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Based on observation and interview, the facility failed to ensure a sanitary environment with easily cleanable surfaces is preserved by maintaining:

- Sealed mattresses and mattress covers free from tears and frayed seams;
- Door and wall surfaces in patient care suites free from tears, scrapes and other damage that prevents easy cleaning;
- Rust and corrosion on equipment stationed in operating suites and regularly used in surgical procedures.

These failures potentially expose facility medical personnel and patients to infection. The facility census was 5.

AORN is a nation-wide practice group that establishes standards of practice for infection control measures. AORN (Associated Organization for Registered Nurses) Preoperative Standards and Recommended Practices, May 2009, states, "A safe, clean environment should be reestablished after each surgical procedure. Routine cleaning and disinfection reduces the amount of dust, organic debris and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practice in health care organizations helps to reduce infections associated with contaminated items."

Findings included:

1. Observations of the Birthing Center on 09/07/11 at 8:30 AM showed the following:
-Torn seam along the pillow edge of a mattress cover in Triage Room.
-Chips of paint and plaster missing and wall scratches at 36 inches above floor outside of Birthing Room 1, where a waste receptacle had damaged the wall.
-Chipped paint and plaster missing from inset corners of door frames to Birthing Rooms 1, 2, and 3 exposed metal corner bead.
-Gouges in the walls, chipped and missing pieces of plaster and deep scratches in the wall surfaces at the entrance to the clean and soiled utility room and outside of the nurse's station also exposed metal corner bead.

2. Observations of the Med Surg wing (200 corridor) on 09/07/30/11 at 9:00 AM showed the following:
-Peeled and scraped wall paper on the lower 30 inches of the walls next to the drinking fountain, janitor's closet and soiled and clean utility rooms across from room 217.
-Peeled wall paper in room 219.
-Several of the metal door frames of bathrooms and utility rooms were rusted at the base; -Door surface finishes on 10 of 12 rooms used for patients were marred by pieces of scotch tape and/or missing areas of the finish that had peeled off when tape was removed.

3. Observations of the Operating Room suites on 9/7/11 at 3:00 PM showed the following:
-Rust spots on the trash rack casters and frame;
-Corrosion and rust on double ring stand casters and frame, wheeled drawer stand, Mayo stand and a large steel work table.

During interviews on 9/07/11 at 8:30 AM, Staff G, Director of OB/GYN stated the mattress was intact and the cover would be removed and discarded. Staff G stated he/she was not sure the purpose of the cover. Staff K, Director of Plant Operations stated work orders and repairs are ongoing to keep everything functioning. He/she stated that high census and volume of OB/GYN patients have made any tear-out and renovation projects a challenge. He/she stated they are familiar with protective trim pieces, as they have used them successfully in other areas of the hospital and have several different types available.

Based on observation, interview, review of facility policy and medication administration record (MAR) review, the facility failed to ensure safe administration of medications to patients when facility staff failed to accurately document the time medications were given to two (#3 and #8) of five patients observed during medication administration during the survey. This had the potential to affect all patients receiving medications.

The facility also failed to follow standards of practice and the facility policy and procedure for one (#7) of one patient who received Percocet (a combination medication used to treat mild to moderate pain) without a complete medication order. This had the potential to affect all patients receiving the medication.

The facility census was five.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration" revised 03/02/10, showed the following direction to facility staff:
- All staff members will address the Six Patient Rights prior to giving any medication. The rights are Right Patient, Right Drug, Right Dose, Right Route, Right Time, and Right Documentation
- All staff members will adhere to the standard drug administration times
- Medications may be administered 30 minutes prior to and 30 minutes after the stated time. (It will be considered a medication error if medications are not given within this 1-hour window.)
Medication Administration Record will be compared with the physician order at the time the order is written and at least one time each day via the 24 hour chart check. The nurse administering a medication will be aware of the following information concerning each medication before administration:
- Normal dosage and maximum safe dosage.
Any medication order that is questionable shall be clarified prior to medication administration and orders for medication that are not specific to strength and/or dosage must be cleared with the physician.

2. Observation on 09/07/11 at 10:15 AM showed Staff O, Registered Nurse (RN) gave the following medications to Patient #3:
Metformin (medication for diabetes) 500 milligrams (mg) one tablet by mouth (PO);
Hydrochlorothiazide (medication to treat high blood pressure) 12.5 mg PO;
Folic Acid (a vitamin supplement) 1 mg PO;
Protonix (medication to decrease stomach acid) 40 mg PO;
Diovan (medication for blood pressure and/or heart problems) 80 mg PO and
Lovenox ( medication to prevent blood clots) 40 mg injectable every 24 hours

Record review of Patient #3's medication administration record (MAR) showed Staff O, RN initialed (documented) these medications were given at 9:00 AM, even though they were observed as given at 10:15 AM, a hour and fifteen minutes later.

During an interview on 09/07/11 at 10:30 AM, Staff O, RN stated that she/he was aware the patient's medications were given late due to the physician having the patient's medical record. However, no explanation was given for the incorrect time recorded on the MAR.

During an interview on 09/08/11 at 11:40 AM, Staff D, RN Vice President of Quality Resources stated that staff should write the actual time the medications were given on the MAR and that it was not accurate or acceptable to simply initial the pre-printed time shown on the MAR. Staff D confirmed the importance of accurate documentation and stated that some medications are time sensitive. She confirmed that if the medications were given too close together or too far apart, they may not be as beneficial and/or safe to the patient.

During an interview on 09/08/11 at 11:50 AM, Staff C, Chief Nursing Officer stated that nurses are required to document the actual time of medication administration and if medications are not given within the hour window (30 minutes prior to and 30 minutes after the stated time) it would be considered a medication error. Staff C stated that this was not an acceptable practice and that prior to the interview, was not aware of these errors.


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3. Observation on 09/08/11 at 10:17 showed Staff B, Nursing Student, with his/her nursing instructor, administering medications to Patient #8.

Record review of Patient #8's MAR showed the medications were given at 09 (9:00 AM) and initialed by the student nurse.

During an interview on 09/08/11 at 11:30 AM, Staff E, RN, Regional Director of Quality and Accreditation, stated that the observations and review of the MAR were correct and the student nurse/instructor documented the time of the medication administration as 9:00 AM when the medication was actually administered at 10:17 AM. Staff E confirmed that the facility was responsible for all the care and services their patients receive including contracted services by a nursing student and instructor.

During an interview on 09/08/11 at 12:30 PM, Staff C, RN, Vice President, Chief Nursing Officer, stated he/she was not aware that the nursing school students and instructors (contracted staff) had documented the incorrect times of medication administration on the MAR. Staff C stated this practice was unacceptable and the exact time(s) of medication administration should be documented.

4. Observation on 09/06/11 at 11:00 AM showed Staff F, RN, administer medication of two Percocet tablets PRN (as needed) to Patient #7 for pain Post-OP (after surgery) Cesarean (childbirth happens through an incision in the abdominal wall and uterus) delivery.

Record review of Patient #7's medical chart showed standing (written instructions authorizing medication administration according to pre-set, physician approved, criteria) orders for post operative cesarean patients written as follows:
- Percocet 1-2 tablet(s) PO (by mouth) q (every) 4 hours PRN for pain.
(NOTE: the Percocet order failed to include the dosage strength.)

According to MedlinePlus, a service of the U.S. National Library of Medicine and National Institutes of Health, Percocet is a combination drug containing Oxycodone and acetaminophen and can be prescribed in the following dosage strengths:
Percocet Oxycodone/Acetaminophen combinations:
2.5/325 mg;
5.0/325 mg;
7.5/325 mg;
7.5/500 mg;
10.0/325 mg; and
10.0/650 mg.

The standing order did not contain the necessary criteria for a medication order according to ISMP's (Institute for Safe Medication Practices) Guidelines for Standard Order Sets as follows:
- Includes the name of the drug and dose/strength on the same line/entry.

During interviews on 09/06/11 at 11:20 AM, Staff E, RN, Regional Director of Quality and Accreditation, Staff F, RN and Staff G, RN, Nursing Director of the Obstetrics Department, stated the standing order for Percocet was incomplete as written.

Based on observation and interview, the facility failed to employ physical security measures and afford minimum protection to patient records storage by not providing smoke detection or fire alarm, or automatic sprinkler assets in a remote steel building located approximately 60 feet from the main structure. Without at least one of these assets connected to the facility's fire alarm notification system, no warning or protection devices are available to warn of, or prevent total destruction of closed patient records. This deficient practice potentially affects thousands of patients, both past and present. The facility census was five.

Findings included:

1. Observations on 09/08/11 at 1:50 PM showed a 30 by 40 foot steel truss framed, metal clad building on a concrete slab foundation with multiple shelves where numerous closed patient records are stored. The shelves and supports were constructed of combustible two by fours. No smoke detectors, fire alarm notification devices or automatic sprinklers were present in the structure.

During interviews on 09/08/11 at 1:50 PM, Staff K, Director of Plant Operations and Staff L, Project Coordinator stated the building had a separate meter and was on a different power source than the hospital. They stated it is not heated during the winter or cooled during the summer. They confirmed the building has no fire alarm detection or notification system and nothing of the sort is connected to the main building's fire alarm system. They stated the building does not transmit an alarm to a signaling station or the fire department as with the main building and if there were a fire in the building, it could potentially go undetected until employees or pedestrians in the area noticed smoke. Staff K stated the building was originally intended to be a maintenance garage, however, other demands prevailed and facility administration determined the building suitable for temporary storage of closed patient records prior to transcription and a corporate-wide movement to electronic data records. Staff K stated the records were due to eventually "go away" as soon as the facility received a high volume scanner and began the transcription process.



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2. During interview on 09/09/11 at 11:15 AM, Staff I, Director of Health Information Management) and Staff J, Quality Resources Assistant stated that they did not know whether the storage area for the medical records had a sprinkler system or not. Both Staff I and Staff J made observation of the storage area and stated that they would have to say, "No, the area did not have a sprinkler system."