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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on May 4, 2011, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 1 of 4 (Pt #12) medical records reviewed, in which restraints were used, the Hospital failed to ensure restraint orders were implemented as per hospital policy.

Findings include:

1. The Hospital policy titled "Use of Restraints and Seclusion" was reviewed on 5/4/11. It indicated "C. Restraint or Seclusion Orders for the Non-Violent... 2. When a staff member ends an ordered restraint or seclusion intervention, the staff member has NO authority to re-instate the intervention without obtaining a NEW order. a. For example: a patient is released from restraint or seclusion based upon the staff's assessment of the patient's condition. If this patient later exhibits behavior that jeopardizes the immediate safety of the patient, a staff member, or others that can only be handled through the use of restraint or seclusion, a new order would be required."

2. The medical record of Pt #12 was reviewed on 5/4/11. Pt #12 was admitted to the Hospital on 3/22/11 with the diagnoses Pneumonia and Sepsis. On 3/30/11 and 3/31/11, there were "Restraint Assessment Physician Order" forms for wrist restraints. Nursing documentation indicated Pt #12 had wrist restraints on 3/30/11 from midnight until 8:00 AM, then they were removed,and were reapplied 8:00 PM that evening. On 3/31/11, the wrist restraints were on from midnight until 10:00 AM, then removed, and reapplied at 10:00 PM. There were no new physician order or documentation to indicate the physician was notified of the need to reapply the restraints in either situation.

3. During a staff interview, conducted with the Director of Quality Management and the Chief Clinical Officer (CCO) on 5/5/11 at 3:30 PM, the above findings were confirmed.

A. Based on a review of employee credential files and staff interview it was determined that in 2 of 11 (E-6 and E-9) employee credential files reviewed, the Hospital failed to ensure all employees who administer restraints maintained current CPR certification.

Findings include:

1. The credential file of E-6 was reviewed on 5/5/11. It indicated E-6 was currently employed by the Hospital as a registered nurse. There was no documentation that indicated E-6 had current CPR certification.

2. The credential file of E-9 was reviewed on 5/5/11. It indicated E-9 was currently employed by the Hospital as a respiratory technician. Documentation indicated that E-9's CPR expired on 1/20/11.

3. During an interview with the CCO on 05-05-11 at 3:30 PM the above findings were confirmed.
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A. Based on a review of Hospital policy and procedure, employee credential files, and staff interview, it was determined that in 2 of 2 (E-1, E-7) personnel credential files reviewed for demonstration of restraint techniques, the Hospital failed to ensure all required staff demonstrated competencies in the application and use of restraints and seclusion.

Findings include:

1. The Hospital policy and procedure titled, "Use of Restraints and Seclusion" was reviewed. It indicated under "III. Staff Education for all levels of Restraint and Seclusion Utilization A. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion..."

2. The credential file of E-1 was reviewed. It indicated E-1 was employed as a certified nursing assistant (CNA). The document titled "Patient Care Providers Test Answer Sheet" indicated that E-1 answered 5 answers related to restraints. There was no documentation that indicated E-1 demonstrated competency in the physical application of restraints or seclusion.

3. The credential file of E-7 was reviewed. It indicated E-7 was employed as a registered nurse. The document titled "Patient Care Providers Test Answer Sheet" indicated that E-7 answered 5 answers related to restraints. There was no documentation that indicated E-7 demonstrated competency in the physical application of restraints or seclusion.

4. During an interview with the CCO on 05-05-11 at 3:30 PM the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 1 (Pt #13) medical record reviewed, in which the patient required a dressing change other then the Vacuum Assisted Closure, the Hospital failed to ensure the dressings were changed in accordance with physician orders.

Findings include:

1. The medical record of Pt #13 was reviewed on 5/4/11. Pt #13 was admitted to the Hospital on 4/23/11 with the diagnosis Osteomyelitis Right Hip. On 4/25/11, there was a physician order "Abdominal (ABD) dressing 2 times a day." On 4/28/11, there was a physician order "Increase ABD change to 3 times a day." Documentation indicated the VAC dressing was then placed on 4/29/11. There was no documentation to indicate the ABD was changed, as ordered by the physician, after the initial placement on 4/25/11 evening.

2. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

B. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 3 of 20 (Pts #12, #13, #14) medical records reviewed, the Hospital failed to ensure Flu and Pneumonia Vaccination was administered per physician order.

Findings include:

1. The Hospital policy titled "Influenza/ Pneumococcal Vaccination" was reviewed on 5/4/11. It indicated "During Influenza season October 1 through March 31, the admitting nurse will assess all patients to receive the Influenza vaccine. Throughout the year, the admitting nurse will assess all patients to receive the Pneumococcal Pneumonia vaccine... For those patients in which the admitting nurse is not able to assess due to confusion, unresponsiveness, etc., the physician will complete the assessment for the administration of the vaccination."

2. The medical record of Pt #12 was reviewed on 5/4/11. Pt #12 was admitted to the Hospital on 3/22/11 with the diagnoses Pneumonia and Sepsis. On 3/22/11, there was a physician order for both Pneumococcal and Influenza vaccinations to be given. There was no documentation to indicate either had been given. The "Pre-Admit Screening Summary Sheet" indicated "Unknown" as to whether Pt #12 had received these prior to hospitalization.

3. The medical record of Pt #13 was reviewed on 5/4/11. Pt #13 was admitted to the Hospital on 4/23/11 with the diagnosis Osteomyelitis Right Hip and a physician order was written that day for both the Pneumococcal and Influenza vaccinations. As of 5/4/11, neither had been administered and neither one was on the MAR to be given.

4.. The medical record of Pt #14 was reviewed on 5/5/11. Pt #14 was admitted to the Hospital on 1/19/11 with the diagnosis Lung Abcess and a physician order was written that day for both the Pneumococcal and Influenza vaccinations. There was no documentation to indicate either had been given.

5. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

C. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 4 of 20 (Pts #12, #15, #19, #20) medical records reviewed, in which the patient had a peripheral intravenous (IV) site, the Hospital failed to ensure IV sites were changed every 72 hours, as per Hospital policy to prevent catheter related blood stream infections.

Findings include:

1. The Hospital policy titled "Prevention of Catheter Related Blood Stream Infections" was reviewed on 5/5/11. It indicated "5... Replace peripheral IV catheters every 72 hours."

2. The medical record of Pt #12 was reviewed on 5/4/11. Pt #12 was admitted to the Hospital on 3/22/11 with the diagnoses Pneumonia and Sepsis.. On 3/22/11, nursing documentation indicated a Saline Lock (SL) initiated at 4:00 PM. On 3/29/11, nursing documentation indicated the site was changed at 4:30 PM, 4 days beyond the required timeframe.

3. The medical record of Pt #15 was reviewed on 5/5/11. Pt #15 was admitted to the Hospital on 2/1/11 with the diagnosis Methicillin Resistant Staph Aureus (MRSA). On 2/4/11, nursing documentation indicated an IV site started at 4:00 AM and the site was discontinued on 4/8/11, 1 day beyond the required timeframe.

4. The medical record of Pt #19 was reviewed on 5/5/11. Pt #19 was admitted to the Hospital on 1/19/11 with the diagnosis Sepsis, Klebsiella. On 1/21/11, nursing documentation indicated an IV was started in the left arm and the site was discontinued on 1/27/11, 3 days beyond the required timeframe.

5. The medical record of Pt #20 was reviewed on 5/5/11. Pt #20 was admitted to the Hospital on 9/3/10 with the diagnosis Liver Cirrhosis. On 9/4/10, nursing documentation indicated an IV was started to the left forearm and the site was discontinued on 9/8/11, 1 day beyond the required timeframe.

6. During a staff interview, conducted with the QA Coordinator and the CNO on 5/5/11 at 3:30 PM, the above findings were confirmed.

A. Based on a review of Hospital resource guidelines, medical record review, and staff interview, it was determined that the Hospital failed to ensure all nursing staff policies were followed. This was evident in 3 ( Pts. #1, #14, #15) of 20 medical records reviewed.

Findings include:

1. The Hospital resource guidelines from Lippincott's Nursing Procedures and Skills, copyright 2011 indicated parenteral drug administration documentation would include drug, dose, date, time, route of administration, site, and patient tolerance.

2. Pt #1 was admitted to the Hospital on 2/16/11 with the diagnosis Right Hip Fracture. The Medication Administration Record (MAR) indicated that Pt. #1 was receiving blood glucose monitoring and sliding scale insulin and heparin injections twice a day. There was no documentation on the MAR to indicate the injection sites utilized for insulin on 02/02 and 02/03. There were no heparin injection sites documented twice per day on 02/02- 02/06/11. There were no saline line or intravenous flushes documented from 02/01- 02/06.

3. The medical record of Pt #14 was reviewed on 5/5/11. Pt #14 was admitted to the Hospital on 01/19/11 with the diagnosis of lung abscess. On 1/19/11, there was a physician order for Accu checks every 6 hours with Mild Sliding Scale Regular Insulin and Lovenox 65 mg subcutaneous twice a day. MAR documentation indicated Pt #14 required insulin on various occasions, such as 1/21/11 at 12:00 PM and 1/22/11 at midnight. There was no documentation, at any time, as to the site of injection or patient tolerance for either insulin or Lovenox.

4. The medical record of Pt # 15 was reviewed on 5/5/11. Pt #15 was admitted to the Hospital on 02/01/11 with the diagnoses of Sepsis and MRSA (Methicillin Resistant Staph Aureus). On 2/1/11, there was a physician order for Accu checks before meals and at bedtime with Mild Sliding Scale Regular Insulin and Heparin 5,000 units subcutaneous twice a day. Pt #15 required insulin on various occasions, such as 2/2/11 at midnight and 2/3/11 at 6:00 AM. There was no documentation, at any time, as to the site of injection or patient tolerance for either insulin or Heparin.

5. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined the Hospital failed to ensure all blood transfusions were administered according to policy. This was evident in 3 (Pts #1, #3, #4) of 6 clinical records reviewed with patients receiving blood or blood products.

Findings include:

1. Hospital policy indicates that "Accurate identification of the donor's blood and intended recipient may be the most important steps in ensuring transfusion safety. Complete the Blood Transfusion Record...."

2. Pt. #1 was admitted to the Hospital on 03/08/11 with the diagnoses of respiratory failure and right hip fracture. Pt. #1 received numerous blood transfusions while hospitalized. Unit donor 4OKE84383 was infused on 04/10/11. The blood transfusion record failed to include the date and time the transfusion was completed and post transfusion vital signs.

3. The medical record of Pt #3 was reviewed on 5/3/11. It indicated Pt #3 was admitted on 3/9/11 with a diagnosis of Acute Respiratory Failure. A blood transfusion record, dated 3/13/11 did not have the date/time the transfusion was stopped. Another blood transfusion record, dated 5/2/11, did not have the time the transfusion was stopped.

4. Pt. #4 was admitted to the Hospital on 03/05/11 with the diagnoses of E. coli bacteremia, cirrhosis of the liver, and renal insufficiency. The patient received 25 units of blood and blood products since hospitalization. Unit donor #4OKC46711 was transfused on 04/16/11. The blood transfusion record was completely blank. There was no patient verification, ID tag verification, vital signs, signatures of the transfusionists, or any required and pertinent information. Unit # 40LE28657 was administered on 04/20/11 and there was not a dual signature that the recipient ID was checked and verified.

5. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on Hospital policy, medical record review and staff interview, it was determined that the Hospital failed to ensure all verbal orders were promptly dated, timed and authenticated by the ordering practitioner. This was evident in 1 of 20 (Pt #8) medical records reviewed.

Findings include:

1. Hospital policy indicates telephone and verbal orders will be written in the patient's chart by authorized licensed staff immediately following the physician's order.

2. Pt. # 8 was admitted to the Hospital on 3/02/11 with the diagnosis of Postoperative Infection. There was no documentation to indicate the 2 verbal orders on 3/18 and 2 verbal orders on 4/6/11 that were received by the RN were not timed.

3. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 2 of 20 (Pts #12, #14) medical records reviewed, the Hospital failed to ensure all physician orders were dated, timed, and authenticated by the physician within 48 hours.

Findings include:

1. The Hospital policy titled "Telephone and Verbal Orders" was reviewed on 5/4/11. It failed to address what the timeframe the physician had to authenticate telephone orders.

2. The medical record of Pt #12 was reviewed on 5/4/11. Pt #12 was admitted to the Hospital on 3/22/11 with the diagnoses Pneumonia and Sepsis. On 3/28/11 at 10:00 AM, there was a telephone order "Nothing by mouth. No ice. Nasogastric tube placed. Dietary to evaluate for Nutritional Replacement." As of 5/4/11, the order had not been signed by the physician.

3. The medical record of Pt #14 was reviewed on 5/5/11. Pt #14 was admitted to the Hospital on 1/19/11 with the diagnosis Lung Abcess. On 1/30/11 at 3:00 PM, there was a telephone physician order "Clarification: Fentanyl Patch 12 mcg, change every 72 hours." As of 5/5/11, the order had not been signed by the physician.

4. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined in 3 of 20 (Pts #12, #14, #20) medical records reviewed, the Hospital failed to ensure documentation accurately reflected patient assessments and/or care provided.

Findings include:

1. The medical record of Pt #12 was reviewed on 5/4/11. Pt #12 was admitted to the Hospital on 3/22/11 with the diagnoses of Pneumonia and Sepsis. On 3/30/11, a procedure note indicated Pt #12 had a Peripherally Inserted Central Catheter (PICC) placed. On 4/5/11, nursing documentation indicated a peripheral IV was started at 2:00 PM in the left arm. Nursing documentation failed to indicate throughout as to when the initial peripheral IV was removed, failed to indicate the presence of a PICC, or when the PICC was discontinued and/or pulled out.

2. The medical record of Pt #14 was reviewed on 5/5/11. Pt #14 was admitted to the Hospital on 1/19/11 with the diagnosis Lung Abcess. Nursing documentation indicated Pt #14 had a peripheral IV. On 2/10/11, a procedure note indicated Pt #14 had a PICC placed. Nursing documentation failed to indicate when the peripheral IV was removed, failed to indicate the presence of a PICC, maintenance of the venous line, or if it was present upon discharge.

3. The medical record of Pt #20 was reviewed on 5/5/11. Pt #20 was admitted to the Hospital on 9/3/10 with the diagnosis Liver Cirrhosis and was transferred to another hospital on 9/14/11. Documentation indicated Pt #20 received inpatient hemodialysis on two occasions while in the hospital and that it was administered thru a Right Internal Jugular (RIJ) Catheter. There was no nursing documentation to indicate the presence of an RIJ Catheter, when it was put in, or whether it was present on admission. During a staff interview, conducted with the CNO on 5/5/11 at 2:45 PM with the record review, it was verbalized that when a patient had a central line for dialysis purposes that nursing does not address it on their assessment and/or record other than the dialysis form. It was further verbalized that no care is provided to the site, except by the dialysis personnel. There were no physician orders to indicate the presence of the RIJ and/or delegating its' care to dialysis personnel only.

4. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on a request for delinquent medical records, it was determined that the Hospital failed to ensure all medical records were completed in a timely manner.

Findings include:

1. A written statement of delinquent medical records was presented on 05/03/11 by the medical records department. The document included information to indicate there were 22 incomplete records, exceeding 30 days.

2. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

A. Based on a review of policy and procedure, review of C-II perpetual count records, and staff interview, it was determined that in 2 of 2 C-II controlled substance logs that had expired medications, the Hospital failed to ensure the perpetual count was accurate.

Findings include:

1. The Hospital policy and procedure titled, "Controlled Drugs: Inventories (Perpetual)" was reviewed on 5/3/11. It indicated under "Procedure: 2. Expired or Unusable Controlled Drugs a. A summary Perpetual Inventory Record (or similar form) should be maintained for expired or unusable controlled drugs. C-II drugs should be recorded on a separate form from other controlled drugs. b. The balance on hand of each expired or unusable controlled drug should be transferred to this separate perpetual inventory page...which is maintained in the Perpetual Inventory Binder."

2. The Perpetual C-II records were reviewed. The Controlled Drug Perpetual Inventory Record for Oxycodone 5/APAP 325 was reviewed. On 4/22/11, the pharmacy inventory indicated a total of 116. Another entry on 4/22/11 indicated 30 tablets were removed to outdate. 30 was subtracted from the total count and the Balance was reflected as a total of 86. There was no log for the expired narcotics which reflected the number of expired Oxycodone. The same for Fentanyl PCA was also reviewed. On 3/31/11, an inventory count reflected 28 cartridges. On 4/21 two expired cartridges were returned as expired from ICU and added to the count which reflected a total of 30. Another entry on 4/21/11 indicated all 30 Fentanyl PCA cartridges expired and the count was changed to 0. The last entry on 4/28/11 indicated an inventory count of 0. There was no log for the expired narcotics which reflected the number of expired Fentanyl PCA. There was no perpetual count for any expired narcotics.

3. During an interview with the Pharmacy Director, conducted on 5/3/11 at 1:45 PM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure dietary dry goods were stored and rotated properly.

Findings include:

1. The Hospital policy and procedure titled, "PRODUCTION, PURCHASING, STORAGE" was reviewed. It indicated under "PROCEDURES: Rotate items; first in, first out."

2. During a tour of the dietary department, conducted on 5/3/11 at 1:45 PM, it was observed that in the dry goods storage room there were 2 large bags of Barilla pasta noodles (1 bow tie and 1 elbow) that were on bottom shelf racks and open to the air. It was also observed that numerous stock items (such as rolled oats) that had no date on the container. Therefore, there was no way to ensure the "first in" stock was the "first out" in accordance with the policy.

3. During an interview with the Dietary Manager, conducted on 4/3/11 at 1:50 PM, the above finding was confirmed.

B. Based on a review of Hospital policy and procedure, a request for temperature logs, and staff interview, it was determined that the hospital failed to ensure food temps were documented.

Findings include:

1. The Hospital policy and procedure titled, "TRAYLINE/TASTE/TEMPERATURE RECORD" was reviewed. It indicated under "Daily Preparation of Forms TEMPERATURES: logs temperatures at all points indicated on the form in conjunction with appropriate maintenance of HACCP records. Takes immediate action if temperatures indicate a violation of HACCP procedures."

2. During a tour of Dietary, conducted on 5/3/11 at 1:45 PM, a request for the temperature logs for the past 3 months for the tray line and cafeteria serving line were requested. As of 5/5/11 at 3:30 PM, no documentation of the temperatures for the tray line or cafeteria serving line were presented.

3. During an interview with the Dietary Manager, conducted on 5/3/11 at 1:55 PM, it was verbalized that food temps are checked but not recorded or documented.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure patient care equipment was maintained in safe operating condition, upon receipt for patient use and ongoing in its' Preventative Maintenance (PM) program.

Findings include:

1. During a tour of the Hospital, conducted on 5/4/11 at 9:30 AM with the Nurse Educator, the following were observed: In the Respiratory Therapy department, the Esprit Vent and the Resp/Atria 6100 EKG Machine both with tags which indicated the last PM was done on 6/09 and was due on 6/10. The Oti-flow Machine, in use for "a few days now," failed to have documentation of a PM being conducted. The Olympus Bronchoscopy for bedside Bronchoscopies, in use for greater than 6 months, failed to have documentation of a PM being conducted. The Cadence Machine for Transtracheal failed to have documentation of a PM being conducted. On the Radiology department and the 2nd floor nursing unit Crash Carts, there was no documentation of a PM being conducted on the suction machines. In the Physical Therapy department, the Celleration Mist Ultrasound Machine, in use for about a year, failed to have documentation of a PM being conducted.

2. The Hospital policy titled "Medical Equipment Management Plan" was reviewed on 5/4/11. It indicated "b. establishing criteria for identifying, evaluating, and taking inventory of equipment to be included in the management program before the equipment is used. These criteria address 1. equipment function, 2. physical risks associated with use, 3. maintenance requirements, and 4. equipment incident history.... g. how an annual evaluation of the equipment- management plan's objectives, scope, performance, and effectiveness will occur.."

3. During a staff interview, conducted with the Director of Quality Management and CCO on 5/5/11 at 3:30 PM, the above finding was confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation Survey conducted on May 4, 2011, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated May 4, 2011.

A. Based on observation and staff interview, it was determined that the hospital failed to ensure the infection control (IC) officer ensured all avenues for potential IC issues were monitored and evaluated to prevent possible contagion transmission.

Findings include:

1. During a tour of the Specialty unit/intensive care area, it was noted that Pt. #1 was on droplet precautions and had multiple drug resistant organisms cultured. Both visitors in the room were noted to be without masks, although the patient was on droplet and contact isolation. Documentation indicated the staff had informed and educated the visitors on 04/24/11 and the visitors were non-compliant. There was no policy to indicate further action necessitated to prevent the possible transmission of contagions.

2. During a tour of the dialysis equipment room, conducted on survey date 05/03/11, it was observed that 2 (Reverse Osmosis) RO portable units had the posterior piping wrapped and taped with white damp bath towels. The biotechnical maintenance man from the dialysis unit indicated that both RO units dripped from back flow pump area and the towels were in place to prevent the leakage. He indicated and documentation verified that both units had been maintained in February 2011 and both needed "cuffs or water collecting containment."

3. During an interview conducted with the IC officer on 05/03/11, it was verified that little monitoring of contractual dialysis service was conducted.

4. The above findings were confirmed with the QA coordinator and Chief Nursing Officer on 05/05/11 at 3:30 PM.

A. Based on medical record review and staff interview, it was determined that in 1 of 20 (Pt #18) medical records reviewed, the Hospital failed to ensure all medications were administered as ordered.

Findings include:

1. The medical record of Pt #18 was reviewed. It indicated Pt #18 was admitted on 1/6/11 with a diagnosis of Septicemia Not Otherwise Specified. A physician's admission order, dated 1/6/11, was for Thermazene application top (topical) q (every) day. Silver Sufadiazine 1% was substituted for the Thermazene. On 1/21/11 a line was drawn through the order on the MAR (medication administration record). The MAR on 1/22/11 and 1/23/11 indicated "No order". On 1/24/11 the MAR indicated that the medication was applied at 10:00am. There was no physician's order to discontinue this medication.

2. During an interview with the CCN, conducted on 5/5/11 at 11:00am, the above finding was confirmed.