HospitalInspections.org

A. Based on a review of Grievance log, a review of Grievance Committee meeting minutes, a review of ER meeting minutes, a review of Emergency Department Committee Meeting notes, a review of physician credential file, a review of Medical Staff Committee meeting minutes, a review of Board of Director meeting minutes, a review of Performance Improvement Plan, and patient and staff interviews it was determined the Hospital failed to ensure its Board of Directors provided effective oversight of the Medical Staff and of the hospital-wide quality assessment and performance improvement program. The cumulative effect of these systemic practices has the potential to effect 100% of the patients serviced by the Hospital who average daily inpatient census is 22 to 24 patients.

Findings include:

1. Failed to ensure the medical staff was held accountable to the governing body for the quality of care provided. Please see deficiency cited at A-049.

2. Failed to ensure the Board of Directors provided effective oversight of the hospital-wide QAPI program. Please see deficiency cited at A-309.

A. Based on a review of Grievance log, a review of Grievance Committee meeting minutes, a review of ER meeting minutes, a review of Emergency Department Committee Meeting notes, a review of Medical Staff Committee meeting minutes, a review of Board of Director meeting minutes, a review of physician credential file, patient interview, and staff interview, it was determined the Hospital failed to ensure all medical staff were held accountable to the governing body for the quality of care provided to patients. This has the potential to effect all patients who receive services in the Hospital Emergency Department.

Findings include:

1. The Grievance Log for January 2012 thru May 2012 was reviewed. 13 of the 20 complaints were related to patient care issues versus financial issues. Of the 13 patient care issues, 6 were related to P-1.

2. The Grievance Committee meeting minutes and ER meeting minutes for January 2012 thru May 2012 were reviewed. The Grievance Committee meeting minutes referred grievances to the ER committee. There was no documentation to indicate the grievances referred to the committee in regards to P-1 were discussed and/or invesitigated. There was no documentation to indicate any of the grievances were discussed or reviewed by the Executive Medical Staff or the Board of Directors.

3. The "Emergency Department Committee Meeting" notes for 8/11/11 were reviewed. The notes indicated "Multiple issues with" P-1 "slandering issues", there was no further documentation to indicate any follow up.

4. The Medical Staff Committee and the Board of Directors meeting minutes for August 2011 thru May 2012 were reviewed. The September 2011 Medical Staff meeting minutes indicated recommendation for approval of P-1 for reappointment to the Active Medical Staff in Family Medicine and Emergency Department. There was no indication that patient grievances against P-1 were taken into consideration.

5. The credential file of P-1 was reviewed on 6/27/12. It indicated P-1 was reappointed to the Active Medical Staff in Family Medicine and Emergency Department on 9/29/11 by both the Medical Staff and the Board of Directors. There was no documentation to indicate P-1 had underwent any investigation and/or counseling related to patient grievances.

6. A patient telephone interview was conducted on 6/29/12 at 12:45 PM with Pt #1. Pt #1 had submitted a grievance due to treatment in ER by P-1 on 5/1/12. Pt #1 verbalized "Pt #1 received one call about one month after submitted complaint and a message was left for Pt #1 to call the hospital. Pt #1 called the hospital back and got voicemail and left a message. No further response was received. No letters at all. This isn't the first time Pt #1 had to deal with Physician #1 in the ED. Always rude and abrupt. Just needs to retire."

7. A patient telephone interview was conducted on 6/29/12 at 8:25 AM with Pt #27's parent. Pt #27's parent had submitted a grievance on 4/9/12 that the parent was "upset over treatment by P-1". Pt #27's parent verbalized "Nothing happened at first then I called the CEO's office and talked with the Executive Assistant 3 or 4 days later. The Executive Assistant verbalized that nothing would be done and that nothing would happen with P-1... You can't even mention P-1's name around town because they all know how P-1 is."

8. During a staff interview conducted with the RN (E-2) on 6/28/12 at 2:50 PM, E-2 was asked if E-2 was aware of any complaints and/or concerns related to P-1, E-2 verbalized "P-1 has become increasingly uncompassionate and rude in caring for the patients and they will sign out AMA and return when P-1 isn't there or they will say something like "Please tell me that's not P-1." When asked if the staff have been instructed on anything related to this, E-2 stated "Document, Document, Document." E-2 verbalized that starting "yesterday" they were to go in to see patients with P-1. When asked how long there have been complaints related to P-1, it was verbalized "ever since I've worked in the ED, but it seems to have gotten worse this last year." When asked if Administration and/ or Medical Staff were aware of these concerns, E-2 verbalized "yes, I have talked with the Director of Quality/Risk (E-3) numerous times and asked for help and that E-3 says E-3 is trying."

9. During a staff interview conducted with the CEO and the VP of Nursing on 6/27/12 at 10:45 AM, the process described for what action/ investigation has occurred related to the complaints/ grievances concerning P-1, the CEO verbalized "It went thru due process in the Medical Staff and that a meeting occurred on 6/20/12. It was felt that the complaints were related to interpersonal issues and not professional, medical, or substance issues. P-1 is going to be suspended from the ED indefinitely effective 6/27/12 (the day of the survey) and was decided due to P-1 being employed by the Hospital and concern related to community/ patient effects related to behavior of P-1." When asked what was meant by the note on the ED Meeting minutes dated 8/11/11 which indicated "Multiple issues with P-1...", it was verbalized that there have been complaints related to P-1 and that these complaints have been related to behavior with patients/ family." When asked what action had been taken at that time, it was repeated that "It went thru due process." There was no documentation of any counseling and/or disciplinary action related to the complaints.

A. Based on a review of Hospital policy, a review of Hospital Grievance log, a review of Grievance Committee meeting minutes, a review of ER Committee meeting minutes, and staff interview, it was determined in 5 of 6 (Pts #1, #26, #27, #28, #29) grievances reviewed for investigation follow up, the Hospital failed to ensure grievances were addressed in a timely fashion, as per its policy.

Findings include:

1. The Hospital policy titled "Patient Grievances" (issued July 19, 2010) was reviewed. It indicated "A. Initial Review: 2. A representative of the Grievance Committee shall conduct an initial review of the complaint within three days of its receipt... 3. All other complaints shall be assigned to one of two categories: (a) Practitioner Issues, or (b) Hospital Issues..." It further indicated "B. Investigation of Practitioner Issues" would be initiated within 10 days of receipt of the complaint from the Grievance Committee. The Grievance Committee would vote as to whether the case could be closed or whether more information was needed. If more information was needed, it would extend the follow up by 7 more days. The "Hospital Issues" was the same with the exception of the initial investigation would be within 14 days of the receipt of the complaint.

2. The grievance log for January 2012 thru May 2012 and the Grievance Committee meeting minutes for December 2011 thru May 2012 were reviewed. Six of six grievances reviewed on the grievance log and in the Grievance Committee meeting minutes failed to indicate what category the grievance was assigned, failed to indicate follow up within the initial 10 or 14 day timeframe, and failed to indicate whether ongoing 7 days of review was required.

3. The ER Committee meeting minutes for August 2011 thru May 2012 were reviewed. There was no documentation to indicate the grievances referred to the committee (Pts #1, #26, #27, #29) were discussed and/or investigated.

4. The grievance log indicated Pt #1 submitted a grievance on 5/1/12. There was no documentation to indicate category(s) the complaint was assigned. It indicated "Department(s) Involved... Disposition of Complaint: Meeting is to be held with... Date to be determined. Grievance Committee minutes for May 21, 2012 indicated the complaint was sent to the Department Managers of ED and Medical Surgical, the VP of Nursing and the Quality Director to begin followup review. This was outside of the designated timeframes.

5. The grievance log indicated Pt #26 submitted a grievance on 2/23/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved:...; Disposition: ..." The Grievance Committee minutes for March 19, 2012 indicated "Forward to ER Committee for review." This was outside of the designated timeframes. As of 6/29/12 at 8:25 AM, there was no documentation to indicate follow up had been completed.

6. The grievance log indicated Pt #27 submitted a grievance on 4/9/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved:..; Disposition: ..." The Grievance Committee minutes for April 16, 2012 indicated "Forward to ER Committee for review..."
This was outside of the designated timeframes. As of 6/28/12, there was no documentation to indicate follow up had been completed.

7. The grievance log indicated Pt #28 submitted a grievance on 4/9/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved...; Disposition: ..." The Grievance Committee minutes for April 16, 2012 indicated "Records to be reviewed with... Patient called." This was outside of the designated timeframes. As of 6/28/12, there was no documentation to indicate follow up had been completed.

8. The grievance log indicated Pt #29 submitted a grievance on 4/19/12. There was no documentation to indicate the category(s) the complaint was assigned. It indicated "Department(s) involved...; Disposition: ..." The Grievance Committee minutes for May 21, 2012 indicated "To be reviewed at ER Committee..." This was outside of the designated timeframes. As of 6/29/12 at 8:25 AM, there was no documentation to indicate follow up had been completed.

9. During a staff interview, conducted with the Executive Assistant (the person designated to initiate the grievance investigative process) on 6/27/12 at 9:25 AM, it was verbalized that grievances are received, reviewed, and sent to the respective persons and the Quality Director for investigation. When asked how these are then tracked for follow up, it was uncertain as to how this is done.

A. Based on a review of Hospital policy, a review of Hospital Grievance log, a review of Grievance Committee meeting minutes, and staff interview, it was determined in 6 of 6 (Pts #1, #25, #26, #27, #28, #29) grievances reviewed for grievance resolution, the Hospital failed to ensure patients were provided with written notice of resolution findings and date of completion, as per its policy.

Findings include:

1. The Hospital policy titled "Patient Grievances" (issued July 19, 2010) was reviewed. It indicated "... 6. Once the Grievance Committee is satisfied that the patient's complaint has been adequately addressed, it shall notify the patient in accordance with the steps specified in the section "Notification of Investigation Results"...Notification of Investigation Results: A... such notification shall be in writing and shall contain...."

2. The grievance log for January 2012 thru May 2012 and the Grievance Committee meeting minutes for December 2011 thru May 2012 were reviewed. Six of six grievances reviewed on the grievance log and in the Grievance Committee meeting minutes failed to indicate whether the complaints were adequately addressed and/or whether the patient was sent a letter of resolution findings and date of completion.

3. During a staff interview, conducted with the Executive Assistant (the person designated to initiate the grievance investigative process) on 6/27/12 at 9:25 AM, it was verbalized that letters are sent to the complainant to acknowledge receipt of the complaint and to convey that an investigation will be conducted. This is the date placed in the "Completed Date" on the Grievance log. When asked if the patient is sent a resolution letter once the investigation is completed with the findings and date of completion, it was verbalized that they were not.

4. During a staff interview, conducted with the CEO and the VP of Nursing on 6/27/12 at 10:45 AM, it was confirmed that no letter of resolution was sent to patients.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure all patient care equipment was monitored and maintained to ensure safe working order. This has the potential to effect 100% of patients serviced by the Hospital.

Findings include:

1. During a tour of the Medical Surgical unit, conducted 6/27/12 at 1:00 PM with the Medical Surgical Nurse Manager, two of two Ready Bath Warmers and two of two Blanket Warmers were observed. The Ready Bath Warmer in the south clean utility room, had a preventative maintenance sticker that indicated it was inspected on 5/3/10 and was due for reinspection 5/11. The Ready Bath Warmer in the north clean utility room, did not have a sticker to indicate when the warmer had been inspected. There was no documentation or sticker to indicate when either of the blanket warmers had been inspected.

2. The Hospital policy titled "Nursing- General Equipment- Safety" (issued August 2008) was reviewed on 6/28/12. It indicated "II. Policy: Special precautions and equipment testing are necessary semi-annually to ensure... III. VII. Electrical Equipment: a. To be inspected quarterly by a biomedical service for any problems..."

3. During a staff interview, conducted with the Medical Surgical Nurse Manager on 6/27/12 at 1:20 PM, it was verbalized that all patient care equipment is checked by Biomed and/or the Plant Operations department. The Medical Surgical Nurse Manager spoke with the Biomed and with the Plant Operations personnel at that time. Both verbalized that they did not monitor the Ready Bath Warmers or the Blanket Warmers. It was verbalized by the both that the contract for this was changed and these items were not included.

A. Based on a review of the Hospital's Performance Improvement Plan, Quality Care Measures, Quality Council Meeting Minutes, a review of the quality measures being tracked in Med/Surg/Peds, OB, and Surgery, interviews with the VP of Nursing, the Perinatal Coordinator, the Director of the Med/Surg/Peds, and the Director of Surgical Services, and a review of the Board of Directors business minutes, it was determined that the Hospital failed to ensure there was a current, effective quality assessment/performance improvement program that was hospital wide with oversight by the Quality Program. The cumulative effect of these systemic practices resulted in the Hospital's inability to ensure there was an effective quality program that implemented and maintained a data-driven, QAPI. This has the potential to effect 100% of the patients at the Hospital, the average daily inpatient census is 22 to 24 patients.

Findings include:

1. It was determined that the Hospital failed to ensure it's overall QAPI program was evaluated to determine overall effectiveness. Please see the deficiency cited at A-264.

2. It was determined that the Hospital failed to ensure the QAPI program documented analysis of collected data, corrective actions, and implementation of changes to correct areas identified as declining quality measures. Please see the deficiency cited at A-276.

3. It was determined that the Hospital failed to ensure it identified any hospital-wide quality improvement projects . Please see the deficiency cited at A-300.

4. It was determined that the Hospital failed to ensure the hospital-wide QAPI Program was accountable to the Board of Directors. Please see deficiency cited at A-309.

5. It was determined that the Hospital failed to ensure it's QAPI plan determined the number of improvement projects it conducted on an annual basis. Please see the deficiency cited at A-317.

A. Based on a review of the Hospital's QAPI plan and staff interview, it was determined that the Hospital failed to ensure it's overall QAPI program was evaluated to determine overall effectiveness.

Findings include:

1. The document titled, "PERFORMANCE IMPROVEMENT PLAN" with a reviewed and Approved By date of 4/13/09. was reviewed 6/28/12 at 10:15 AM. It indicated under, "Authority and Responsibility - Board of Directors: The Board of Directors has the ultimate authority and responsibility for an effective and comprehensive performance improvement program that promotes excellence and quality patient care and services. This responsibility is delegated to the Medical Staff and Hospital President to implement and maintain the program activities as described...." Under "PROGRAM COMPONENTS...B. Performance Measurement:...The hospital leaders will determine the scope of measurement based on important patient services and organizational functions, and prioritize its focus by placing emphasis upon the dimensions of performance....." Under "Program Evaluation: The Performance Improvement Program will be evaluate periodically for effectiveness and revised as necessary, to assure that the appropriate approach to planning, setting priorities, assessing performance, implementing improvement activities, and maintaining achieved improvements are accomplished." The most recent documentation that indicated the Hospital's Quality Improvement Plan was reviewed/updated by the Medical Staff was 4/30/09.

2. During an interview with the VP of Nursing, conducted on 6/28/12 at 2:00 PM, it was verbalized that the Hospital's QAPI program was meeting annually and that that was not enough. The most recent Quality Committee meeting was April 2012. It was further verbalized by the VP of Nursing that there was no update to the Performance Improvement Plan since the above date of 4/30/09.

A. Based on a review of the Hospital's Quality Care Measures, the quality measures being tracked in Medical/Surgical/Pediatrics, OB, and Surgery, Quality Council Meeting Minutes, and staff interview, it was determined that the Hospital failed to ensure the QAPI program documented analysis of collected data, corrective actions, and implementation of changes to correct areas identified as declining quality measures.

Findings include:

1. The Quality Care Measures for 10/1/2010 to 12/31/2010 and for 7/1/2011 to 9/30/2011 were reviewed on 6/27/12 at 10:45 AM. The scores for the quality measures percentages were printed in green for improved performance and red for decrease in performance. There were 34 quality measures whose scores were in red.

2. The Medical/Surgical/Pediatric Director was interviewed on 6/28/12 at 11:15 AM. She presented documentation of the quality indicators she is currently tracking. These included Medication Errors, Falls, Call Light Response Time, Blood Transfusion Protocol, etc. She verbalized that the results of her quality tracking are given to the Quality Coordinator.

3. The Director of Surgical Services was interviewed on 6/28/12 at 12:45 PM. She presented documentation of the quality indicators she is currently tracking. These included Conscious Sedation, Time Out, Pain Level Documentation, Scope Cleaning, Returns to Surgery, History and Physical on chart 24 hours prior to surgery, etc. She verbalized that her quality statistics are reported to the Perioperative Executive Committee and the Surgery Committee for peer review.

4. The Perinatal Coordinator was interviewed on 6/28/12 at 1:05 PM. She presented documentation of the quality indicators she is currently tracking. These included C-Sections, Repeat C-Sections, Maternal Transfers, Neonatal Transfers, Hemorrhage, deaths, Neonatal Oxygen use, etc. She verbalized and her documentation indicated that all of her quality statistics went to the ePerinet for monitoring by level 3 hospital and reviewed at her quarterly meetings.

5. The Quality Council Meeting Minutes for 6/29/11 and 4/3/12 were reviewed. There was no documentation to indicate that any of the above quality indicators tracked in Medical/Surgical/Pediatrics, OB, and Surgery were reviewed by the Quality Committee or of any corrective actions or implementation of changes for improvement for data collected.

6. During an interview with the VP of Nursing, conducted on 6/28/12 at 2:30 PM, the VP of Nursing was asked for documentation that indicated the Hospital's QAPI committee took the results of the declining quality standards and the quality indicators tracked and analyzed the identified problem areas and implemented corrective actions. It was verbalized that there was no documentation that would indicate the Hospital's QAPI program implemented any corrective actions that would have brought the declining quality measures back into an improved performance. She verbalized that based on this surveyors findings, there is a "disconnect" in the Quality Program.

A. Based on a review of the Hospital's QAPI program, Quality Council Meeting Minutes, and staff interview it was determined that the Hospital failed to ensure it identified any hospital-wide quality improvement projects.

Findings include:

1. The Hospital's "Performance Improvement Plan" was reviewed. The most recent Performance Improvement Plan was dated 4/30/09.

1. The "Quality Council Meeting Minutes" for 6/29/11 and 4/3/12 were reviewed. There was no documentation to identify any hospital-wide quality improvement projects.

2. The VP of Nursing was interviewed on 6/28/12 at 2:30 PM. She verbalized that there were individual department quality indicators being tracked but that there was no hospital-wide quality improvement projects currently being conducted.

A. Based on a review of the Hospital's Performance Improvement Plan, Board of Directors business minutes, and staff interview it was determined the Hospital failed to ensure the hospital-wide Quality Assessment Performance Improvement Program was accountable to the Board of Directors. This has the potential to effect all patients at the Hospital.

Findings include:

1. The Hospital's "Performance Improvement Plan" dated 4/30/09 was reviewed. It indicated under "Authority and Responsibility" "Board of Directors: The Board of Directors has the ultimate authority and responsibility for an effective and comprehensive performance improvement program that promotes excellence and quality patient care and services. This responsibility is delegated to the Medical Staff and Hospital President..." It further indicates "The Executive Medical Staff Committee has the responsibility to exercise leadership in measuring, assessing, and improving performance..."

2. The "Board of Directors" business minutes for 4/26/12 and 5/31/12 were reviewed. There was no documentation to indicate oversight of the Medical Staff Committee by the Governing Body in regards to an effective hospital-wide Quality Assessment Performance Improvement Program and it's activities.

3. During an interview with the VP of nursing on 6/28/12 at 2:00 PM, it was verbalized that the Board of Direcotrs had delegated the responsibility of the QAPI program to the Medical Staff and the Hospital administration. She verbalized that there is a "disconnect" in the Quality Program.

A. Based on a review of the Hospital's Performance Improvement Plan, Quality Council meeting minutes, and staff interview, it was determined that the Hospital failed to ensure it's QAPI plan determined the number of improvement projects it conducted on an annual basis.

Findings include:

1. The Hospital's most recent "Performance Improvement Plan" approved/revised 4/30/09 was reviewed. There was no documentation to indicate the determination of the number of improvement projects that was to be conducted annually.

2. The "Quality Council Meeting Minutes" for 6/29/11 and 4/3/12 were reviewed. There was no documentation to that indicate the determination of the number of improvement projects to be conducted on an annual basis.

3. During an interview with the VP of Nursing, conducted on 6/28/12 at 3:45 PM, it was verbalized that the Hospital's QAPI plan should have been revised/updated since 4/30/09

A. Based on medical record review and staff interview, it was determined the Hospital failed to ensure medications were administered as ordered by the physician in 1 of 24 (Pt #1) medical records reviewed.

Findings include:

1. The medical record of Pt #1 was reviewed. It indicated Pt #1 presented to the ED on 4/18/12 with the Chief Complaint of Back Pain and was admitted to 23 hour observation. Medical Surgical nursing documentation indicated Pt #1 presented to Room 211 at 12:06 AM with order " Dilaudid 1 mg IV every 4 hours as needed for pain. " 4/19/12 at 4:44 AM Pain - 10 Severe pain, Pt just received Dilaudid in ER before coming up. (11:40 PM) " No pain medication given and greater than 4 hours had passed.

2. During a staff interview, conducted with the Medical Surgical Nurse Manager on 6/28/12 at 2:00 PM, it was confirmed that Pt #1 had an order for Dilaudid every 4 hours as needed and that this was not given at 4:44 AM with the pain scale rating of 10.

A. Based on Hospital policy, medical record review and staff interview, it was determined all patient information was not incorporated into the medical record as necessary. The cumulative effect of this practice has the potential to affect all patients presenting to the Hospital with nutritional risk.

Findings include:

1. The Hospital policy titled Nutrition Assessment, issued in 02/2012, indicates "Policy: It is the policy of St. Margaret's Health Dietary Department that patients screened at nutritional risk will have a complete nutritional assessment... 2. Nutrition Assessements for medical patients are charted in the Meditech Electronic Medical Record..."

2. Twenty four medical records were reviewed. There were no nutritional screenings in the medical records to indicate if the patients were a nutritional risk to determine if a nutritional assessment needed to be completed.

3. During a staff interview conducted with the Dietician on 06/26/12 it was verbalized that nutritional assessments are completed as needed by physician request or screening triggers, but information is kept in a dietary file, not the patient's record.

A. Based on a review of the delinquent medical record rate, it was determined the Hospital failed to ensure all medical records were completed in a timely manner for 10 medical records as of 06/28/12.

Findings include:

1. A written request for the medical staff record delinquency rate was received on 06/28/12. The medical records statistics form was reviewed and indicated the cumulative number of delinquent records is 10. There are no physician suspensions due to the delinquent records.

2. The above finding was verified with the VP of Nursing Services on 06/28/12 at 2:00 pm.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure its Multiple Dose Vials policy was followed. This has the potential to effect 100% of patients serviced by the Hospital.

Findings include:

1. During a tour of the Emergency Department and Radiology, conducted on 6/26/12 with the EMS Coordinator/ Safety Director and the Diagnostics Manager, the following was observed. In the ED Medication refrigerator, one open 3 ml vial of Humulin R and one open Novolog 10 ml. Both failed to indicate the date as to when it was opened. In the Major Room cabinet, one open 500 ml NS for irrigation with 375 ml remaining in it. There was no date as to when it was opened. In the Barium "Kitchen" cabinet, one open 50 ml vial of Lidocaine 1%, one open 5 ml vial Betamethasone Sodium Phosphate, one open 20 ml vial Lidocaine 1% with Epinephrine 1:100,000. There was no date to indicate when any of the vials were opened.

2. The Hospital policy titled "Multiple Dose Vials" (issued February 21, 2011) was reviewed. It indicated "II. Policy: A... it is MANDATORY to : 1. Upon initial entry, date the container with the exact EXPIRATION DATE which will be 28 days after the date of initial entry... B. Containers of sterile saline or sterile water for irrigation will be dated and timed when opened. These bottles will be discarded after 24 hours..."

3. During a staff interview, conducted with the Infection Control Nurse on 6/27/12 at 3:30 PM, the above findings were reviewed and it was confirmed that multi dose vials were to be dated upon opening and disposed of in accordance with the Hospitals policy.

A. Based on observation and staff interview, it was determined that the Hospital failed to ensure the dietary department was maintained in a sanitary manner. This has the potential to effect all patients at the Hospital.

Findings include:

1. During a tour of the Dietary Department, conducted on 6/26/12 at 1:10 PM, the following observations were made: 1. In the cooler/freezer behind the serving line - there was a white debris on the cooler floor, there was a personal green aluminium drinking bottle, and a 5 lb unopened container of cottage cheese that expired 6/24/12. 2. In the cafeteria warmer - a brown, dried debris was on the floor of the warmer. 3. The #10 manual can opener had the cutting blade encrusted in hard brown debris.

2. During an interview with the Food Service Manager, conducted on 6/26/12 at 1:20 PM, it was verbalized that the above findings should not have been found in that manner and confirmed the above findings.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure its hand hygiene policy was followed to prevent cross contamination. This has the potential to effect 100% of patients serviced by the Hospital.

Findings include:

1. During a tour of the Medical Surgical unit, conducted 6/27/12 at 1:00 PM with the Medical Surgical Nurse Manager, four of four hospital personnel who entered, provided patient care, and exited Room #1, and 2 of 3 hospital personnel who entered, provided patient care, and exited Room #2 failed to perform hand hygiene.

2. The Hospital policy titled "Hand Hygiene" (issued June 28, 2011) was reviewed. It indicated "III. B. Personnel will use hand hygiene techniques: ... Before each patient encounter... After coming in contact with patient's intact skin..."

3. During a staff interview, conducted with the Medical Surgical Nurse Manager on 6/27/12 at 1:20 PM, it was verbalized that hand hygiene is to be performed upon entering and exiting the patient room and also before and after providing patient care. Hand Hygiene dispensers are located just inside the doorway of each patient room for this purpose.

B. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure outdated biologicals were not available for use in patient care areas. This has the potential to effect 100% of the patients serviced by the Hospital.

Findings include:

1. During a tour of the Emergency Department and Radiology Department, conducted on 6/26/12 with the EMS Coordinator/ Safety Director, the following was observed. In the ED Major Room, 3 of the 7 compartments of the Braslow Kit was checked and two 24 gauge 3/4" angiocaths expired 10/11, three 22 gauge 1"angiocaths (2 expired 11/11, 1 expired 10/11), 1 Female Spec-Cath Kit expired 8/11, two 20 gauge 1" (1 expired 1/12, 1 expired 11/11), one 18 gauge 1 1/4" expired 6/11. It was verbalized by the EMS Coordinator/ Safety Director that the Braslow Kit is checked monthly for outdated supplies. In the Nuclear Medicine Cart, one Ultra Tag RBC expired 6/19/12 and two Pyrolite expired 5/12. The Nuclear Medicine technician verbalized that the supplies are checked "regularly" and upon use. It was further verbalized that the computer module utilized "will not allow the use of an outdated item and it contains each item inventoried along with that item's expiration date."

2. The Hospital policy titled "Inventory Management" (Issued 5/31/12 and it preceding policy were reviewed. The previous policy was updated in relation to Sections IV. A. and B.) Both indicated "II. Policy:... All end user departments will check inventories supplies on a quarterly basis and at the time of use for outdates...III... Each department will develop a checklist to include items checked, location of items, and identification of who completed check..."

3. During a staff interview, conducted with the Infection Control Nurse on 6/27/12 at 3:30 PM, the above findings were reviewed and it was confirmed that each area is to check for outdated drugs and/or biologicals on a "regular" basis.

C. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure employee food and drink items were not stored and/or present within the patient care areas. This has the potential to effect 100% of patients serviced by the Hospital.

Findings include:

1. During a tour of the Radiology department, conducted on 6/26/12 at 12:15 PM with the Diagnostics Manager, the following was observed. In the Barium "Kitchen" drawer, there was a package of Ranch Dressing. In Sonogram Room #1, there was one CoffeeMate Creamer and one box of Great Grains cereal observed in the cabinet. In Sonogram Room #2, there was one Yoplait yogurt, Crystal Light, and cans of soda pop in the refrigerator and there was one General Foods International coffee in the cabinet. It was verbalized by the Diagnostics Manager that "they were not aware that they could not have these items in these areas."

2. The Hospital policy titled "Bloodborne Pathogens Exposure Control Plan" (Issued 9/08) was reviewed on 6/27/12. It indicated "Methods of Compliance: General.... all body fluids shall be considered potentially infections materials... Engineering and Work Practice Controls... Eating, drinking... is prohibited in work areas..."

3. During a staff interview, conducted with the Infection Control Nurse on 6/27/12 at 3:30 PM, the above findings were reviewed and it was confirmed that food and drink are not to be stored in the patient care areas.

A. Based on a review of Hospital policy and procedure manual, a review of AORN 2012 guidelines, a review of surgical room temperatures/ humidity logs, and staff interview, it was determined that the Hospital failed to ensure proper temperature/ humidity was maintained in the surgical/ sterilization rooms. This has the potential to effect 100% of the patients who receive surgical services.
Findings include:

1. The Hospital policy and procedure manual was reviewed on 06/28/12. It indicated the Hospital utilized the AORN guidelines as one of their Nationally Recognized Standards for Infection Control guidance. The 2012 AORN guidelines for "Perioperative Standards and Recommended Practices" was reviewed on 06/28/12. It indicated on page 218 under "Recommendation V V.b. Relative humidity should be maintained between 30% and 60% within the perioperative suite, including operating rooms, recovery area...endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 70% in sterile storage areas." "Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen rich environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed." On page 219 under, "V.c.1. Temperature should be maintained between 68 to 73 F (20 C to 23 C) within the operating room suite and general work areas in sterile processing."

2. The temperature/ humidity logs for the surgical suites #1 - #5, were reviewed on 06/28/12. Documentation for the month of June 2012 was reviewed. There was no documentation for temperatures or humidity in the sterilization rooms. The following are the number of times the OR suite humidity levels were recorded above the acceptable parameter of 60% and the temperature levels were recorded below the acceptable parameter of 68 degrees:
OR suite #1 - all 24 humidity recordings were above 60%, 21 of 25 temperature recordings were below 68 F.
OR suite #2 - all 25 humidity recordings were above 60%, all 26 temperature temperature recordings were below 68 F.
OR suite #3 - all 27 humidity recordings were above 60%, all 27 temperature recordings were below 68 F.
OR suite #4 - 21 of 25 humidity recordings were above 60%, 2 of 25 temperature recordings were below 68 F.
OR suite #5 - 1 of 26 humidity recordings were above 60%, all 26 temperature recordings were below 68 F.

3. During an interview with the Plant Operations Manager, conducted on 06/28/12 at 10:00 am, the above findings were confirmed. The Plant Operations Manager indicated the sterilization room was never monitored for temperature or humidity. It was indicated by the Plant Operations Manager that the thermometer sensors were inaccurate/incorrect and that nothing had been initiated to resolve the problem.