interview, the facility failed to provide two patients (#19 and #22), in a total active sample of 37, with the services of a qualified dietitian, per facility policy and/or when the patient's clinical condition required such services.

Findings include the following:

Review of the hospital policy for nutrition assessment and re-assessment, revealed that the purpose was to provide appropriate and timely nutrition care to patients who are at nutrition risk. The nutrition care provided to the patient would be based on their degree of nutritional risk. Those patients at high to moderate risk would further be investigated by a comprehensive nutritional assessment by a clinical dietitian or diet tech and an appropriate nutrition care plan would be implemented. Re-assessment would occur according to established time frames and when a significant change in the patients condition or diagnoses occurs.

Nutrition risk criteria was divided into three levels;
Level 1 (increased risk) where the initial assessment would be conducted within 48 hours of admission, and MD consult within 24 hours.
Level 2 (potential risk) where the initial assessment would be conducted within 72 hours of admission.
Level 3 (minimal risk) where the initial assessment would be conducted by day 5 of admission.

1. Patient #19 was evaluated in the emergency room then admitted to the hospital on 1/8/10 with diagnoses that included atrial fibrillation and alcohol withdrawal with secondary diagnoses of dehydration, nausea, vomiting and elevated blood pressure. On the day of record review, 1/13/10, the patient was being discharged to a short term rehabilitation facility.

Medical record review on 1/13/10 revealed that during the patients stay at the hospital he was never assessed by the clinical dietitian as per hospital policy/procedure. Interview with the hospital clinical dietitian on 1/19/10, confirmed that the patient should have been assessed by a dietitian based on the length of stay and the secondary diagnoses of dehydration, nausea and vomiting.

Based on the patients length of stay and secondary nutrition issues including dehydration, there was no assessment conducted by a qualified professional.

2. Patient #22 was admitted to the hospital on 1/7/10, with diagnoses that included acute and chronic renal failure, pneumonia and delirium. Record review was conducted on 1/14/10.

Review of the interdisciplinary progress notes on 1/14/10, revealed that a physician documented on 1/13/10 that although the patient's renal function improved, there was a new diagnoses of hepatic encephalopathy and the patient was positive for myelodysplasia secondary to hemochromatosis. Further review of the medical record revealed that the patient had not been assessed by the dietitian despite the patient had a length of stay of 7 days and a new diagnoses of hepatic disease, placing the patient at nutrition risk.

Despite the complexity of the patient's nutritional issues, including a new diagnoses of hepatic disease, there was no assessment conducted by a qualified professional.

Based on observations, record reviews and staff interviews, the Hospital failed to ensure the Whitcomb building was maintained to an adequate level of safety and quality. The findings are:

During the initial tour of the 20 bed in-patient unit in the Whitcomb building, on 1/12/2010 AM, it was noted that throughout the unit the furniture was mis-matched and in disrepair, the protective screens on the windows were dirty and the patient bed rooms were in need of painting and repairs. Observations include the following:

- The front entrance waiting area was furnished with a collection of mis-matched chairs in disrepair. The upholstery was torn/split on 3 of the 5 green chairs and the upholstery on the red chair was "stapled" together.
- The shower room vent was rusty, there was debris in the light fixture and the shower surround had a build-up of mold on the caulk. The "handicap accessible" shower was cluttered with equipment including an over-bed table and chair.
- There was a large wall area across from the nursing station that had been replastered but not repainted. (work orders indicated the hole in the wall was replastered in February 2009).
- The seclusion/quiet room (115 B) floor was scratched and scuffed. The protective screen over the window was dirty and had dried, old paint drips. The door frame to the toilet room was rusted. The ceiling/light fixture was not secured and hanging loosely. The ceiling was discolored with brown matter.
- The wall paint in room 117 was scratched and stained.
- Furniture in room 112 was mismatched. Four of four cabinets in the room had broken drawers. The mattress on the "hill rom" bed was over 12" shorter than the bed frame.
- There was a hole (approximately 6 inches by 1 inch in size) in the wall above the bed in room 121.
- The shower room adjacent to the nursing station had a shower chair with dirty adhesive on the seat. The light fixture had a heavy build-up of dirt and debris. The caulk and shower surround had a build-up of mold.
- The floor in room 107 was scuffed and scratched. The plastic cover on the light fixture was discolored.
- The bathroom in room 110 had a putrid odor and the exhaust fan was not functioning.
- The light fixture in room 109's bathroom had a cover that was browned and appeared to have been burned by the light bulbs.
- Room 114's bathroom had dirt-laden light fixtures, holes in the tiles and discolored grout on the floor.
- The common "dining room" had mis-matched chairs with torn upholstery. The "comfort zone" room rug was stained.

The maintenance manager was interviewed on 1/19/2010 and provided detailed work order reports for the Whitcomb building for 2009. Review of all work orders for 2009 revealed repeated calls for repairs to door locks, electrical issues and clogged toilets. Although the television and dining rooms had been painted in July 2009, there was no record of ongoing maintenance of the patients' bed and toilet rooms including painting.

Based on documentation review,and interview, the Hospital failed to ensure a post anesthesia evaluation was completed and documented by an anesthesiologist in 2 of 2 ( RR #16, RR # 27 ) applicable patient records reviewed.

Findings include:

1. For Patient RR #16, the hospital failed to provide a completed and documented post anesthesia evaluation by an individual qualified to administer anesthesia, no later than 48 hours after undergoing a procedure which requires anesthesia services .

Patient #16 was admitted to the hospital on 1/11/2010 with diagnosis including coronary artery disease, obstructive cardiopathy and aortic stenosis.

The patient underwent an aortic valve replacement on this date. Record review revealed that the patient entered the operating room under general anesthesia at 8:05 AM, departing after the procedure ended at 2:30 PM. The patient left the postanesthesia recovery unit at 2:45 PM.

Further record review on 1/14/2010 revealed there was no documented post anesthesia evaluation. This was confirmed by the unit manager in the cardiovascular intensive care unit where the patient was transfered.

2. For patient # 27, the hospital failed to provide a completed post anesthesia evaluation, no later than 48 hours after undergoing a procedure which requires anesthesia services.

Patient #27 was admitted to the hospital on 1/11/2010 with diagnosis including acute lung collapse and aortic stenosis.

The patient underwent aortic endarterectomy and an aortic valve replacement on this date. Record review revealed that the patient entered the operating room under general anesthesia at 8:10 AM, departing after the procedure was completed at 2:55 PM. The patient left the post anesthesia recovery unit at 3:13 PM.

Further record review revealed there was no documented post anesthesia evaluation. This was confirmed by the unit manager in the cardiovascular intensive care unit where the patient was transfered.