HospitalInspections.org

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2014, the hospital leadership failed to have an effective governing body responsible for the functions of the hospital.

The findings include:

The hospital leadership failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross refer to 482.41 Physical Environment - Condition Tag A0700.

Based on Medical Staff Rules and Regulations, observation, and staff interviews, the hospital's medical staff failed to ensure rules and regulations were followed as evidenced by a physician who was present on the hemodialysis unit failed to write an order that was not emergent for 1 of 4 for 1 of 4 sampled hemodialysis patients with verbal orders. (Physician #1, RN #1, Patient #48).

The findings include:

Review on 01/09/2014 of the hospital's "Medical Staff Rules and Regulations" (Reviewed/Amended 10/2012) revealed "Orders: All orders for treatment shall be written, dated, timed, and signed, including identification and/or pager number, either manually or electronically, and may be issued only by appropriately credentialed Practitioners acting within the scope of their Clinical Privileges. Physicians shall make every effort to write their own orders while physically on the unit. Verbal orders may be given only in urgent or emergency situations".

Observation on 01/09/2014 at 1015 in the hospital's hemodialysis treatment unit and adjacent unit revealed Physician #1 making rounds for patients. At 1020, patient #48 was observed having his hemodialysis treatment initiated by RN #1. The observation further revealed there was no physician orders written for the patient's hemodialysis treatment by any physician. The patient was observed to begin his hemodialysis treatment without any documented hemodialysis prescription physician order.

Interview on 01/09/2014 at 1040 with RN #1 revealed "I obtained a verbal order from the physician (Physician #1) for the treatment. I did not write it down and the physician did not document an order. He gave me the order verbally. This was not considered an emergency hemodialysis treatment".

Interview on 01/09/2014 at 1045 with the hospital's "Inpatient Services Manager" for dialysis revealed that the physician (Physician #1) should not have given a verbal order to the nurse since he was on the unit at the time. The interview also revealed the nurse should have encouraged the physician to document a order for the patient's treatment. The interview also revealed the patient received his hemodialysis treatment without any documented verbal order before the treatment was started. The interview confirmed the finding.

Based on policy review, medical record review, and staff interviews the hospital's nursing services failed to monitor and ensure implementation of physician orders according to policy for 2 of 7 patients with "ED to Admitting Provider Rapid Admit Bridge Orders" reviewed (#34 and #49).
The findings include:
On 01/10/2014 at 1030 interview with nurse #4 revealed "Rapid Admit Bridge Orders" were "temporary" orders written by the Emergency Department physician, following a call to a patient's physician or the Hospitalist, to expedite a patient's admission to a hospital unit. Interview revealed once the patient arrived to the unit the patient's physician or Hospitalist would be notified and "more comprehensive orders" would be written.
On 01/08/2014 review of Policy Number: 6117, Titled: Medical Record Review-Point of Care (Last Review Date: 7/2010) revealed " ...POLICY: Medical Record Review at the point of care is designed to assure the completeness, timely entry, clarity, authentication of data and timely completion of medical records on a concurrent basis. PROCEDURE: Each licensed nurse will review the medical record(s) of his or her assigned patients, focusing on the documentation from the previous shift ...Entries into, transcription and follow through of physician orders will be reviewed for timeliness and completeness ...Medical record review includes, but is not limited to: ...Reviewing for any missed physician orders. A chart review form will be utilized to assure audit consistency, with results forwarded to the unit manager ... Results from daily medical record review will be aggregated and forwarded to the Nursing Performance Improvement Committee ... "
On 01/10/2014 review of Policy Number: 6015.20.3.H, Titled: Transcribing Physician Orders (Last Revised Date 11/2013) revealed: " ...PURPOSE: To ensure the completeness and accuracy of transcription of physician orders. PROCEDURE: ...C. Handwritten medication orders will be faxed to the pharmacy immediately upon obtaining the order ... "
On 01/10/2014 review of Policy Number: 6015.20.2.S, Titled: Transfer of the Inpatient-In House (Last Revised Date: 10/2013) revealed: "...PROCEDURE: ...10. Receiving unit will be responsible for transcribing orders, EXCEPT stat orders, which will be carried out prior to transfer ..."
1. Open medical record review on 01/08/2014 at 0930 for patient #34 revealed a 64 year old male admitted from hospital's Emergency Department (ED) to the Progressive Care Unit (PCU) on 01/04/2014 with diagnoses of Post obstructive pneumonia and LLL (Left Lower Lobe) lung mass. Review of "ED to Admitting Provider Rapid Admit Bridge Orders" revealed "...IVF's: Heplock ....Meds: Acetaminophen 650 mg po (by mouth) q4 hr prn (every four hours as needed) pain or fever >101¿ F (may give via suppository if unable to take po)..." Review revealed ED physician Bridge Order was written on 01/08/2014 at 0612. Review revealed nurse noted Bridge Order sheet on 01/04/2014 at 1201. Further review of the electronic medication administration record revealed the Heplock and Acetaminophen orders originating from Bridge Orders were absent.
Interview on 01/08/2014 with nurse #4 during chart review confirmed the Heplock and Acetaminophen orders originating from Bridge Orders were not faxed to pharmacy. Interview revealed because the Heplock flush order was missing there was no documentation in the electronic medication administration record of dates and times flushes were performed. Interview revealed pt #34 did have an order for Acetaminophen obtained at a later date. Interview revealed it was the responsibility of the receiving nurse to fax Bridge Orders to the pharmacy upon transfer to unit from the ED. Interview revealed patient #34 was transferred from PCU to 2nd floor medical observation unit on 01/04/2014 at approximately 1800. Interview revealed the 12 or 24 hour chart check performed by 2nd floor Medical Observation Unit nursing staff did not captured the error, Bridge Order not faxed to pharmacy, because of the length of time patient #34 remained on the PCU.
2. Open medical record review on 01/09/2014 at 1400 for patient #49 revealed a 50 year old female admitted from hospital's ED to the PCU on 01/04/2014 with diagnoses of right pneumonia and Congestive Heart Failure. Review of "ED to Admitting Provider Rapid Admit Bridge Orders" revealed "...Meds: Acetaminophen 650 po q4 hr prn pain or T>101¿ F (may give via suppository if unable to take po) ..." Review revealed ED physician Bridge Order was written on 01/04/2014 at 1739. Review of Bridge Order revealed no nursing signature was present on the order sheet.
Review of the electronic medication administration record revealed Acetaminophen orders was absent.
Interview on 01/0920/14 at 1400 with nurse #3 during chart review confirmed Acetaminophen order on the Bridge Orders sheet was not faxed to pharmacy. Interview revealed the nurse receiving patient #49 from the ED was responsible for reviewing Bridge Orders and faxing the document to pharmacy. Interview revealed the nursing 12 hour and 24 hour chart checks did not capture the error, Bridge Order sheet not faxed to pharmacy.
Interview on 01/10/2014 at 1030 with nurse #4 revealed patient #49's first 24 hour chart check was performed on 01/06/2014 at 0325 approximately 34 hours after Bridge Orders were written (01/04/2014 at 1739).

Based on hospital policy review, medical record review, observation, physician interview, and staff interview, the hospital failed to ensure non-employee dialysis nurses followed the hospital's policies and procedures by failing to obtain and document pre and post dialysis weights for 2 of 4 sampled hemodialysis patients (Patients #26, 27) and by failing to obtain and document verbal physician dialysis prescription orders in 4 of 4 sampled hemodialysis patients (Patients #25, 26, 27, 48).

The findings include:

Review on 01/09/2014 of the hospital's policy "Calculating Ultrafiltration Goal" (Effective 08/25/2008) revealed "The purpose of this procedure is to ensure removal of the correct amount of fluid during each hemodialysis treatment according to the dry weight goal ordered by the credentialed Physician. Procedures for Calculation of Ultrafiltration Goal: 1. Subtract the estimated dry weight (EDW) from the pre-treatment weight to calculate the difference between the two weights. Please note: if this is a first treatment use the first weight obtained by the nursing staff in the contracted hospital. Note: if there is no bedscale or means of obtaining weights at the contracted hospital, notify the credentialed Physician for order for initial Ultrafiltration Goal".

Review on 01/09/2014 of the hospital's policy "Physician Order Documentation" (Effective 06/19/2013) revealed "Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures,and other treatments, based on physician orders. Providing service without physician orders is in violation of nurse practice acts. A written/electronic order is needed whenever a new medicine, lab test, or other procedure is ordered, or when the dose of a medication is changed".

1. An open medical record review on 01/09/2014 for patient #26 revealed the patient was admitted to the hospital on 12/21/2013 and required hemodialysis treatment at the hospital. Review of the physician dialysis prescription orders for hemodialysis dated 12/22/2013 at 1130 revealed no dry weight or fluid removal amount was ordered. The section of the "Hemodialysis Order" sheet's section for "Dry Weight" was documented with "TBD" (To be determined). Review of the patient's hemodialysis treatment sheets for the dates of 12/22/2013, 12/23/2013, 12/26/2013 and 12/27/2013 revealed the non-employee dialysis nursing staff failed to obtain and document post dialysis weights. Documentation for 12/23/2013 revealed that both the pre dialysis weight and post dialysis weight were missing.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that weights were not being done for some patients due to no scales being available on the dialysis unit. The interview revealed the dialysis nursing staff were supposed to have the unit nurses from the patient's location obtain the weights for the dialysis nurses for both the pre and post dialysis weights. The interview also revealed that the lack of documentation for the patient weights was a surprise to the director as she was not aware of the missing weights.

Interview on 01/10/2014 at 1230 with the hospital's hemodialysis "Medical Director" revealed that he was not aware of the hospital's nursing staff not obtaining weights on the hemodialysis patients. The interview also revealed that was a significant problem and he was told on 01/10/2014 by the hospital administration that the unit now had weight scales that would be used on all patients. The interview confirmed the finding.

2. An open medical record review on 01/09/2014 for patient #27 revealed the patient was admitted to the hospital on 12/18/2013 and required hemodialysis treatment at the hospital. Review of the physician dialysis prescription orders for hemodialysis dated 12/18/2013 at 1000 revealed a dry weight of "110.5 kilograms was ordered for the patient's hemodialysis treatments. Review of the patient's hemodialysis treatment sheets for the dates of 12/27/2013 and 12/30/2013 revealed the non-employee dialysis nursing staff failed to obtain and document post dialysis weights. The documentation in the treatment sheets revealed no pre and post dialysis weights were obtained with the documentation stated as "No Scales" by the dialysis nursing staff.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that weights were not being done for some patients due to no scales being available on the dialysis unit. The interview revealed the dialysis nursing staff were supposed to have the unit nurses from the patient's location obtain the weights for the dialysis nurses for both the pre and post dialysis weights. The interview also revealed that the lack of documentation for the patient weights was a surprise to the director as she was not aware of the missing weights.

Interview on 01/10/2014 at 1230 with the hospital's hemodialysis "Medical Director" revealed that he was not aware of the hospital's nursing staff not obtaining weights on the hemodialysis patients. The interview also revealed that was a significant problem and he was told on 01/10/2014 by the hospital administration that the unit now had weight scales that would be used on all patients. The interview confirmed the finding.

3. An open medical record review on 01/09/2014 for patient #25 revealed the patient was admitted to the hospital on 01/06/2014 and required hemodialysis treatment at the hospital. On 01/06/2014, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to receive the medication "Heparin" (anticoagulant medication) 1000 units per milliliter with Load: 1000 units. A review of the patient's hemodialysis treatment record for 01/08/2014 revealed the hospital's non-employed hemodialysis nurse failed to administer any "Heparin" to the patient as ordered.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have administered the Heparin and it was not documented as done. The interview confirmed the finding.

4. An open medical record review on 01/09/2014 for patient #26 revealed the patient was admitted to the hospital on 12/21/2013 and required hemodialysis treatment at the hospital. On 12/22/2013, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to have a dialysate flow rate of "1.5X" ran during her hemodialysis treatment. Review of the patient's hemodialysis treatments on 12/22/2013, 12/23/2013, 12/26/2013, and 12/27/2013 revealed the hospital's non-employed hemodialysis nursing staff ran the patient's dialysate flow rate at "A2.0" instead of the prescribed order of "1.5X". The review revealed no documentation for the reason that the nursing staff failed to follow the prescription order.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have ran the patient's dialysate flow rate as ordered. The interview confirmed the finding.

5. An open medical record review on 01/09/2014 for patient #27 revealed the patient was admitted to the hospital on 12/18/2013 and required hemodialysis treatment at the hospital. On 12/18/2013, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to have a dialysate flow rate of "2.0X" ran during his hemodialysis treatment. Review of the patient's hemodialysis treatments on 12/23/2013 and 12/26/2013 revealed the hospital's non-employed hemodialysis nursing staff ran the patient's dialysate flow rate at "A1.5" instead of the prescribed order of "2.0X". The review revealed no documentation for the reason that the nursing staff failed to follow the prescription order.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have ran the patient's dialysate flow rate as ordered. The interview confirmed the finding.

6. Observation on 01/09/2014 at 1020 in the hospital's dialysis unit revealed patient #48 being initiated on hemodialysis treatment by RN #1. Observation further revealed that the patient's "Hemodialysis Order" sheet was blank at the time of the patient's initiation of hemodialysis treatment. The observation revealed the hospital's non-employee nurse failed to obtain and document dialysis orders before initiating hemodialysis treatment to the patient.

Interview with RN #1 during the observation on 01/09/2014 at 1040 revealed that there was no documented dialysis prescription orders. The interview with the RN revealed "I do not have any orders written down. I got verbal order from the physician that is here. He did not write any orders".

Interview on 01/09/2014 at 1043 with the hospital's "Inpatient Services Manager" for dialysis revealed "The nurse should have had the orders written down before she provided the treatment and the physician should have actually written the orders and not give a verbal order since he was here onsite". The interview confirmed the finding.

Based on hospital policy review, observation of care, medical record review, and staff interviews, the hospital's dialysis nursing staff failed to document a verbal order before administering a hemodialysis treatment prescription in 1 of 2 observed hemodialysis patients beginning treatment (Patient #48, RN #1).

The findings include:

Review on 01/10/2014 of the hospital's policy "Verbal and Telephone Orders" (Review Date 10/2013) revealed "1. Verbal orders pose an increased risk of miscommunication that could result in a patient adverse event (which includes medication errors). Verbal orders should be used only to meet the care needed of the patient when the ordering practitioner is unable to write the order himself/herself. Verbal orders are not to be used for the convenience of the ordering practitioner. 2. All orders shall be in writing. A verbal order shall be considered to be in writing if dictated to a registered nurse, nurse practitioner, or licensed practical nurse functioning within her/his sphere of competence and signed by the responsible practitioner. 4. The content of verbal orders must be clearly communicated. The entire verbal order should be read back to the prescriber. All verbal orders must be reduced immediately to writing and signed by the individual receiving the order. Verbal orders must be documented in the medical record, and reviewed and countersigned by the prescriber as soon as possible which would be the earliest time".

Observation on 01/09/2014 at 1020 in the hospital's dialysis unit revealed patient #48 being initiated on hemodialysis treatment by RN #1. The observation revealed the RN entering the patient's hemodialysis prescription in the hemodialysis machine control panel settings. Interview with RN #1 during the observation on 01/09/2014 at 1040 revealed that there was no documented dialysis prescription orders including which dialysis drugs to be used for the patient's hemodialysis treatment. The interview with the RN revealed "I do not have any orders written down. I got verbal order from the physician that is here. He did not write any orders".

An open medical record review on 01/10/2014 for patient #48 revealed the patient was admitted to the hospital on 01/06/2014. The review of the patient's treatment orders revealed there was no documented verbal order by RN #1 for the patient's hemodialysis treatment done on 01/09/2014.

Interview on 01/09/2014 at 1043 with the hospital's "Inpatient Services Manager" for dialysis revealed "The nurse should have had the orders written down before she provided the treatment and the physician should have actually written the orders and not give a verbal order since he was here onsite". The interview confirmed the finding.

Based on policy review, observations during tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure non-food contact surfaces were maintained in a clean and sanitary manner.

The findings include:

Review of current hospital policy "Cleaning and Sanitation," Policy Number: 6320.V.A, last reviewed: 05/15/2013, revealed "...4. CLEANING & SANITIZING STANDARDS & PROCEDURES 4.1 GENERAL CLEANING & SANITIZING STANDARDS ...Non-Food-Contact Surfaces ...Maintain non-food-contact surfaces free of dirt and debris. ...4.3 CLEANING & SANITIZING FREQUENCY ...4.3.2 NON-FOOD-CONTACT SURFACES ...Maintain non-food-contact surfaces clean according to the following standards: ...Keep non-food-contact surfaces free of an accumulation of dust, dirt, food residue, and other debris. ...Clean up food splashes and spills on non-food-contact surfaces immediately. ...Clean floors at lease once daily. ..."

Observation during tour of the main kitchen on 01/09/2014 from 0945 to 1230 revealed the following:

In the Dry Storage Areas:
1. Observation during tour at 0955 of the Bottle/Beverage/Disaster Food storage room revealed multiple areas of various sized dried liquid spills, black/grey/brown in color, on the storage room floor. Interview during tour with the Dietary Director revealed "the floor does have excessive wear." Interview confirmed the spills observed appeared to be old. Interview revealed the Director could not determine when the floor was last cleaned. Interview revealed the floor is supposed to be cleaned daily. Interview revealed staff do not sign a log to indicate the floor was cleaned daily. Interview revealed it was routine to clean the floor daily. Interview confirmed the Dietary staff failed to follow policy.

2. Observation during tour at 1005 of the Paper Products/Soda Fountain Rack storage room revealed a large wet yellow colored liquid spilled on the floor at the base of the soda fountain storage rack. Observation revealed a dried brown/black colored liquid spilled on the wall adjacent to the soda fountain storage rack. Observation revealed one brown colored insect approximately one inch long stuck on an insect trap (glue pad) in the corner of the storage room adjacent to the soda fountain rack. Further observation revealed debris (i.e. plastic wrap, plastic cup lids, cardboard, fork) on the floor under multiple storage racks within the storage room. Interview during tour with the Dietary Director revealed the yellow liquid on the floor was Mountain Dew. Interview revealed staff must have mis-threaded the hose connector when changing out the soda product container. Interview revealed the liquid spills on the floor and the wall should have been cleaned-up immediately. Interview revealed there should be no debris under the storage shelving. Interview confirmed the Dietary staff failed to follow policy.

In the Refrigerator/Freezer Areas:
3. Observation during tour at 1000 of the Emergency Disaster Food walk-in Refrigerator/Freezer unit revealed excessive dust build up on the inner surfaces/ceiling of the unit and on the cooling unit pipes and electrical cords. Interview during tour with the Dietary Director revealed there should not be any dust build up inside the walk-in refrigerator/freezer. Interview revealed the Dietary staff are responsible for cleaning the inner surfaces and hospital maintenance staff are responsible for the preventative maintenance on the cooling unit. Interview revealed the inner surfaces should be cleaned daily. Interview revealed the Director could not verify when the inner surfaces of the refrigerator/freezer was last cleaned by dietary staff. Interview confirmed the Dietary staff failed to follow policy.

In the Food Preparation/Cooking Area:
4. Observation during tour at 1141 of the Cooking area revealed Hood #1 located above the deep fryer/char-grill/steamer/oven area. Observation of Hood #1 revealed excessive dust build up on the outer surface of the hood above the deep fryer. Observation revealed excessive grease build up on the inner hood surfaces above the deep fryer and char-grill; and on the fire suppression system nozzles hanging over the deep fryer and char-grill. Further observation revealed grease pooling in droplets on the inner surfaces of the hood and fire suppression system nozzles. Interview during tour with the Dietary Director revealed Hood #1 is cleaned weekly by staff. Interview revealed the staff member responsible for cleaning the hood was off several days and the hood did not get cleaned. Interview revealed the hood is normally cleaned each week. Interview confirmed the observations.

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2014, the hospital staff failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

2. The hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702

3. The hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709

4. The hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710

5. The hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure emergency lighting was provided at all exit discharges and fixtures were properly connected to the Essential Electrical System.

~Cross-refer to 482.41(b)(4) Physical Environment Standard Tag A-0711

6. The hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

~Cross-refer to 482.41(b)(9) Physical Environment Standard Tag A-0716

7. The hospital staff failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms.

~Cross-refer to 482.41(c)(4) Physical Environment Standard Tag A-0726

Based on observations as referenced in the Life Safety Report of Survey completed 01/10/2014, the hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st Floor the cross corridor doors located in at x-ray in the north emergency hall did not close on activation of fire alarm system with a person in the vicinity of the door sensor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 052.

B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor patient rehab there was no signage noting oxygen being stored in that space.
2. 3rd floor room 329 (sleep lab storage), there was no signage noting oxygen being stored in that space.
3. 3rd floor room 329 distances between the stored oxygen and combustible storage in the room did not meet the requirements for a sprinklered building.
4. Main oxygen cylinder storage area, The Main medical gas storage is not individually secured.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

C. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd Floor, the smoke damper located in the soiled utility room in the Dialysis unit did not close upon activation of fire alarm system.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 104.

D. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 5th floor Bright Leaf Tower administration are older bath tub room has exposed bulbs on the light fixture.
2. 1st Floor endoscopy rooms 2 and 3 has temporary power used as permanent power for the endoscopy camera machines.
3. 4th floor. Human resources break room is utilizing a power strip in place of permanent wiring for the microwave and coffee pot.
4. 3rd floor 3-B. A power strip was used in place of permanent wiring for the medication refrigerator on 3B.
5. 2nd floor, medication refrigerator in PCU B-wing was not connected on emergency power.
6. 3rd floor inside the old nurse's locker room 320 there is an exposed light bulb without a lens cover in room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 02
E. Based on the observations and staff interviews on 01/7/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Smoke curtain at Food Service between the AED and the fire extinguisher did not release & reengage with fire alarm activation when an obstacle was placed under the fire curtain

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 052.

F. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. Smoke duct detector M1-45 was not clean and maintained in good condition.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 054.

G. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. Ground Floor Medical records area had dust and lint on the heat sensitive elements of the sprinkler head in the stack room.
2. Ground floor Food Service area the sprinkler head has dust/grease on the heat sensitive element of the sprinkler head, above the dietary fryer location.
3. The shower curtains in the patient room showers are not provided with a 18 inch mesh tops in order to allow for proper sprinkler coverage.
4. Ground floor food service, there are two light fixtures blocking sprinkler heads in refrigerator number 5.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

H. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Ground floor food service, the hood suppression system nozzles are not pointing at the equipment it is designed to protect.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 069.

I. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor Operating Room Suite, the clean utility near OR room 5-oxygen cylinders at that location did not meet the requirements for separation from combustible material in a sprinklered building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

Building 03
J. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. In the bulk oxygen storage room, oxygen cylinders were found gang chained together and not individually secured.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

Building 04
K. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Oxygen farm, the Medical Mall Wound Care oxygen storage cylinders outside are not protected with:
1. Over head protection for the cylinder valves from extremes of weather.
2. Ground protection under the cylinders from extremes of weather.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

Based on observations as referenced in the Life Safety Report of Survey completed 01/10/2014, the hospital staff failed to assure the safety of patients by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 03
Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The generator annunciator panel did not show that the generator was currently supplying the load when power was transferred from normal to emergency power.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 144.

Based on observations as referenced in the Life Safety report of survey completed 01/10/2014, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st floor, the interior courtyard located at building #1 is not equipped with exit signage

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 042.

B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor, exit directional signage is incomplete at cross corridor door leading to Dialysis Unit.
2. 1st floor, the exit directional sign located at the cross corridor doors leading to the corridor in front of Behavioral Health was not verified to be connected to an emergency circuit emergency.
3. Ground Floor, and exit directional signage is incomplete leading from the elevator and to the linen room.
4. 1st floor cross corridor doors leading from CT to MRI. The exit directional signage leading to the MRI area from the CT area is misleading as that corridor is not a required exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

C. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 1st floor Women's pavilion-mechanical room does not have an access door for smoke damper in the rated wall at that location.
2. 4th floor, in the corridor outside Human Recourses waiting room, the access door to the smoke duct detector and smoke damper was blocked by a light fixture and was not easily accessible.
3. 3rd floor, and access door was not provided for to the smoke duct detector located in the corridor outside Education Storage.
4. 2nd floor Soiled Utility Room Dialysis Unit. An access door was not provided for the smoke duct detector located in the unit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2014, the hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor housekeeping closet near room 258 has unsealed penetrations around the sprinkler heads.
2. 3rd floor, in the old nurse locker room there is an unsealed penetration in the rated ceiling that is not properly sealed.
3. 3rd floor, in the old nurse locker room. At the time of the survey a fire damper in the HVAC duct penetrating the 2hr fire rated wall could not be verified as there was no access door installed at that location

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 012.

B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor library this area is not sprinklered the paneling for this area was not verified to be Class A or Class B.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 015.

C. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 3rd floor room 311A/B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
2. 3rd floor room 309B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
3. 3rd floor corridor doors to rooms 4 and 332 in the case management department do not have positive latching hardware installed.
4. 5th floor. The corridor door to room 410 does not close smoke tight. As there was a Gap at top of door not allowing the room to resist the passage of smoke.
5. 2nd floor Dialysis unit. The corridor door to the rooms 247, 246 and 244 in the Dialysis unit have and inactive leaf and did not close smoke tight if the inactive leaf bolt was not engaged.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

D. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor in the old nurse locker room there the penetrations in the floor are not filled with approved fire stop materials.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

E. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor bright leaf tower unsealed penetrations in the smoke wall at elevator 4 and 5 at the building joint on both sides of the building.
2. 2nd floor bright leaf tower at the elevator 4 and 5 have unapproved foam fire stop insulation in the rated wall above the time clock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025.

F. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 1st floor. The cross corridor doors leading for CT to MRI the doors have a door stops that keeps the door form closing installed a floor level hook.
2. 1st floor same day surgery both sets of cross corridor doors that defined the suite have a gap greater than 1/8th of an inch.
3. 3rd floor near room 324 when testing the fire door (DR#3-030) left leaf of the door scrubs the carpeted floor and did not close when released from magnet.
4. 1st floor, Emergency Waiting Room, cross corridor door located at the waiting room did not close tight at the bottom. There is gap at the bottom of the door greater than 1/8 of an inch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 027.

G. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 3rd floor room 318 is being used as storage and did not have a door closure installed.
2. 3rd floor sleep lab area near room 329 there is soiled linen stored in the exit egress corridor.
3. 4th floor. Storage room located on the corridor is not 1hr fire rated construction or have sprinkler coverage.
4. Ground Floor, the corridor door to storage room G-046 was not self closing.
5. Ground Floor, old boiler room, the corridor door to the old boiler room was not self closing.
6. Ground Floor, the corridor door to storage room G-047 was not self closing.
7. Ground Floor, there are unsealed penetrations in the in the wall above the door on the inside of the room that was not sealed in order to maintain the required rating of the wall.
8. 3rd floor. The linen room storage corridor door was not self-closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

H. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 5th floor Bright Leaf Tower the older bathroom in the old patient rooms require two ranges of motion as there is a dead bolt that does not retract when tested.
2. 2nd floor door to room 200/211 has a hasp installed and if engaged would require more than two ranges of motions to exit the rooms.
3. 1st floor cross corridor doors leading from CT to MRI the door release switch at that area is a momentary switch and not a simple on and off switch.
4. 5th floor soiled utility room has Dead bolt installed on the door.
5. 5th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed.
6. 4th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed.
7. 5th floor administration copy room has a Slide bolt locking device installed on the door not allowing single motion of the hand to enter the egress corridor.
8. 4th floor door to room 415 has a padlock installed on the door not allowing single motion of the hand to enter the egress corridor.
9. 2nd floor bright leaf tower dialysis center has a North Carolina Special locking magnets and plates installed on cross corridor doors, but were not able to be tested during the survey as they were out of service.
10. Stairwell "L" the Emergency Department tunnel landing at the top of the emergency department tunnel does not have protection in place to direct potential traffic exiting at that location from exiting down the stairs.
11. 1st floor Behavioral Health, Building is equipped with keyed exit doors and the facility is required to be sprinklered or covered with smoke detectors in all areas. The cloth storage closet located in the front hall is not equipped with a smoke detector.
12. 5th floor next to room 525E the Fire door at that location needs more than 15 pounds of force to get into the open position.
13. 5th Floor, Rooms 524 through 529 have chain latches install on the inside of the of the door frame that when latched would require more than one motion of the hand to exit the room.
14. 4th floor, conference room corridor door across from Human resources waiting room is equipped with dead bolt that requires two motions of the hand to open when the lock is engaged.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

I. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor staff shower room in the ICU has sprinkler head blocked by shower curtain that does not have mesh on the top.
2. It was determined with staff interviews that there were no sprinkler head at the top of the #83 and #49 dumb waiters that are no longer in service.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

J. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 4th floor Linen Chute on 4th floor opens onto the corridor was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 071.

K. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor storage closet near room 207 it was determined that the facility had a storage closet near room 207 opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
2. 5th floor it was determined that the facility had a bathroom in the administrative area near room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
3. 5th it was determined that the facility had a ladies toilet door near elevator # 2 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
4. Ground floor Environmental Services corridor next to elevator # 3 has large clean linen cart stored in exit egress corridor.
5. 2nd floor pharmacy/Rehab area there is IT equipment rack stored in the corridor without direct visual supervision from the regularly manned station.
6. 5th Floor, it was determined that the facility had a bathroom next to room 508 that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.
7. 4th floor North Hall Human Resources corridor it was determined that the facility had a soiled linen room door that opened into the corridor, this door did not open 180 degrees flat to the corridor wall nor had a door closure installed to automatically keep the door closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

Building 02
L. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor. The corridor door to patient room 282 was blocked from closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

M. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 2nd floor B- wing data room, there are pipe penetrating the deck below and there were two of the pipes that were not sealed with approved fire stop materials.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

N. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. Stairwell "K," a door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
2. 2nd floor Stairwell "O," a door release override switch was not provided for the magnetically locked door at the stairwell for use in an emergency other than fire.
3. Ground floor loading dock the Exit egress at the loading dock is not clearly identified so not to lead persons exiting towards the loading and unloading area.
4. Ground floor Cross corridor doors next to nursing supervisor office has North Carolina Special Locking device installed and not in service at time of the survey. The device must be in use or disabled in some way.
5. Ground floor food service older freezer and cooler door release mechanism is not visible in all levels of light at the beverage storage area across the corridor from the dietary department.
6. 4th Floor Room 414 has a hasp installed and if engaged would not allow for a one motion of the hand to exit that room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

O. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. Ground floor Food service corridor has items store in the egress corridor that is currently not in use. This corridor is not currently included in the designated suite for that area.
2. The facility had storage in the corridor in front of the cross corridor door located near the soiled linen storage area that would prevent the cross corridors from closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

Building 03
P. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. Clayton Facility. The corridor door to the clean linen room was found wedged open preventing the door from closing with one motion.
2. Clayton Facility. The storage room door located inside PACU leading to the oxygen storage room was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

Building 04
Q. Based on the observations and staff interviews on 01/7/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit at Medical Mall, The mechanical room houses the gas fired water heater and that rooms door was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

R. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Cancer Unit Medical Mall, the rear exit egress corridor was not maintained clear and unobstructed as there was storage items left in the egress corridor during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

Based on observations as referenced in the Life Safety Report of Survey completed 01/10/2014 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure emergency lighting was provided at all exit discharges and fixtures were properly connected to the Essential Electrical System.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. Ground floor, Exit light at exit discharge door from 2 East stairwell was not illuminated during the survey.
2. 1st floor, North Emergency Entrance, emergency discharge lighting on the emergency circuit was not provided for at the walk way past that exit door discharge.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 045.

Building 03
B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The exit path to the public way from the side and rear of the building was not provided with sufficient exit discharge path illumination connected to emergency. Illumination of means of egress, including exit discharge, shall be arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 045.

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2014, the hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 3rd floor nurses station has ABHR in the vicinity of an ignition source.
2. 2nd floor Bright leaf tower inside the dialysis soiled utility room there was an ABHR above an ignition source. (Light Switch)

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K211.

Building 02
B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 1st Floor Labor and delivery - delivery room # 5 has an ABHR installed over or adjacent to an ignition source. (Light Switch)

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K211.

Based on observations as referenced in the Life Safety Report of Survey completed 01/10/2014, the hospital staff failed to ensure the relative humidity was maintained at appropriate levels within the operating rooms.

The findings include:

Building 03
Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: Clayton Facility. The relative humidity in operating room #1 and #2 was not maintained equal to or greater than 35%.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 078.

Based on hospital policy review, observation of care on tour, and staff interviews, the hospital's infection control officer failed to develop an effective system for standard infection control precautions within the Dialysis Unit by failing to ensure the contracted hospital staff wore personal protective equipment correctly during potential exposure to blood in 1 of 2 observed dialysis patient treatments (Patient #48, RN #1) and ensuring that the staff performed hand hygiene between glove changes in 1 of 2 observed dialysis patient treatments (Patient #48, RN #1).

The findings include:

Review on 01/09/2014 of the hospital's policy for hemodialysis "Personal Protective Equipment" (Effective 03/20/2013) revealed "OSHA (Occupational Safety and Health Administration) Directive Number: CPL 2-2.69 Enforcement Procedures for the Occupational Exposure for Bloodborne Pathogens 1910.1030, 11/27/2001: "Requirements for the use of protective body clothing, such as fluid-resistant gowns, aprons, laboratory coats, clinic jackets, surgical caps, or shoe covers, and the degree to which the PPE must resist penetration, are performance-based. The employer must evaluate the task and the type of exposure expected and, based on the determination, select the "appropriate" personal protective clothing. Fluid-resistant gowns with long sleeves must be used for procedures in which exposure of the forearm to blood or other potentially infectious material (OPIM) is reasonable anticipated to occur". The policy also revealed "Gloves: Hand Hygiene must always be performed after glove removal".

Review on 01/09/2014 of the hospital's policy for hemodialysis "Hand Hygiene" (Effective 03/20/2013) revealed "Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Decontaminated using alcohol based hand rub or by washing hands with antimicrobial soap and water. Immediately after removing gloves".

Observation on 01/09/2014 at 1020 in the hospital's dialysis unit revealed patient #48 being initiated on hemodialysis treatment by Registered Nurse (RN) #1. Observation revealed the RN was wearing Personal Protective Equipment (PPE) that included a gown with long sleeves, mask, face shield and disposable gloves. The RN was observed to have her gown sleeves rolled above her forearms while potentially exposed to the patient's blood. Observation further revealed the RN changed her disposable gloves while accessing the patient's permcath without washing her hands or performing hand hygiene between the glove changes.

Interview on 01/09/2014 at 1040 with the hospital's "Inpatient Services Manager" for dialysis revealed the dialysis staff should wear their PPE gown sleeves over forearms and they should also perform hand hygiene between glove changes. The interview confirmed the finding.

Based on review of the hospital's medical staff rules and regulations, medical record review and staff interview, the surgeon failed to complete an immediate operative report including procedure performed, findings, type of anesthesia and/or sign the immediate operative report in 1 of 8 surgical patients reviewed (#14).

The findings include:

Review of the hospital's medical staff rules and regulations, revised 10/2012, revealed, "...E. Operative Reports An operative report must be written or dictated immediately following surgery and prior to patient transfer to another level of care. If the operative report is dictated, a progress note is written prior to transfer to another level of care...".

Closed medical record review of Patient #14 revealed a 56 year-old male admitted on 12/03/2013 with a lung mass. Record review revealed the patient had a left upper lobectomy and left thoracotomy on 12/03/2013. Record review revealed the patient was admitted and was discharged on 12/19/2013. Record review revealed an operative report was dictated by the surgeon on 12/05/2013 (2 days after surgery). Further record review revealed no progress note was written by the surgeon immediately after surgery and prior to transfer to an inpatient unit.

Interview on 01/08/2014 at 1535 with administrative surgical personnel revealed, "there was not an immediate operative report written or dictated by the surgeon". Interview confirmed the surgeon failed to follow the medical staff rules and regulations concerning an immediate operative report for Patient #14.

Based on hospital policy review, medical record review, observation, physician interview, and staff interview, the hospital failed to ensure non-employee dialysis nurses followed the hospital's policies and procedures by failing to obtain and document pre and post dialysis weights for 2 of 4 sampled hemodialysis patients (Patients #26, 27) and by failing to obtain and document verbal physician dialysis prescription orders in 4 of 4 sampled hemodialysis patients (Patients #25, 26, 27, 48).

The findings include:

Review on 01/09/2014 of the hospital's policy "Calculating Ultrafiltration Goal" (Effective 08/25/2008) revealed "The purpose of this procedure is to ensure removal of the correct amount of fluid during each hemodialysis treatment according to the dry weight goal ordered by the credentialed Physician. Procedures for Calculation of Ultrafiltration Goal: 1. Subtract the estimated dry weight (EDW) from the pre-treatment weight to calculate the difference between the two weights. Please note: if this is a first treatment use the first weight obtained by the nursing staff in the contracted hospital. Note: if there is no bedscale or means of obtaining weights at the contracted hospital, notify the credentialed Physician for order for initial Ultrafiltration Goal".

Review on 01/09/2014 of the hospital's policy "Physician Order Documentation" (Effective 06/19/2013) revealed "Nurse practice acts require nurses to carry out treatment care, medication administration, lab tests, procedures,and other treatments, based on physician orders. Providing service without physician orders is in violation of nurse practice acts. A written/electronic order is needed whenever a new medicine, lab test, or other procedure is ordered, or when the dose of a medication is changed".

1. An open medical record review on 01/09/2014 for patient #26 revealed the patient was admitted to the hospital on 12/21/2013 and required hemodialysis treatment at the hospital. Review of the physician dialysis prescription orders for hemodialysis dated 12/22/2013 at 1130 revealed no dry weight or fluid removal amount was ordered. The section of the "Hemodialysis Order" sheet's section for "Dry Weight" was documented with "TBD" (To be determined). Review of the patient's hemodialysis treatment sheets for the dates of 12/22/2013, 12/23/2013, 12/26/2013 and 12/27/2013 revealed the non-employee dialysis nursing staff failed to obtain and document post dialysis weights. Documentation for 12/23/2013 revealed that both the pre dialysis weight and post dialysis weight were missing.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that weights were not being done for some patients due to no scales being available on the dialysis unit. The interview revealed the dialysis nursing staff were supposed to have the unit nurses from the patient's location obtain the weights for the dialysis nurses for both the pre and post dialysis weights. The interview also revealed that the lack of documentation for the patient weights was a surprise to the director as she was not aware of the missing weights.

Interview on 01/10/2014 at 1230 with the hospital's hemodialysis "Medical Director" revealed that he was not aware of the hospital's nursing staff not obtaining weights on the hemodialysis patients. The interview also revealed that was a significant problem and he was told on 01/10/2014 by the hospital administration that the unit now had weight scales that would be used on all patients. The interview confirmed the finding.

2. An open medical record review on 01/09/2014 for patient #27 revealed the patient was admitted to the hospital on 12/18/2013 and required hemodialysis treatment at the hospital. Review of the physician dialysis prescription orders for hemodialysis dated 12/18/2013 at 1000 revealed a dry weight of "110.5 kilograms was ordered for the patient's hemodialysis treatments. Review of the patient's hemodialysis treatment sheets for the dates of 12/27/2013 and 12/30/2013 revealed the non-employee dialysis nursing staff failed to obtain and document post dialysis weights. The documentation in the treatment sheets revealed no pre and post dialysis weights were obtained with the documentation stated as "No Scales" by the dialysis nursing staff.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that weights were not being done for some patients due to no scales being available on the dialysis unit. The interview revealed the dialysis nursing staff were supposed to have the unit nurses from the patient's location obtain the weights for the dialysis nurses for both the pre and post dialysis weights. The interview also revealed that the lack of documentation for the patient weights was a surprise to the director as she was not aware of the missing weights.

Interview on 01/10/2014 at 1230 with the hospital's hemodialysis "Medical Director" revealed that he was not aware of the hospital's nursing staff not obtaining weights on the hemodialysis patients. The interview also revealed that was a significant problem and he was told on 01/10/2014 by the hospital administration that the unit now had weight scales that would be used on all patients. The interview confirmed the finding.

3. An open medical record review on 01/09/2014 for patient #25 revealed the patient was admitted to the hospital on 01/06/2014 and required hemodialysis treatment at the hospital. On 01/06/2014, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to receive the medication "Heparin" (anticoagulant medication) 1000 units per milliliter with Load: 1000 units. A review of the patient's hemodialysis treatment record for 01/08/2014 revealed the hospital's non-employed hemodialysis nurse failed to administer any "Heparin" to the patient as ordered.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have administered the Heparin and it was not documented as done. The interview confirmed the finding.

4. An open medical record review on 01/09/2014 for patient #26 revealed the patient was admitted to the hospital on 12/21/2013 and required hemodialysis treatment at the hospital. On 12/22/2013, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to have a dialysate flow rate of "1.5X" ran during her hemodialysis treatment. Review of the patient's hemodialysis treatments on 12/22/2013, 12/23/2013, 12/26/2013, and 12/27/2013 revealed the hospital's non-employed hemodialysis nursing staff ran the patient's dialysate flow rate at "A2.0" instead of the prescribed order of "1.5X". The review revealed no documentation for the reason that the nursing staff failed to follow the prescription order.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have ran the patient's dialysate flow rate as ordered. The interview confirmed the finding.

5. An open medical record review on 01/09/2014 for patient #27 revealed the patient was admitted to the hospital on 12/18/2013 and required hemodialysis treatment at the hospital. On 12/18/2013, review of the patient's "Hemodialysis Order" sheet for the patient's hemodialysis prescription orders revealed the patient was to have a dialysate flow rate of "2.0X" ran during his hemodialysis treatment. Review of the patient's hemodialysis treatments on 12/23/2013 and 12/26/2013 revealed the hospital's non-employed hemodialysis nursing staff ran the patient's dialysate flow rate at "A1.5" instead of the prescribed order of "2.0X". The review revealed no documentation for the reason that the nursing staff failed to follow the prescription order.

Interview on 01/09/2014 at 1410 with the hospital's "Inpatient Services Director" for hemodialysis revealed that the nursing staff should have ran the patient's dialysate flow rate as ordered. The interview confirmed the finding

Based on observations as referenced in the Life Safety Report of survey completed 01/10/2014, the hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
A. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor housekeeping closet near room 258 has unsealed penetrations around the sprinkler heads.
2. 3rd floor, in the old nurse locker room there is an unsealed penetration in the rated ceiling that is not properly sealed.
3. 3rd floor, in the old nurse locker room. At the time of the survey a fire damper in the HVAC duct penetrating the 2hr fire rated wall could not be verified as there was no access door installed at that location

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 012.

B. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor library this area is not sprinklered the paneling for this area was not verified to be Class A or Class B.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 015.

C. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 3rd floor room 311A/B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
2. 3rd floor room 309B has door latching hardware missing not allowing the door on the corridor to latch to keep the door smoke tight.
3. 3rd floor corridor doors to rooms 4 and 332 in the case management department do not have positive latching hardware installed.
4. 5th floor. The corridor door to room 410 does not close smoke tight. As there was a Gap at top of door not allowing the room to resist the passage of smoke.
5. 2nd floor Dialysis unit. The corridor door to the rooms 247, 246 and 244 in the Dialysis unit have and inactive leaf and did not close smoke tight if the inactive leaf bolt was not engaged.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

D. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include: 3rd floor in the old nurse locker room there the penetrations in the floor are not filled with approved fire stop materials.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

E. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor bright leaf tower unsealed penetrations in the smoke wall at elevator 4 and 5 at the building joint on both sides of the building.
2. 2nd floor bright leaf tower at the elevator 4 and 5 have unapproved foam fire stop insulation in the rated wall above the time clock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 025.

F. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 1st floor. The cross corridor doors leading for CT to MRI the doors have a door stops that keeps the door form closing installed a floor level hook.
2. 1st floor same day surgery both sets of cross corridor doors that defined the suite have a gap greater than 1/8th of an inch.
3. 3rd floor near room 324 when testing the fire door (DR#3-030) left leaf of the door scrubs the carpeted floor and did not close when released from magnet.
4. 1st floor, Emergency Waiting Room, cross corridor door located at the waiting room did not close tight at the bottom. There is gap at the bottom of the door greater than 1/8 of an inch.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 027.

G. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 3rd floor room 318 is being used as storage and did not have a door closure installed.
2. 3rd floor sleep lab area near room 329 there is soiled linen stored in the exit egress corridor.
3. 4th floor. Storage room located on the corridor is not 1hr fire rated construction or have sprinkler coverage.
4. Ground Floor, the corridor door to storage room G-046 was not self closing.
5. Ground Floor, old boiler room, the corridor door to the old boiler room was not self closing.
6. Ground Floor, the corridor door to storage room G-047 was not self closing.
7. Ground Floor, there are unsealed penetrations in the in the wall above the door on the inside of the room that was not sealed in order to maintain the required rating of the wall.
8. 3rd floor. The linen room storage corridor door was not self-closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

H. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 5th floor Bright Leaf Tower the older bathroom in the old patient rooms require two ranges of motion as there is a dead bolt that does not retract when tested.
2. 2nd floor door to room 200/211 has a hasp installed and if engaged would require more than two ranges of motions to exit the rooms.
3. 1st floor cross corridor doors leading from CT to MRI the door release switch at that area is a momentary switch and not a simple on and off switch.
4. 5th floor soiled utility room has Dead bolt installed on the door.
5. 5th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed.
6. 4th floor older bathroom doors, the door hardware does not have integrated pass-through locksets installed.
7. 5th floor administration copy room has a Slide bolt locking device installed on the door not allowing single motion of the hand to enter the egress corridor.
8. 4th floor door to room 415 has a padlock installed on the door not allowing single motion of the hand to enter the egress corridor.
9. 2nd floor bright leaf tower dialysis center has a North Carolina Special locking magnets and plates installed on cross corridor doors, but were not able to be tested during the survey as they were out of service.
10. Stairwell "L" the Emergency Department tunnel landing at the top of the emergency department tunnel does not have protection in place to direct potential traffic exiting at that location from exiting down the stairs.
11. 1st floor Behavioral Health, Building is equipped with keyed exit doors and the facility is required to be sprinklered or covered with smoke detectors in all areas. The cloth storage closet located in the front hall is not equipped with a smoke detector.
12. 5th floor next to room 525E the Fire door at that location needs more than 15 pounds of force to get into the open position.
13. 5th Floor, Rooms 524 through 529 have chain latches install on the inside of the of the door frame that when latched would require more than one motion of the hand to exit the room.
14. 4th floor, conference room corridor door across from Human resources waiting room is equipped with dead bolt that requires two motions of the hand to open when the lock is engaged.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

I. Based on the observations and staff interviews on 01/07/2014 approximately 10:00 AM onward till 01/10/2014 the following Life Safety item was observed as noncompliant, specific findings include:
1. 2nd floor staff shower room in the ICU has sprinkler head blocked by sh