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Based on review of documents and interviews, it was determined that the Hospital failed to ensure all clinical records are completed, within 30 days post patient discharge.

Findings include:

1. On 3/19/13 at approximately 10:45 AM the Hospital presented an attestation letter that documented as of March 18, 2013 the Hospital had 52 incomplete records greater than 30 days post discharge.

2. The Director of Health Information Management stated during an interview on 3/19/13 at approximately 10:45 AM, that there are 52 delinquent records.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Full Survey Due to a Complaint conducted on March 18 - 20, 2013, 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.

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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 Medicare Full Survey Due to a Complaint conducted on March 18 - 20, 2013, 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 March 20, 2013.

Based on observational tour and interview, it was determined for 1 of 3 Operating Room (OR) Suites (OR #3), the Hospital failed to ensure the OR floor tile was maintained in good repair. This potentially affected 5 patients on the 3/19/13 surgery schedule.

Findings include:

1. On 3/19/13 between 11:40 AM and 12:30 PM, an observational tour was conducted in the operating area. In OR suite 3, floor tile was chipped, preventing thorough disinfection during room cleaning.

2. On 3/19/13 at approximately 12:15 PM, an interview was conducted with the Manager of Surgical Services. The Manager stated the chipped floor tile had been reported and was to be repaired soon.

A. Based on document review, observation and interview, it was determined that for 1 of 3 (OR #1) rooms in the Operating Room Suite (OR), the Hospital failed to ensure adherence to the policy regarding surgical attire. This potentially affected the 5 patients scheduled for surgery on 3/19/13.

Finding include:


1. On 3/19/13 the Hospital's policy titled, "Attire in the Operating Room (revised 8/11)" was reviewed and the policy required, "...hats or surgical hoods that completely cover all possible head and facial hair are to be worn by all personnel entering the O. R. restrictive area."

2. On 3/19/13 at approximately 11:30 AM an observation of the Operating Room Suite was conducted. In Operating Room #2 the Surgeon (E #1) had approximately 2 inches of hair exposed below the scrub hat on the back and side of the head.

3. During an interview at approximately 1:00 PM on 3/19/13, the Manager of Surgical
Services confirmed this finding.


B. Based on document review, observation, and interview, it was determined the Hospital failed to ensure for 1 of 3 (OR #1) OR rooms, the doors were closed when sterile packets were opened.

Finding include:

1. On 3/19/13 the Hospital policy titled, "Aseptic Technique Practices/Maintaining a Sterile Field (revised 8/11)" was reviewed and required, "G...11. Doors into the OR Suite are kept closed."

2. On 3/19/13 during an observational tour of the OR Suites, the door to the OR#1 was kept open for approximately 15 minutes while sterile packages were being opened, an exposed.

3. In an interview with the OR Charge Nurse (CN) during the observational tour, the CN stated that "it is the practice to keep doors to the operating rooms opened until the patient is brought into the room."

4. This finding was discussed with the Manager of Surgical Services on 3/19/13 at approximately 1:00 PM, during an interview.