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Based on observation and interview, it was determined that the facility failed to remove expired supplies in the Emergency Department and from Emergency Carts in other areas of the hospital.

Findings were:

Tour of the Emergency Department on 4/21/15 revealed the following expired supplies:
· ER Room #1 had AED Pediatric Pad with the expiration date of 7/28/14 and one opened AED Pediatric Pad that expired 12/28/12. 6 bundled lab tubes expired 7/14 and EZ Scrub pads expired 4/14.
· ER Room #4's Thermosonic Gel Warmer was last maintained in October 2013
· In the ER Trauma Room expired items found included: Easy Cap II C02 Detector expired 2/2015, Pedi Intubation Box had the following expired supplis: Provent Arterial Blood Sampling Kit expired 3/2013; 6.0 Trach Tube cuffed 10/2011; 3.0 Trach Tube cuffed expired 2/2015; 2.5 Trach Tube cuffed expired 2/2015.
· The Crash Cart on the Medical Surgical nursing floor contained the following expired items: (2) 4.5 Trach Tube cuffed expired 10/2011; 8.0 Trach Tube expired 11/2012; (2) 6.0 Trach Tube cuffed expired 2/2015; (2) 2.5 Trach Tube cuffed expired 2/2015; (2) 3.0 Trach Tube cuffed expired 2/2015; sterilized Trach tray expired September 12, 2014.
· The Crash Cart in the Surgical area had the following expired supplies: (2) 2.5 Trach Tube cuffed expired 2/2015 and (2) 3.0 Trach Tube cuffed expired 2/2015.

In an interview with staff #1 on 4/21/15 he stated they checked the emergency equipment on the crash cart on a monthly basis but there was no form to document the monthly checks. Staff #1 stated the nurses check the supplies on the crash cart for expiration dates and the pharmacy checks the medications on the crash cart.

In an interview with the Director of Nursing on 4/21/15, the above expired emergency supplies were confirmed.

C0220 Condition Physical Plant

Based on review of records and interview, it was determined that the facility was not maintained to ensure the safety of its staff and patients.

Findings were:

Cross refer to:

C0222
C0225
C0226

In interviews with the CEO, COO, and the Director of Nurses on 4/21/15, the above deficits were acknowledged.

Based on observation and staff interview the facility failed to maintain the proper control of the water provided for use in the surgical scrub sink and there were no temperature/humidity readings documented for all areas of the surgical suite that contained sterilized supplies for patient use.

Findings were:

During a tour of the surgical suite on 4/21/15 the following was noted:
* The scrub sink outside the operating rooms was divided into 3 sections. The right section had no water. The middle section had only cold water. The left portion had water that was very hot.
* The South Operating Room had no thermometer or humidity sensor in the room.
* The storage room for sterile processed supplies had no thermometer or humidity sensor in the room.
* Temperature and Humidity Log did not have parameters for temperature and humidity on the form for staff and who to notify if readings are outside of parameters.

On the morning of 4/22/15 the water coming from the faucet on the left hand side of the scrub sink was tested and the temp was as high as 115 degrees within 1 minute of the water running and at 5 minutes was still at a recorded temperature of 103 degrees.

Staff #2 stated the surgeons did complain about the temperature of the water at the scrub sink being too hot. She stated the scrub time for surgeons was 5 minute initial scrub and 2 minutes after the initial scrub. She further stated she had not reported this to anyone.

Staff #2 stated that they did not have a thermometer/humidity sensor in the operating room or storage room for processed supplies because all were on the same air conditioning system. They only checked the North Operating Room thermometer for temperature and humidity. Staff #2 confirmed the log did not have parameters for patient use on the log and no indication of any notification when temperature or humidity was outside of range.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its patients and staff.

Findings were:

Facility policy titled "Soiled Linen Collection" stated "Soiled linen is stored in covered containers and is picked up Wednesdays and Fridays by National Linen Services."

" OSHA/Bloodborne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

According to FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens, "4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils."

Tour of the Emergency Department on 4/21/15 revealed the following:
· High horizontal dust in ER Room #1 which indicated improper cleaning of the area.
· Gouges in the sheet rock on the walls in ER Rooms #1 and #4 (rooms #2 and #3 were occupied) which made cleaning of the walls impossible;
· No hot water was available in the entire Emergency Department. Per the Director of Nursing, this problem had been ongoing for several weeks;
· In ER Room #4, a chair was noted to have paper tape wrapped around the bottom of the chair. Hair and visible dirt was observed clinging to the tape;
· In the Trauma Room several "sterilized" hinged instruments (2 hemostats, 1forcep, 1 sponge forceps, 1 nasal speculum and 1 right angle retractor) were noted to be closed. This indicated improper sterilization of the instruments;
· The Trauma Room had high horizontal dust on cabinetry and on the lighting fixture over the OR table;
· A round, 18 inch in diameter and 24 inch tall ceramic crock was observed in the corner of the Trauma Room. The hand washing sink drained into this crock. When asked what it was, a maintenance worker told the survey team it was a "sediment tank." When the lid was removed from this tank, a fetid odor arose and mold and sediment was detected inside. When asked the purpose of this tank and when it was cleaned, the maintenance worker said it was cleaned yearly and it served no purpose.
Tour of the Radiology Department on 4/21/15 revealed the following:
· Molding was noted to be pulling away from the walls and a stained ceiling tile was observed. These deficits indicated water damage.
· The tile floor was cracked and was gouged. The gouges in the tile floor made the floor impossible to clean thoroughly;
· The patient restroom/dressing area had a dirty air conditioning vent which indicated improper cleaning of the area.
Tour of the kitchen on 4/21/15 revealed the following:
· The dishwashing room in the kitchen had 3 missing ceiling tiles which indicated improper maintenance of the area;
· Stacked "hotel pans," sheet pans and pitchers were stacked wet and in some cases dripping water. These wet utensils could lead to cross contamination.
Tour of the Physical Therapy Department on 4/21/15 revealed the following:
· A stool in a patient treatment room had 2, 1 inch tears in the vinyl covering. The "Vigor Gym" had a large tear in its vinyl covering and a plinth table had 3 small cuts in the vinyl covering. These tears make sanitation impossible and cross contamination likely;
· 2 "return" air conditioning vents were heavily covered in dust. This indicated improper cleaning of the area.
Tour of the Pharmacy on 4/21/15 revealed the following:
· 4 stained ceiling tiles which indicated a water leak. The Pharmacist stated "I have been here 4 months. The ceiling has always been like that." In the hallway directly outside of the pharmacy, 3 stained ceiling tiles were observed.
Tour of the Laboratory area on 4/21/15 revealed the following:
· The eye wash sink was situated next to a printer on one side and patient records housed in a cardboard box on the other side. Were the eye wash station utilized, the printer and cardboard box could have been contaminated.
Tour of the Respiratory Therapy Department on 4/21/15 revealed the following:
· A treatment bed with an egg crate mattress. According to the Therapist, this mattress had never been changed. The vinyl mattress underneath the egg crate mattress was not sanitized between patients. When asked how the treatment bed was cleaned, the therapist stated that she changed the top sheet and pillow case between patients.
Tour of the Nursing Floors on 4/21/15 revealed the following:
· 2 of 2 dirty linen rooms had containers that were overflowing with dirty linen. These containers had no lids;
· Fluorescent lighting fixtures throughout the nursing floors were dusty indicating improper cleaning of the area.
Tour of the Operating Room and Sterilization areas on 4/21/15 revealed the following:
· The employee break room in the surgical area had surgical supplies stored in the cabinets above the sink. These supplies included liter sized bottles of normal saline and sodium chloride. An RN surgical nurse confirmed that the supplies were used for patient care;
· The scrub sink was divided into 3 hand wash stations. The right station had no water. The middle station had only cold water. The left station had water that was scalding hot. The RN Surgical Nurse stated that the surgeons often complained about the heat of the water;
· In the dirty instrument processing room there were boxes of gloves stored on top of the water heater. There were water stained ceiling tiles and holes in the walls where piping was removed. There was a 4 by 12 inch hole in back of the water heater which revealed exposed piping. These holes in the walls could allow entry of vectors into the area;
· The room that housed the back of the autoclaves had disintegrating sheet rock which indicated water damage. This room had trash on the floor including 2 bottles filled with an unidentified liquid;
· The South Operating Room had no thermometer or humidity sensor in the room. Staff #2 stated that they did not have a thermometer/humidity sensor in that room because both Operating Rooms were on the same air conditioning system. They only checked the North Operating Room (OR) thermometer for temperature and humidity;
· In the North OR, holes were noted in the walls which made cleaning of the area impossible;
· The cove base that adjoined the walls to the floor had gaps in it. These gaps exposed concrete;
· The cold air return vent beside the infant warmer was dust covered. The infant warmer was dust covered which indicated improper cleaning of the area;
· The medication cart had cracks in the corners which were held together with dirty tape. This made cleaning of the cart impossible;
· The anesthesia cart had dust and debris on the top of it which indicated improper cleaning of the cart.

In interviews with the RN Surgical Nurse, the Kitchen Chef, the Radiologist, the Director of Laboratory, the Director of Nurses, the Chief Operating Officer, the Pharmacist and the Respiratory Therapist on 4/21/15, the above deficits were acknowledged.

Based on review of documentation, tour of the facility and interview, it was determined that the facility failed to control the temperature and humidity in all areas of the hospital.

Findings were:

Tour of the OR areas on 4/21/15 revealed the following:

Facility policy titled "Surgical Services Department Safety" stated in part "The humidity shall be kept at 50-55 percent. Temperature of the Operating Room will be maintained at 68-72 degrees Fahrenheit."

The South Operating Room had no thermometer or humidity sensor in the room. Staff #2 stated that they did not have a thermometer/humidity sensor in that room because both Operating Rooms were on the same air conditioning system. They only checked the North Operating Room thermometer for temperature and humidity.

Temperature/humidity logs were consulted for the months of January 30, 2015 through April 21, 2015. The following dates had out of range temperature/humidity:
· 1/30/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/2/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/3/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/4/15: 24 hour temperature range: 80/64: humidity: 27%
· 2/5/15: 24 hour temperature range: 80/64: humidity: 26%
· 2/6/15: 24 hour temperature range: 80/64: humidity: 26%
· 2/9/15: 24 hour temperature range: 80/64: humidity: 24%
· 2/10/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/11/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/12/15: 24 hour temperature range: 80/64: humidity: 24%
· 2/13/15: 24 hour temperature range: 80/64: humidity: 24%
· 2/16/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/17/15: 24 hour temperature range: 80/64: humidity: 24%
· 2/18/15: 24 hour temperature range: 80/64: humidity: 25%
· 2/19/15: 24 hour temperature range: 80/64: humidity: 24%
· 2/20/15: 24 hour temperature range: 80/64: humidity: 26%
· 2/23/15: 24 hour temperature range: 80/61: humidity: 26%
· 2/24/15: : 24 hour temperature range: 80/61: humidity: 24%
· 2/25/15: 24 hour temperature range: 80/61: humidity: 23%
· 2/26/15: 24 hour temperature range: 80/61: humidity: 24%
· 2/27/15: 24 hour temperature range: 80/61: humidity: 24%
· 3/2/15: 24 hour temperature range: 80/61: humidity: 23%
· 3/3/15: 24 hour temperature range: 80/61: humidity: 27%
· 3/4/15: 24 hour temperature range: 80/61: humidity: 36%
· 3/5/15: 24 hour temperature range: 80/61: humidity: 26%
· 3/6/15: 24 hour temperature range: 80/61: humidity: 24%
· 3/9/15: 24 hour temperature range: 75/70: humidity: 28%
· 3/10/15: 24 hour temperature range: 75/70: humidity: 27%
· 3/11/15: 24 hour temperature range: 75/70: humidity: 27%
· 3/12/15: 24 hour temperature range: 75/70: humidity: 26%
· 3/13/15: 24 hour temperature range: 75/70: humidity: 25%
· 3/16/15: 24 hour temperature range: 75/70: humidity: 25%
· 3/17/15: 24 hour temperature range: 75/70: humidity: 40%
· 3/18/15: 24 hour temperature range: 75/70: humidity: 28%
· 3/19/15: 24 hour temperature range: 75/70: humidity: 39%
· 3/20/15: 24 hour temperature range: 75/70: humidity: 31%
· 3/23/15: 24 hour temperature range: 75/70: humidity: 28%
· 3/24/15: 24 hour temperature range: 75/70: humidity: 28%
· 3/25/15: 24 hour temperature range: 75/70: humidity: 38%
· 3/26/15: 24 hour temperature range: 75/70: humidity: 24%
· 3/27/15: 24 hour temperature range: 75/70: humidity: 24%
· 3/30/15: 24 hour temperature range: 75/70: humidity: 25%
· 3/31/15: 24 hour temperature range: 75/70: humidity: 24%
· 4/1/15: 24 hour temperature range: 75/70: humidity: 25%
· 4/2/15: 24 hour temperature range: 75/70: humidity: 25%
· 4/6/15: 24 hour temperature range: 75/70: humidity: 48%
· 4/7/15: 24 hour temperature range: 75/70: humidity: 59%
· 4/8/15: 24 hour temperature range: 75/70: humidity: 61%
· 4/9/15: 24 hour temperature range: 75/68: humidity: 55%
· 4/10/15: 24 hour temperature range: 75/68: humidity: 27%
· 4/13/15: 24 hour temperature range: 75/67: humidity: 61%
· 4/14/15: 24 hour temperature range: 75/67: humidity: 36%
· 4/15/15: 24 hour temperature range: 75/67: humidity: 36%
· 4/16/15: 24 hour temperature range: 75/67: humidity: 56%
· 4/20/15: 24 hour temperature range: 75/67: humidity: 30%
· 4/21/15: 24 hour temperature range: 75/67: humidity: 31%

In an interview with the RN Surgical Nurse on April 21, 2015, the above out of range temperatures and humidity levels were confirmed. It was also acknowledged that there was no temperature/humidity monitor available in 1 of 2 Operating Suites.

Based on review of documentation and interview, it was determined that the governing body did not always ensure that its patients received quality care while in the hospital. The Governing Body failed to ensure history and physicals were completed prior to patient surgical procedure as per facility policy. 4 of 5 history and physicals for patients with operative procedures were not completed and in the patient medical record prior to the performance of the surgical procedure as per facility policy.


Findings were:

"Medical Staff Bylaws" stated in part "Whereas, it is recognized that the Medical Staff is responsible for the quality of medical care in the hospital and must accept and discharge this responsibility, subject to the ultimate authority of the Hospital Governing Body, and that the cooperative efforts of the Medical Staff, the Hospital Chief Executive Officer and the Governing Body are necessary to fulfill the Hospital's obligations to its patients."

Review of three active patient records (1 med/surg, 2 swing beds) revealed that nursing staff did not always follow physician orders when caring for patients.

Patient # 7 had an order written for weekly weights dated 3/11/15. The patient was weighed on the following dates:

· 3/11/15: weight 115 lbs
· 3/23/15: weight 141 lbs
· 4/14/15: weight 128 lbs

In interviews with the Director of Operations and the Director of Nurses on 4/21/15, it was confirmed that Patient # 7 did not have weekly weights as ordered. It was also acknowledged that the weights on Patient # 7 fluctuated and the documented weights were probably not accurate.

Review of medical records on 4/21/15 revealed 4 of 5 patient's history and physicals were not completed and in the patient medical record prior to the performance of the surgical procedure. Patients #1, 2, and 3 did not have a written, transcribed, or dictated history and physical in their medical record prior to the patient having an operative procedure. Patient #5 had a dictated history and physical from 3/31/15, procedure performed on 4/14/15, and no notation on the medical record to indicate the physician reviewed the history and physical for changes prior to the surgical procedure.

Facility policy titled "Preoperative Testing/Assessment Criteria for Inpatient Procedures" states in part "The following items must be present in the patient's medical record prior to operative/invasive procedures. Written patient history and physical (H&P). The H&P must be recent (within seven days), if the physical examination has been more than seven days prior, the physician must make a notation on the H&P about any current changes in the patient's condition within 24 hours of the procedure. A written (dictated and transcribed or hand written) patient history and physical examination must be readily available in the medical record prior to surgery."

In an interview with staff #2 she stated there was not a current, per policy, history and physical present on the medical record for patient #1 when the surgical procedure was started. In an interview with staff #2 and #18 both indicated this is an ongoing problem with history and physicals not being done per policy for surgical patients. Staff #18 acknowledged there was no current performance improvement plan in place by the Governing Body to address the problem with no H&P on the chart preoperatively for surgical patients.

Based on medical record review, policy review, and staff interview the faciity failed to ensure history and physicals were completed prior to patient surgical procedure as per facility policy. 4 of 5 history and physicals for patients with operative procedures were not completed and in the patient medical record prior to the performance of the surgical procedure as per facility policy.

Findings were:

Review of medical records on 4/21/15 revealed 4 of 5 patient's history and physicals were not completed and in the patient medical record prior to the performance of the surgical procedure. Patients #1, 2, and 3 did not have a written, transcribed, or dictated history and physical in their medical record prior to the patient having an operative procedure. Patient #5 had a dictated history and physical from 3/31/15, procedure performed on 4/14/15, and no notation on the medical record to indicate the physician reviewed the history and physical for changes prior to the surgical procedure.

Facility policy titled "Preoperative Testing/Assessment Criteria for Inpatient Procedures" states in part "The following items must be present in the patient's medical record prior to operative/invasive procedures. Written patient history and physical (H&P). The H&P must be recent (within seven days), if the physical examination has been more than seven days prior, the physician must make a notation on the H&P about any current changes in the patient's condition within 24 hours of the procedure. A written (dictated and transcribed or hand written) patient history and physical examination must be readily available in the medical record prior to surgery."

In an interview with staff #2 she stated there was not a current per policy history and physical present on the medical record for patient #1 when the surgical procedure was started. In an interview with staff #2 and #18 both indicated this is an ongoing problem with history and physicals not being done per policy for surgical patients. Staff #18 stated there is not a performance improvement plan in place to address the patient H&P not being present and current on the patient medical record prior to surgery.