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Based on observations, medical record review, interviews, and facility policy review, the facility failed to ensure a nursing care plan was developed and kept current for three (#7, #9, and #49) patients of fifty-two patients reviewed.

The findings included:

Patient #7 was admitted to the facility on January 17, 2011 at 5:17 a.m., with diagnosis to include Induction of Labor.

Medical record review of the High Risk Factor form, dated January 17, 2011 at 5:20 a.m., revealed "...Risk Factors: History of Depression; Multiple positive UDS (urine drug screen) for cocaine; History of Domestic Abuse, Smoker..." Continued medical record review revealed no documentation on the patient Care Plan of the patient's risk factor.

Review of the facility's policy Interdisciplinary Patient Plan of Care Problem List, policy number HVMC-AD-911-0073-PO, last updated March 2008, revealed, "...Problems/Needs identified during admission will be documented on the Interdisciplinary Plan of Care/Problem List...".


Interview with the Registered Nurse Manager and the Vice President of Clinical Services at the Post Partum nurses' station on January 19, 2011 at 3:00 p.m., confirmed the patient's risks were to be documented on the Care Plan and the patient's risks had not been included.

Patient #9 was admitted to the facility on December 11, 2010, with diagnosis to include Premature at 29 Weeks Gestation.

Medical record review of the lab report, dated January 15, 2011, revealed "...foot culture...MRSA (Methicillin Resistant Staphylococcus aureus)..."

Medical record review of a physician's order dated January 17, 2011, no time noted, revealed "...Isolation..."

Medical record review of the Care Plan revealed no documentation of the patient being in isolation.

Review of the facility's policy Interdisciplinary Patient Plan of Care Problem List, policy number HVMC-AD-911-0073-PO, last updated March 2008, revealed, "...Problems/Needs identified during admission will be documented on the Interdisciplinary Plan of Care/Problem List...".

Interview with the Registered Nurse Manager of the NICU and the Vice President of Clinical Services on January 19, 2011 at 10:50 a.m., at the NICU nursing station, confirmed the patient was in isolation, it was to be documented in the Care Plan, and the isolation had not been included.

Medical record review revealed Patient #49 was admitted to the facility on January 18, 2011, at 9:27 a.m., with diagnoses of End Stage Renal Disease. Further review of the medical record revealed the Interdisciplinary Patient Care Plan/Problem List was blank with no problems or interventions listed.

Review of the facility's Policy Number W-SY-17100-338-PO revealed, "A Interdisciplinary plan of care...will be initiated by the RN/LPN within 24 hours and documented in the Medical Record".

Observations of Patient #49, on January 19, 2011, at 3:00 p.m., on the dialysis unit, revealed the patient was recieving a dialysis treatment.

Interview with the Assistant Clinical Manager of the Fourth Floor Medical Surgical Unit, in the Dialysis Unit Nurses Station, on January 19, 2011, at 3:10 p.m., confirmed the Care Plan had not been completed.



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Based on observation, facility policy review, and interview, the facility failed to ensure medications were secured on the Neonatal Intensive Care Unit (NICU).

The findings included:

Observation on January 19, 2011 at 9:05 a.m., of an unsecured cabinet located at the NICU nurses' station revealed a pre-filled syringe containing 2 ml (milliliters) of 19 mg (milligrams) Phenobarbital (narcotic anti-convulsant medication).

Review of the facility policy Pharmacy Automated Dispensing Cabinets, policy number HVMC-DT-13500-MM.4.103, last revised March 2009, revealed "...Narcotics/Controlled Substance Access...only authorized (named automated dispensing machine) users will have access to narcotics and controlled substances..."

Interview with the Registered Nurse Unit Manager and Vice President of Clinical Services in the nurses' station on January 19, 2011 at 9:05 a.m., confirmed the medication had not been secured as required.

Based on observation, facility policy review, and interview, the facility failed to ensure expired medications were not available for patient use in the Neonatal Intensive Care Unit (NICU) and the Gastroenterology Department (GI Lab).

The findings included:

Observation with the Registered Nurse Unit Manager and the Vice President of Clinical Services on January 19, 2011 at 9:05 a.m., of a cabinet located at the NICU nurses' station revealed a pre-filled syringe containing 2 ml (milliliters) of 19 mg (milligrams) Phenobarbital (narcotic anti-convulsant medication) with an expiration date of January 17, 2011 (expired two days).

Review of the facility policy Unit Inspection, policy number HVMC-DT-13500-MM.4.2300, last revised March 2009, revealed "...There shall be a monthly documented inspection of all drugs and pharmaceuticals kept at the nursing stations...and other areas of the institution...Pharmacy staff will be given areas of responsibility...A Nursing Unit Inspection Form will be completed and for each area..." Review of the facility form Patient Care Area Inspection Form revealed "...Area is clean of expired...medications..."

Interview with the Registered Nurse Unit Manager and Vice President of Clinical Services in the NICU nurses' station, on January 19, 2011 at 9:05 a.m., confirmed the medication had expired and the expired medication was available for patient use.



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Observation of the emergency crash cart in the GI Lab on January 19, 2011, at 2:30 p.m., revealed the cart was checked by pharmacy on October, 2010, and no medications were due to be expired. Continued observation revealed the top drawer contained two vials of Vasopressin 20 units/milliliter with an expiration date of November, 2010, and one vial with an expiration date of December, 2010.

Review of the facility's policy Emergency Drug Carts and Trays #HVMC-DT-13500-MM.2.3210 revised March, 2009, revealed, "The Pharmacy is responsible for the medications stocked on the emergency carts...The emergency medication carts as stocked on all nursing units are for use in any emergency situations where the drugs contained can be used...The cart also has a label on the outside denoting the shortest expiration date of any of the medication inside the cart. These carts are also checked monthly during routine nursing station checks...The expiration dates of the drugs replaced will be noted. After determining the shortest expiration date of any medication in the tray the date will be indicated on the outside of the plastic overwrap..."

Interview with the Associate Vice President of Patient Care Services and the Director of Surgical Services on January 19, 2011, at 2:30 p.m., in front of the crash cart, confirmed the date on the label indicated no expired medications and the medications were expired.

Based on observations, interviews, and facility policy review, the facility failed to provide for safe storage and disposal of medical waste.

The findings included:

Observations of the waste disposal/back dock area, on January 19, 2011, at 2:20 p.m. revealed ten uncovered wheeled containers filled with red hazardous waste bags, and a fenced area twenty feet long and five feet wide with red hazardous waste bags stacked five feet high filling the area. The fenced area was open to the rain and wind on one side.

Review of the facility's policy number W-SY-15070-0015-PR revised October 26, 2009, revealed, "Infectious waste will be stored in a manner and location that affords protection from animals, precipitation, wind, and direct sunlight...".

Interview with the Director of Environmental Services, on January 19, 2011, at 2:30 p.m., in the waste disposal/back dock area confirmed the red hazardous waste bags had been stored on the ground in the fenced area over night.

Based on observations, interview, and facility policy review, the facility failed to track and remove expired supplies from the patient care areas and failed to ensure routine quality checks were performed for the emergency crash cart on the Cardiac Care Step Down Unit.

The findings included:

Observations of the Pediatric Crash Cart, in the Emergency Room, on January 19, 2010, at 9:00 a.m., revealed:
1. One Central Venous Catherterization Kit with expiration date of April 2009.
2. Two Suction Catheter Kits with expiration dates of November 2010.
3. One Endotracheal Tube Stylet with expiration date of December 2010.

Review of the facility's policy number HVMC-DT-11000-W-775-PR revised April, 2009, revealed, "All carts/bins will be checked daily to verify that the expiration date was checked...It will be the responsibility of the person checking the cart/bin to restock all expired items."

Interview with the Emergency Room Manager and the Senior Lead Technician for Central Sterilizing, in the Emergency Room, at 9:10 a.m., on January 19, 2011, confirmed the supplies were expired.


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Observation of the emergency crash cart on the Cardiac Care Step Down Unit on January 18, 2011, at 2:25 p.m., revealed the checklist indicated the cart was last checked January 13, 2011. Observation of the defibrillator monitor screen indicated the last function test was completed on January 13, 2011.

Review of the Crash Cart Checklist/Heart Start MRx sheet located on the machine revealed, "Items are to be checked every 24 hours..."

Review of the facility's policy Cardiac Cart Checklist #HVMC-DT-1100-2129-W656-PR revised March, 2007, revealed, "...Lock checks are done Q 24 hours (every 24 hours)...Place the date the cart is being checked in the box at the top of the sheet..."

Interview with the Associate Vice President of Patient Care Services and with the Cardiac Care Unit Clinical Leader on January 18, 2011, at 2:25 p.m., in front of the crash cart, confirmed the cart was not checked every 24 hours and had not been checked since January 13, 2011.

Based on medical record review, observation, facility policy review, and interview, the facility failed to ensure hand hygiene practices were followed for housekeeping staff on the Neonatal Intensive Care Unit (NICU) and the Pediatric Unit; failed to ensure the integrity of the cleanliness of items intended for patient use brought to the facility by volunteer staff on the Postpartum Unit, the Nursery, the Pediatric Unit, the Pediatric Intensive Care Unit (PICU), and the NICU; failed to ensure isolation precuations were followed for one (#1) of fifty-two patients reviewed; and failed to ensure Bloodborne Pathogen Exposure precautions were followed in the Medical Intensive Care Unit (MICU).

The findings included:

Observation, with the Registered Nurse Manager and the Vice President of Clinical Services, on the NICU on January 19, 2011 at 9:05 a.m., revealed a housekeeper entered the unit pushing a large trash bin with gloved hands. Continued observation revealed the housekeeper, without removing the gloves, entered the soiled storage area, gathered numerous bags of bio-hazardous refuse, exited the soiled storage area, placed the bags of bio-hazardous refuse in the trash bin, and without removing the gloves or washing the hands, exited the unit.

Review of the facility policy Infection Control/Epidemiology, policy number W-SY-17100-0222-PO, last revised March 2010, revealed "...to provide a safe and healthful environment...Gloves - may be worn when it can be reasonably anticipated that the employee may have hand contact with bloody fluids, secretions, excretions...gloves are single use..." Review of facility policy Hand Hygiene, policy number W-SY-17100-327-PO, last revised October 2010, revealed "...All staff will adhere to this policy to reduce the transmission of microorganisms to patient and colleagues in healthcare settings...Hand hygiene is monitored upon Entry/Exit of patient room or area...hands should be washed or decontaminated before putting on gloves and after removing them..."

Interview, with the Registered Nurse Manager and the Vice President of Clinical Services, on the NICU on January 19, 2011 at 9:05 a.m., confirmed gloves are to be removed and hands washed before exiting the soiled storage area after handling bio-hazardous refuse. Continued interview confirmed the policy was not followed.

Interview with the Infection Control Practitioner on January 20, 2011, at 9:00 a.m., in the Quality Department Conference Room, confirmed the housekeeping staff were to remove gloves before leaving soiled utility areas.

Observation, with the Registered Nurse Manager and the Vice President of Clinical Services, on the Pediatric Unit on January 19, 2011 at 10:15 a.m., revealed a housekeeper entered the unit pushing a large trash bin with gloved hands. Continued observation revealed the housekeeper, without removing the gloves, entered the soiled storage area, gathered numerous bags of soiled linens, exited the soiled storage area, placed the bags of soiled linens in the transport bin, and without removing the gloves and washing the hands, exited the unit.

Interview, with the Registered Nurse Manager and the Vice President of Clinical Services, on the NICU on January 19, 2011 at 10:15 a.m., confirmed gloves are to be removed and hands washed before exiting the soiled storage area after handling soiled linens. Continued interview confirmed facility policy was not followed.

Interview with the Infection Control Practitioner on January 20, 2011, at 9:00 a.m., in the Quality Department Conference Room, confirmed the housekeeping staff were to remove gloves before leaving soiled utility areas.

Observation of the Postpartum Unit, the Nursery, the Pediatric Unit, the PICU, and the NICU with the Registered Nurse Manager of each unit and the Vice President of Clinical Services between January 18 - 19, between the hours of 8:30 a.m. and 4:00 p.m., revealed each unit had a supply of hand knitted caps, handmade blankets, and store purchased items for infants and pediatric patients. Continued observation revealed each item had a tag indicating a store purchased item or the item had been given by a volunteer.

Interview with the Infection Control Nurse on January 20, 2011 at 9:30 a.m., in the Quality Department Conference Room, confirmed all items brought to the facility by the volunteers and intended for patient use in the Postpartum Unit, the Nursery, the Pediatric Unit, the PICU, and the NICU were to be cleaned in the facility laundry before distribution to patients.

Interview with the Registered Nurse Managers on each unit between January 18 - 19, 2011, between the hours of 8:30 a.m. and 4:00 p.m., confirmed the items were brought to the unit from the volunteers for patient use and the cleanliness of the items could not be verified.


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Patient #1 was admitted to the facility on January 17, 2011, with an emergency Heart Catheterization due to Chest Pain in the Emergency Department.

Observation in the Cardiac Care Unit (CCU) on January 18, 2011, at 1:25 p.m., revealed the patient was in bed and the patient room doors had a sign indicating the patient was in Contact Isolation, which required applying a gown and gloves prior to entering the room. Further observation revealed Registered Nurse (RN) #1 entered the patient's room, without applying a gown or gloves, leaned on the patient's over bed table with the hands; walked to a sink area in the patient's room to fold two bed linens; washed the hands and exited the room.

Review of the facility's policy Isolation Precautions Guidelines #W-SY-17100-302-GL revised August, 2010, and interview with the Infection Control Practitioner on January 20, 2011, at 9:00 a.m., in the Quality Department Conference Room, confirmed the facility followed CDC (Centers for Disease Control) guidelines and any patient with a current or history of multi-drug resistant organism, such as MRSA (Methicillin-Resistant Staphylococcus aureus), must be placed in contact isolation until a negative laboratory result for the organism was obtained. Review of the policy revealed, "Contact Precautions are used for patients who are suspected...and known to be infected or colonized with organisms that can be transmitted by direct contact with the patient (hand or skin) contact that occurs when performing patient-care activities or indirect contact with environmental surfaces or patient care items in the patient's environment...Contact Isolation requires the use of gown and gloves to enter the room regardless of patient contact..."

Interview with RN #1 on January 18, 2011, at 1:40 p.m., at the CCU nursing station, confirmed patient #1 had a history of MRSA, was in contact isolation which required a gown and gloves prior to entering the patient's room, and the RN did not follow hospital isolation guidelines.

Observation of MICU on January 19, 2011, at 2:40 p.m., with the Clinical Leader, revealed the unit was a 20 bed unit designed with a desk for nursing located in an alcove between every two patient rooms. Further observation of the nursing desks located between the patient rooms revealed the desks contained various items including a computer for charting, books, patient charts, and stethoscopes. Further observation revealed multiple drink cups and bottles located at each desk.

Review of the facility's policy Bloodborne Pathogen Exposure Control Plan #W-SY-17100-0222-PO revised March, 2010, revealed, "...the major intent of the Exposure Control Plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA Standard 29 CFR 1910.1030, 'Occupational Exposure to Bloodborne Pathogens '...Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are strictly prohibited in clinical and lab areas or where there is likelihood or exposure. Food and drink is not kept in refrigerators, freezers, on countertops or in other storage areas where blood or other potentially infectious materials are present..."

Interview with the Infection Control Practitioner on January 20, 2011, at 9:00 a.m., in the Quality Department Conference Room, confirmed staff food and drinks were not allowed in clinical or patient care areas where possible contamination from bloodborne pathogens may occur.

Interview with the MICU Clinical Leader on January 19, 2011, at 2:40 p.m., in MICU, confirmed the unit had nursing desks located between patient rooms, for use by nursing to chart and monitor patients, and the nurses kept their personal drink items at the desks in the clinical area.