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Based on observation and interview, it was determined the facility did not meet Life Safety Code requirements in that fire drills were not conducted for five of eight quarters in 2009 and 2010. Failure to conduct fire drills had the potential to affect patient safety from fire because proper fire response training was not tested and evaluated. The failed practice had the potential to affect to all staff, visitors, and patients admitted to the facility with an average daily census of 28 patients. See CMS 2567, K50.

Based on review of the Infection Control Policy and Procedure titled "TB (Tuberculosis) Plan" and review of the Maintenance Log of negative air pressure room check, the facility failed follow its policy for negative air pressure room checks daily. Failure to monitor negative air pressure checks daily had the potential to allow the spread of airborne disease to patients, visitors and staff. The failed practice had the potential to affect any patient requiring isolation, any immunocompromised patients, visitors and staff in the facility on the days the isolation rooms were not checked. Findings follow:
A. Review of the policy and procedure titled "TB Plan" revealed the facility's isolation rooms were to be checked daily by the Maintenance Department.
B. Review of the isolation room check log provided by the Maintenance Department revealed weekly checks 01/04/10 through 04/02/10, then bi-weekly checks from 04/01/10 through 05/31/11, and then Monday through Friday checks from 06/01/10 through 01/12/11.
C. The above was confirmed by the Infection Control Nurse on 01/14/11 at 0830.

Based on observation, the insertion tip of three of five colonoscopy scopes hanging in a storage cabinet in Operating Room (OR) #3 were observed to be touching a blue plastic box. Failure to ensure the colonoscopy scopes were properly stored had the potential to allow contaminated items to be used in patient care. The failed practice had the potential to affect any patient undergoing colonoscopy in the facility. Findings follow:

A. During the hospital tour on 01/08/11 at 1350, the insertion tip of three of five colonoscopy scopes hanging in a storage cabinet in Operating Room (OR) #3 were observed to be touching a blue plastic box.
B. The above findings were confirmed by the OR Manager at 1350 on 01/08/11.

Based on clinical record review and interviews, it was determined the facility lacked a written procedure related to the provision of updraft treatments ordered by physicians and the procedure to follow when the respiratory therapist could not provide the treatment as ordered. The failed practice affected three ( #8, #11 and #12) of three patients who had orders for updraft treatments and had the potential to affect all patients admitted with orders for updrafts every 4 hours. Evidence follows:

A. Interview with Respiratory Therapist #1 at 1301 on 01/13/11 revealed the practice was to perform the updraft treatments within 30 minutes before and 30 minutes after the ordered treatment time. He stated the standard treatment times for every four hour updrafts was 0700, 1100, 1500. 1900, 2300 and 0300. He was unaware of a written procedure.
B. Review of 13 current records revealed 3 patients (#8, #11 and #12) had orders for updraft treatments every 4 hours.
C. Review of current clinical records for Patient #8, #11 and #12 with orders for updraft treatments revealed the following:
1) The Physician's Orders for Patient #8 contained an order written at 2300 on 01/09/11 for Albuterol and Atrovent updrafts every 4 hours. The updrafts were not provided every 4 hours. See A 1163.
2) The Physician's Orders for Patient #11 contained an order written at 1450 on 01/11/11 for Albuterol and Atrovent updrafts every 4 hours. The updrafts were not provided every 4 hours. See A 1163.
3. The Physician's Orders for Patient #12 contained an order written at 1630 on 01/10/11 for Albuterol and Atrovent updrafts every 4 hours. The updrafts were not provided every 4 hours. See A 1163.
D. Interview with the Chief Nursing Officer (CNO) at 1520 on 01/13/11 revealed the facility lacked a procedure related to time frames for updraft treatments and for what to do when the respirator therapist could not perform the updraft treatments within the specified time frame, due to emergency or increased number of patients with updrafts ordered.

Based on clinical record review and interviews, it was determined physician orders were not followed for three (#8, #11 and #12) of three patients currently in the facility with orders for Albuterol and Atrovent updrafts every 4 hours. The failed practice allowed for respiratory therapy treatments to be less effective than when given as ordered. The failed practice affected Patient #8, #11 and #12 and had the potential to affect all patients admitted to the facility with orders for Albuterol and Atrovent updrafts every 4 hours. Evidence follows:

A. Interview with Respiratory Therapist #1 at 1301 on 01/13/11 revealed the practice was to perform the updraft treatments within 30 minutes before and 30 minutes after the ordered treatment time. He stated the standard treatment times for every four hour updrafts was 0700, 1100, 1500. 1900, 2300 and 0300. He was unaware of a written procedure.
B. Review of 13 current records revealed 3 patients (#8, #11 and #12) had orders for updraft treatments every 4 hours.
C. Review of current clinical records for three (#8, #11 and #12) of three patients with orders for updraft treatments revealed the following:
1) The Physician's Orders for Patient #8 contained an order written at 2300 on 01/09/11 for Albuterol and Atrovent updrafts every 4 hours.
a) Documentation in the Respiratory Therapy Clinical Procedure Notes revealed on 01/09/11, the updraft was administered 1 hour and 15 minutes early at 2145. On 01/10/11, the updraft was administered 1 hour and 20 minutes early at 1740. On 01/11/11, the updraft was administered 1 hour and 15 minutes early at 1745. On 01/12/11, the updraft was administered 50 minutes early at 1410.
b) The above was confirmed by the CNO during interview at 1510 on 01/13/10.
2) The Physician's Orders for Patient #11 contained an order written at 1450 on 01/11/11 for Albuterol and Atrovent updrafts every 4 hours.
a) Documentation in the Respiratory Therapy Clinical Procedure Notes revealed on 01/11/11, the updraft was administered 1 hour and 25 minutes early at 1735.
b) The above was confirmed by the CNO during interview at 1515 on 01/13/11.
3) The Physician's Orders for Patient #12 contained an order written at 1630 on 01/10/11 for Albuterol and Atrovent updrafts every 4 hours.
a) Documentation in the Respiratory Therapy Clinical Procedure Notes revealed on 01/10/11, the updraft was administered one hour early at 1800 and one hour and forty minutes late at 2340. On 01/11/11, the updraft was administered one hour early at 1800 and one hour and fifty minutes late at 2350.
b) The above was confirmed by Respiratory Therapist #1 during interview at 1305 on 01/13/11.