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Based on findings from document review and interview, the hospital did not ensure compliance with the state licensing standard at 405.3 (d) (6) of Title 10 New York Codes Rules and Regulations (10NYCRR) which requires biennial review of operational policies and procedures (P&Ps).

Findings include:

--Part 405.3 (d) (6) of 10NYCRR requires that operating procedure manuals for all services or units of the hospital organization be reviewed at least biennially or more frequently as determined appropriate by each service or unit.

--Per review of the hospital's P&Ps for its services and units, the following are examples of P&Ps that were not reviewed every 2 years:

"Admission of the Patient to Newborn Nursery," last reviewed/revised 02/2007

"Infection Control for Radiology," last reviewed/revised 09/2011

"Patient's Own Medications," last reviewed/revised 08/2011

"Suspected Transfusion, Reaction or Complications," last reviewed/revised 05/2010

--During interview of the Vice President of Patient Care Services on 1/6/14 at 2:00 pm, he/she indicated that the hospital reviews its P&Ps every 3 years as required by its accrediting organization, Det Norske Veritas (DNV).

Based on findings from document review, observation and interviews, informed consent was not obtained to take a security photo of a newborn infant, in 1 of 3 obstetrical medical records reviewed (Patient A).

Findings include:

--Per review of Patient A's medical record, on a form titled "Newborn Safety Information Sheet," the signature of the patient (mother of a newborn) was witnessed by RN #1 on 1/4/14 at 12:25 pm. The check box for consent to a newborn infant security photo was not checked.

-- Upon observation on 1/7/14 at 4:15 pm, a security photo of the patient's newborn infant (Patient B) was stored in the nursery digital camera. The Obstetrical Unit Nurse Manager was present at the time of this observation.

--During interviews of RN #2 and the Obstetrical Unit Nurse Manager on 1/7/14 at 4:15 pm, they confirmed these findings.

Based on findings from document review and interviews, in 1 of 10 inpatient medical records (MRs) reviewed for advance directives (Patient C), nursing staff did not notify the attending physician when the patient reported the existence of a Non-Hospital Do Not Resuscitate (DNR) Order (not presented at the time of hospital admission). Additionally, 2 out of 5 adult outpatient MRs reviewed (Patients D and E) lacked evidence of whether the patient had an Advance Directive (AD).

Findings include:

-- Per MR review on 1/6/14, Patient C was admitted on 12/27/13 at 23:56. At 02:55 on 12/28/13, nursing staff documentation indicated that the patient had a Non-Hospital DNR order, that a copy was not provided by the patient at the time of admission and that the supervisor was contacted to request a copy from the previous medical record. On 12/31/13, 1/1/14 and 1/2/14, nursing staff documented in the advance directive followup section of the MR that a copy of the Non-Hospital DNR order was not provided by the patient, a request was made to the nursing supervisor for a copy from the patient's previous medical record, and that the copy was not obtained.

There was no documentation indicating the patient's attending physician was contacted by nursing staff when Patient C reported the existence of a Non-Hospital DNR order.

During interview of the Medical Surgical Clinical Coordinator on 1/6/14 at 2:00 pm, he/she acknowledged that nursing staff should have contacted the patient's attending physician to address the reported existance of a Non-Hospital DNR order.

-- Per reviews of the outpatient MRs of Patients D and E on 1/6/14, each lacked documentation of whether they had ADs.

The hospital policy and procedure titled "Advance Directives," last reviewed 5/2012, indicated the policy of the hospital was to document in the MR whether a patient has an AD.

During interview of the Director of the Outpatient Services on 1/6/14 at 12:30 pm, he/she confirmed the findings above.

Based on findings from document review and interview, in 2013 the hospital's quality assessment and performance improvement (QAPI) program did not include measurements of any processes of care for the Obstetrics Department and did not collect data for 1 of 2 processes of care planned to be measured for its Cancer Treatment Center (CTC). Also, in 1 of 2 cases reviewed, the QAPI program did not ensure that all data derived from its grievance process was included in medical staff practitioners' quality files for tracking and assessment during credentialing.

Findings include:

-- Review of meeting minutes for the 12/9/13 Hospital Performance Improvement Committee revealed the "Department PI (performance improvement) Activity 3rd Quarter Report" lacked information concerning the hospital's Obstetrics Department. While the Obstetrics Department was listed on the report, corresponding columns describing an opportunity for improvement, baseline status, goal, and data for the first, second and third quarters of 2013 lacked information. Instead, "No report" was listed in the "Opportunity for improvement" column for the Obstetrics Department.

Also, the same "Department PI Activity 3rd Quarter Report" lacked information about any data collected for 1 of 3 opportunities for improvement planned to be assessed for the Cancer Treatment Center during 2013. Specifically, "Orders properly noted and processed prior to filling" lacked corresponding data for the 3 quarters addressed in the report.

These findings were confirmed during interview with the hospital Director of Quality / Performance Improvement at 3:30 pm on 1/8/14.

-- Review of a "RECORD OF GRIEVANCE" form and a "GRIEVANCE INVESTIGATION" form for a grievance registered on 10/8/13 revealed the following information: The complainant reported that Certified Registered Nurse Anesthetist (CRNA) #1 was on his/her private cell phone looking up sports-related information while a patient was under anesthesia (date of service not recorded). Investigation confirmed the CRNA "often engages in this 'risky' behavior during procedures ... while the patient is anesthetized." Corrective action entailed counseling CRNA #1 about this issue.

The hospital policy and procedure titled "SUBJECT: Complaint / Grievance Management," last revised 2/2012, contained the statement "Data from grievances involving physician and midlevel providers will become part of the medical staff's quality file."

Review of the quality file for CRNA #1 on 1/7/14 revealed it did not contain information from the grievance investigation described above.

These findings were confirmed during interview with the hospital Patient Safety Officer / Risk Manager at 4:40 pm on 1/8/14.

Based on findings from interview, document review and observation, nursing assessment and patient care interventions were not complete, timely and/or implemented in accordance with hospital policy. Specifically, a patient's allergy was not affixed to the medical record (the allergy was addressed via a bracelet on Patient F but not the chart). Additionally, in 1 of 3 medical records (MRs) reviewed, the initial nursing assessment of a newborn (Patient G) was not documented and a physician's order for a heel stick was not performed timely. Also, MR forms for documenting patient teaching were blank in 2 of 3 MRs reviewed (Patients H and A).



Findings include:

--Per interview of RN #2 at 8:05 am on 1/7/14, patient allergies are listed on the outside front of the patient's chart. He/She indicated bracelets are not used at this hospital to identify a patient has allergies.

Per review of Patient F's MR, an allergy to codeine that was described in the prenatal records was not addressed in the nursing admission assessment, and the MR lacked an allergy label affixed to the outside front of the chart. However, per observation of the patient at 10:38 am on 1/7/14, a red bracelet was on her wrist indicating she had a medication allergy.

Per review of the hospital policy and procedure titled "Patient Safety: Color -Coded Wristband Identification System," last revised 6/2012, it required nursing staff to document a patient's allergies on the patient admission assessment, and, when they do have an allergy(ies), to place an allergy label on the front of the patient's chart and a red arm band / bracelet on the patient.

--Per review of Patient G's MR, the Initial Newborn Assessment form dated 1/4/14 contained documentation by a Licensed Practical Nurse describing newborn and admission data for the infant (e.g., type of delivery, vital signs, medications administered at delivery), but lacked documentation by a Registered Nurse (RN) completing the physical assessment section of the form (e.g., breath sounds, reflexes, number of vessels in the cord). Also, because this newborn's mother was diabetic, physician orders required a heel glucose level to be drawn on the baby within 2 hours of birth. Patient G was born at 10:39 am on 1/4/14 but the heel stick was not done until 1:30 pm, 3 hours later. These findings were confirmed by RN #3 at 9:30 am on 1/8/14.

--Per review on 1/8/14 of newborn Patient G's MR (following her hospital discharge in the morning of 1/6/14), the Newborn Daily Flow Record form contained a section with check boxes to document teaching. The check boxes addressed infant bath, diaper changes, cord care, bottle feeding, et cetera. These check boxes were blank. There was a notation on the form that "all complete documentation of teaching must be done on the OB Teaching sheet on the mother's chart." Review of the maternal MR (patient H) following her discharge from the hospital revealed it also lacked documentation of teaching.

Review on 1/8/14 of the MRs for newborn Patient B and for his mother Patient A (following their discharge from the hospital on 1/6/14) revealed the same findings.

Based on findings from document review and interviews, hospital policies and procedures (P&Ps) did not address the timing of medication administrations based on the nature of the medication and its clinical application, per generally accepted standards of practice.

Findings include:

--Per review of the hospital P&P titled "Administration of Medication," last revised 06/2012, it indicated that medications must be administered within the time frame of 60 minutes before to 60 minutes after the scheduled time. The P&P did not identify the following:

*Medications not eligible for scheduled dosing times;
*Medications eligible for scheduled dosing times; and
*Administration of eligible medications outside their scheduled dosing times and windows.

--During interview with the Director of Pharmacy on 1/7/14 at 3:00 pm, he/she acknowledged the finding above and indicated the hospital did not have any other P&P that addressed the timing of medication administrations.

Based on findings from document review, observation and interview, the volume of a unit of packed red blood cells (PRBCs) was not accurately listed on the hospital's Blood/Blood Product Transfusion Order Form or on the label of a unit of PRBCs that was brought to the Obstetrical Unit for patient use.

Findings include:

--Per review of Patient F's medical record (MR), on 1/8/14 a physician order was entered on a Blood/Blood Product Transfusion Order Form for a blood transfusion with 2 units of PRBCs.

--Per observations on 1/8/14 at 2:10 pm, although the Blood/Blood Product Transfusion Order Form indicated the volume of a unit of PRBCs was 250 ml (milliliters), the label on the unit of PRBCs that arrived on the Obstetrical Unit listed the volume as "500 ml ... from whole blood." Registered nurse (RN) #1 then documented on the Unit Transfusion Card form that the volume of blood was 500 ml and verbally indicated during interview at the same time that the volume of the unit of blood was 500 ml. The surveyor interviewed RN #1 who called the Supervisor of the Blood Bank at 2:20 pm to clarify and was informed by him/her that the volume of a unit of PRBCs was 300 ml. The Supervisor of the Blood Bank came to the obstetrical unit with documentation verifying that the volume of a unit of PRBCs was 300 ml.

--Per review of the hospital policy and procedure titled "Blood Transfusions and Blood Product Transfusion: FFP (fresh frozen plazma), Platelets, 5% and 25 % Albumin, Cryoprecipitate (fibrinogen replacement) and Other Products," last revised 7/2012, it stated the volume of a unit of PRBCs is 300 ml.

Based on findings from observation and interview, medical records (MRs) were stored in an unlocked attic at the Canton Health & Diagnostic Center (CHDC) hospital extension clinic.

Findings include:

--Per observation during a tour of the CHDC on 1/6/14 at 12:30 pm, several shelves of MRs were stored in an unlocked attic that could be accessed by patients en route to patient treatment areas. This observation was confirmed with the Director of Outpatient Services during the tour.

Based on findings from document review and interviews, verbal orders were not authenticated within 48 hours in 1 of 8 medical records (MRs) that contained verbal orders (Patient C). Also, 2 of 6 surgical patient MRs contained physician orders that lacked dates and/or times (Patients I and J).

Findings include:

--Per review of the hospital policy and procedure titled "Verbal or Telephone Orders/Read Back," last revised 01/2013, it stated that verbal/telephone orders must be signed by the physician within 48 hours.

Per review of Patient C's MR on 1/6/14 at 11:00 am, it contained a telephone order provided by Physician #1 on 12/31/13 at 13:58 for Vancomycin intravenously (IV) daily and Zofran IV prior to meals. The order remained unsigned by a physician 6 days later. The MR also contained a telephone order provided by Physician #1 on 1/2/14 at 17:48 for Latanoprost 1 drop both eyes at 2200. The order remained unsigned by a physician 4 days later.

During interview with the Medical Surgical Clinical Coordinator on 1/6/14 at 11:15 am, he/she acknowledged the findings above.

--Per review of Patient I's closed MR on 1/7/14, it contained an order form titled "Standing Pre-op Orders," signed by Physician #2. This form included orders for medications and IV fluids. The form lacked a date and time.

Per review of Patient J's MR on 1/7/14, it contained preoperative orders dated 12/11/13 that lacked a time.

During interview with the Director of Surgical Services on 1/8/14 at 11:30 am, he/she acknowledged these findings.

Based on findings from observation, document review and interview, expired medications and solutions were available for patient use.

Findings include:

--During a tour of the Ogdensburg Health Center on 1/6/14 at 2:30 pm, the first aid kit at the pool contained two 20 cubic centimeter ampules of Ocufresh (eye wash), with expiration dates of 01/02/08.

--During a tour of the Canton Health and Diagnostic Center on 1/6/14 at 11:00 am, Alcohol Spray 70% with an expiration date of 11/2013 was found in the Nurse Practitioner's Exam Room #1. Also, the medication room contained an opened multidose vial of Xylocaine 1% dated 10/19/13, i.e., it was not discarded 28 days after opening, per generally accepted pharmaceutical standards. The Director of Outpatient Services was present during these observations.

--Per observations on 1/7/14 at 3:00 pm, the following expired supplies were available for use on the Obstetrical Unit:

Two sterile water bottles for infant ingestion which had expired 10/2013 - in Labor Room B

One 250 milliliter intravenous solution of D5.2%NS (Dextrose 5 /.2% normal saline) which had expired 11/2013 - in the emergency cart in the Nursery.

These observations occurred in the presence of the Obstetrical Unit Nurse Manager.

Based on findings from document review and interview, the hospital's laboratory lacked a policy and procedure (P&P) stating which tissue specimens require both a macroscopic and microscopic examination. Also the P&P did not indicate that the medical staff are involved in this determination.

Findings include:

--Per review of the hospital laboratory P&P titled "Criteria for Preparation of Microscopic Sections," last revised 03/2012, it stated that the pathologist determines if microscopic sections are needed on any specimen. The P&P was approved by the Laboratory Director and Laboratory Manager.

--During interview with the Laboratory Director on 1/8/14 at 4:15 pm, the above findings were confirmed.

Based on findings from observation and interview, not all doors in the hospital were compliant with NFPA 101 (2000) Chapter 7.2 which prohibits more than one releasing action to operate a door.

Findings include:

--Per observation at 8:45 am on 1/7/14, dead bolts were installed on six doors in the Operating Suite on the third floor of the hospital which would require more than one releasing motion to operate these doors in the event of a fire.

--The Director of Facilities Management & Safety who was present, agreed with these findings and stated that the dead bolts would be removed.


Based on findings from observation and interview, the medical records storage area in the hospital basement was not maintained in a manner consistent with the requirements of NFPA 101 (2000) and NFPA 13 (1999) referenced in NFPA 101 for a storage area containing combustibles.

Findings include:

--Per observation on 1/6/14 at 12:15 pm, the exits in the medical records storage area were not equipped with exit signs as required by NFPA 101, section 7.10, which states that exits must be marked with exit signs readily visible from any direction of exit access.

--Per observation on 1/6/14 at 12:15 pm, a clearance of 18 inches was not maintained below the sprinkler heads in the medical records storage area. NFPA 13, section 5, requires a clearance of 18 inches below the sprinkler heads in order to avoid interference with the spray pattern of the water emitted by the sprinkler heads during a fire.

--Per observation on 1/6/14 at 12:20 pm, penetrations above the drop ceiling were observed negating the smoke rating of the medical records room. NFPA 101 (2000) requires the separation of an area deemed hazardous by the authority having jurisdiction from other spaces by smoke-resisting partitions and doors when sprinklers are present.

--The supervisor of Facilities Management & Safety who was present at the time the above observations were made was interviewed and concurred with these findings.

Based on findings from observations and interview, trash at 1of the 2 hospital extension clinics toured and in the Emergency Department (ED) was not properly stored and promptly disposed.

Findings include:

--Per observations during a tour of the Canton Health & Diagnostic Center hospital extension clinic on 1/6/14 beginning at 11:30 am, in the attic used paint cans, carpet adhesive, old chairs, lights, et cetera were stored next to shelves of archived medical records (MRs).

During interview with the Director of Outpatient Services on 1/6/14 at 11:30 am, he/she confirmed that the items stored with the MRs were trash needing to be disposed.

-- Per observations during a tour of the ED on 1/7/14 beginning at 8:00 am, the soiled utility room contained 10 bags of trash. Two trash cans each contained 2 bags; 3 bags were stored directly on the floor with 3 more bags piled on top. Two (2) filled sharps containers and a box of expired (5/2012) solidifier pouch gel (used to clean up blood spills) were also stored on the floor. Also, a used urinal with residual urine was hanging from the hopper.

During interview with the ED Nurse Manager on 1/7/14 at 8:15 am, he/she confirmed these findings and indicated that housekeeping services are only provided to the ED from 7:30 am till 3:30 pm and at 8:00 pm each day. When housekeeping presents at 8:00 pm the ED bathrooms are cleaned and the trash is picked up. Housekeeping does not return to the ED until 7:30 am the following day.

Based on findings from observations, document reviews and interviews, the hospital process for checking completeness and outdates of emergency supplies and equipment in the Obstetrical (OB) Unit was not effective. Expired equipment was identified in 1 of 5 emergency cart / boxes. In Labor and Delivery, the acceptable temperature range for a blanket warmer was not known to a staff member interviewed and a flashing light indicating low battery for the temperature indicator on the refrigerator was not addressed at the time noted.

Findings include:

--Per observations on 1/7/14 at 3:00 pm, each of 3 Labor Rooms had an emergency equipment box, Box #1, Box #2, and Box #3. The Obstetrical Unit Nurse Manager and Registered Nurse (RN) #2 indicated that each box was to be checked daily, to be sure it was locked. Although the Daily Worksheet (completed by the Charge Nurse) also indicated the black boxes were being checked daily, review of the Black Emergency Box check list form for each box revealed nurses had last documented checks of Box #1 on 11/5/13 and Box #2 on 3/1/13. The check list for Box #3 lacked a date corresponding to the last check documented. Also, the check lists lacked expiration dates for the contents listed (no expired items identified upon checking the contents).

--Per observations on 1/7/14 at 3:25 pm, the Emergency Equipment Check form for an emergency cart in the Nursery indicated staff were checking the cart twice a day to be sure it was locked. Upon checking the contents the following outdated supplies were noted in the cart:

12 - 24 gauge angiocatheters (expired 9/2013)
6 - 22 gauge angiocatheters (exp 5/2013)
1- BD vacutainer (exp 8/2013)
1- BD vacutainer blood culture tube (exp 12/2013)
2 - arterial blood gas kits (exp 6/2013)
2 - triple lumen umbilical vessel catheter kit (exp 6/2013)
1 - triple lumen umbilical vessel catheter kit (exp 5/2013)
1- umbilical artery catheter tray (no expiration or sterilization date noted)

These observations were made in the presence of the Obstetrical Unit Nurse Manager.

--Per observation on 1/7/14 at 4:00 pm, a transport emergency box (to take when a newborn is transferred to a higher level of care) was stored in the locked medication room in the Labor and Delivery area. Review of the Transport Box Sign Out Log revealed staff were checking whether it was locked, once to twice a day. However, the transport box lacked an inventory list describing contents and expiration dates, and the Obstetrical Unit Nurse Manager and RN #2, present at the time of these observations, could not describe the contents. (No expired items identified upon checking the contents.)

--Per observation on 1/7/14 at 10:20 am, a temperature indicator light on a refrigerator in the OB unit storage room was flashing. Per interview of Housekeeper #1, who had already checked the refrigerator earlier in the morning, the flashing light meant the battery for the temperature indicator was low. He/She is supposed to contact maintenance to address it but acknowledged not yet making that contact.

--Per observation on the OB unit on 1/7/14 at 3:25 pm, a blanket warmer contained newborn blankets and adult bath blankets. It displayed a temperature that staff were recording on the unit's Daily Worksheet. However, during interview of RN #2, he/she was not aware of the acceptable temperature range for the blanket warmer.

Based on findings from observations and interviews, the former staff break room in the main laboratory, the bacteriology laboratory, the soiled utility room in the ultrasound suite, and the clean storage room across from room 228 were not properly ventilated in accordance with the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) requirements as referenced in the 1996/1997 and 2010 editions of the Guidelines for the Design and Construction of Health Care Facilities. These guidelines are listed in Title 10 Part 711.2 as pertinent technical standards for the construction and physical environment of health care facilities.

Findings include:

--Per observation at 12:00 pm on 1/6/14, the former staff break room in the main laboratory was being used to house both soiled materials including blood products as well as clean supplies used in chemical analyses. In addition, there was no door on the room. According to the technical standards referenced above, airflow must be negative if the room is used as a soiled holding or utility room with 10 air exchanges per hour (ach) and positive if used as a clean room with 4 ach. Without a door, airflow in these rooms cannot meet either of these criteria. Further, clean and soiled materials should not be comingled for infection control purposes.

--Per observation at 12:10 pm on 1/6/14, the exhaust fans in the bacteriology laboratory were not functioning. For this reason, airflow in the laboratory cannot meet ASHRAE criteria that requires airflow to be negative in relationship to adjacent areas with 6 ach.

--Per observation at 1:50 pm on 1/6/14, air could not be exhausted in the soiled utility room in the Ultrasound Suite because there was no exhaust fan. For this reason, airflow cannot meet ASHRAE criteria that requires soiled rooms to have negative airflow in relationship to adjacent areas with 6 ach.

--Per observation at 8:10 am on 1/7/14, there was no supply air diffuser in the clean storage room across from room 228. Per ASHRAE criteria, clean holding rooms must have a positive air pressure relationship to adjacent areas with 4 ach.

--The supervisor of Facilities Management & Safety who was present at the time the above observations were made was interviewed and concurred with these findings.

Based on findings from observations, document reviews and interviews, hospital staff did not implement generally accepted standards of infection control, as follows:

(1) Isolation carts were not stocked with isolation gowns ( 4 out of 6 carts),
(2) Staff did not follow isolation procedures (2 occurrences),
(3) Staff did not know contact time of disinfectant cleaning products (1 staff),
(4) The top of the emergency cart in the Nursery was covered with dust and dirt,
(5) Unsanitary conditions were noted at 1 of the 2 hospital extension clinics toured and in the Emergency Department (ED), and
(6) Clean and soiled materials were stored comingled in a room in the main Laboratory - see the first finding in Tag A 726.

Findings regarding (1) and (2) above include:

--Per review of hospital policy and procedure (P&P) titled "Isolation Precautions," last revised 8/2009, it indicated that a gown should be worn when entering an isolation room if you anticipate you will have contact with the patient or patients environment and that the gown should be removed prior to leaving the isolation room.

--Per observation on 1/8/14 at 11:30 a.m., 3 isolation carts placed outside rooms of patients on contact isolation (1 on the swing bed / alternate level of care wing and 2 on the medical surgical unit) lacked isolation gowns. This was acknowledged by registered nurse (RN) #4 who indicated housekeeping had been contacted to obtain disposable gowns because they were out of cloth gowns.

--Per observation on 1/9/14 at 8:55 am, the isolation cart outside room 203 lacked isolation gowns. RN #5 was present during this observation and acknowledged the finding.

--Per observation on 1/8/14 at 11:40 am, Nurse Aide (NA) #1 provided care to the patient in room 240 who was on contact isolation. He/She did not don a gown as required. During interview of NA #1, he/she acknowledged he/she should have worn a gown to provide care to this patient.

--Per observation on 1/9/14 at 9:15 am, RN #6 provided care to the patient in room 229 who was on contact isolation. RN #6 wore gown and gloves as required. He/she exited the room and removed the contaminated gown, then placing it on top of the medication cart. When asked why he/she placed the contaminated gown on this clean area, RN #6 stated he/she was going to take it to the dirty utility room to discard.

Findings regarding (3) above include:

--Per review of the manufacturer's instructions on a bottle of the disinfectant Virex, the contact time required to attain effective disinfection is 10 minutes.

--Per interview of RN #2 on 1/7/14 at 9:00 am, the contact time for Virex is 3 minutes.

Findings regarding (4) above include:

--Per observation of the top of the emergency cart in the Nursery on 1/7/14 at 3:25pm, it was noted to be covered in dust and dirt. This finding was confirmed by the Obstetrical Unit Nurse Manager at the time.

Findings regarding (5) above include:

--During a tour of the Canton Health & Diagnostic Center hospital extension clinic on 1/6/14 beginning at 11:30 am, the following observations were made:

- The janitor's closet contained 2 boxes of rags and 2 boxes of mop heads. Per interview of the Director of Outpatient Services, one was probably clean and the other dirty. Signage or labels indicating which boxes contained clean items and which contained dirty items were lacking.

- In the clean storage room, clean laundry in a plastic open bag and boxes of patient care supplies were stored on the floor.

During interview with the Director of Outpatient Services on 1/6/14 at 11:30 am, these findings were confirmed.

-- Per observations during a tour of the ED on 1/7/14 beginning at 8:00 am, the floors throughout contained mud (dirt and sand) and the soiled utility room was not maintained in a sanitary manner (see findings in Tag A 713).

During interview with the ED Nurse Manager on 1/7/14 at 8:15 am, he/she confirmed the observations and indicated that housekeeping services are only provided to the ED from 7:30 am till 3:30 pm and at 8:00 pm, each day. When housekeeping presents at 8:00 pm the ED bathrooms are cleaned and the trash is picked up. Housekeeping does not return to the ED until 7:30 am the following day.

Based on findings from document reviews and interview, in 2 of 6 medical records (MRs) reviewed (Patients J and K), the physician orders were not dated and timed within 24 hours before the procedure and after an update to the initial history and physical (H & P) was completed.

Findings include:

--Per MR review, Patient J presented to the hospital for a surgical procedure on 12/17/13 at 7:00 am. An intravenous (IV) line was started and medications were administered at 7:20 am. The order for these interventions was written on 12/11/13, 6 days before the surgical procedure and prior to the physician review / update of the initial H & P (completed on 11/20/13).


--Per MR review, Patient K presented to the hospital for a surgical procedure on 12/17/13 at 8:00 am. An IV line was started and medications were administered at 8:25 am. The order for these interventions was written on 12/13/13, 4 days before the surgical procedure and prior to the dictation of the H & P (completed on 12/17/13).

--During interview of the Vice President of Medical Affairs on 1/8/14 at 10:00 am, these findings were acknowledged.

Based on findings from document reviews and interviews, the medical records (MRs) of 3 of 6 surgical patients (Patients L, M and I) lacked documentation of complete preanesthesia evaluations.

Findings include:

--Per MR review, Patient L underwent a surgical procedure on 1/6/14. Her preanesthesia assessment, dated 12/4/13 and updated on 1/6/14, lacked documentation of an airway assessment by the Anesthesia provider. This finding was acknowledged by Anesthesiologist #1 on 1/9/14 at 8:45 am.

-- Per MR review, Patient M underwent a surgical procedure on 1/6/14. Her preanesthesia assessment dated 1/6/14 lacked documentation of an airway assessment by the Anesthesia provider. (It is further noted that documentation in Patient M's MR indicated she had asthma and sleep apnea.) Although it is also documented that the patient had hypertension, history of murmur and cardiac catheterization, no heart assessment was described. These findings were acknowledged by Certified Registered Nurse Anesthetist (CRNA) #1 on 1/6/14 at 12:30 pm.

--Per MR review, Patient I underwent a surgical procedure on 11/14/13. Her preanesthesia assessment dated 11/13/13 lacked documentation of an airway assessment by the Anesthesia provider. This finding was acknowledged by the Director of Surgical Services on 1/8/14 at 11:30 am.