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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

Based upon observation, interview, and record review the facility failed to ensure equipment and supplies are maintained in a manner to ensure the safety and well being of patients.
Findings Include:
On 8/26/10 between the hours of 8:30 AM and 12:00 PM, mop sinks in janitors closets throughout the facility were observed with chemical dispensers improperly connected to the water supply. Chemical dispensers were observed connected to the mop sink faucets, downstream from the built-in atmospheric vacuum breaker (AVB) subjecting the AVB to continuous pressure.

On 8/26/10 at 9:50 AM, based upon observation, the condensate drain line from the walk in cooler in the kitchen was observed to terminate below the flood rim of the mop sink. The proper air gap for this drain line was not provided.

On 8/26/10 at 10:40 AM, based upon observation, it was discovered that the Steris scope washer in the utility room of the Outpatients area is not equipped with a Reduced Pressure Principle Backflow Preventer (RPZ) (American Society of Sanitary Engineering (ASSE) #1013). A Double Check valve with Intermediate Vent (ASSE #1012) was observed installed on the water inlet connection. This device is only approved for low hazard situations.
On 8/26/10 at 10:45 AM based upon observation, the medical gas shut off valves in the Outpatient area were discovered to be improperly labeled as "OB Wing".

On 8/26/10 at 11:05 AM, based upon interview and record review it was determined that the facility is not ensuring annual testing of testable backflow prevention devices (including RPZ's). Interview with the Environmental Services Supervisor at 11:05 AM, he stated that he thought the city did the RPZ test on the main water inlet line, but was unaware of the most recent date. Record review confirmed that maintenance records or invoices of RPZ tests are not kept at the facility.

On 8/26/10 at 9:30 AM based upon observation and interview it was discovered that the Hot Lab location used to be a toilet room. The toilet was observed still installed in this location, with active running water still connected.

On 8/26/10 at 9:05 AM based upon interview and record review it was discovered that weekly testing of the emergency eyewash station in the Lab are not taking place. Interview with the Environmental Services Supervisor indicated that records are supposed to be kept in the individual eyewash locations. Records of eyewash inspections could not be located in the Lab area at the time of the survey.

Based upon interview, and record review, the facility failed to ensure proper ventilation control in the airborne isolation room and humidity control in the operating room.

Findings Include:
On 8/26/10 at approximately 8:30 AM, based upon interview and record review, it was determined that humidity levels in the operating room are not being monitored. Interview with the Environmental Services Supervisor and the OR Supervisor indicated that there is no monitoring taking place, and no log kept for humidity. Record review of temperature graphs with the Environmental Services Supervisor confirmed that humidity is not being recorded.

On 8/26/10 at approximately 10:15 AM based upon interview, it was determined that there is no policy regarding how the Airborne Infection Isolation (AII) Room is monitored in the event of a suspected TB positive patient. Interview with the Environmental Services Supervisor and Chief Nursing Officer revealed that there is no policy in place, and that they are unaware of the CDC Guidelines for AII use with a suspected TB positive patient.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on August 26, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated August 26, 2010 for Life Safety Code.

Based on observation and interview the facility failed to ensure that outdated, mislabeled or otherswise unuseable drugs were not available for patient use. Findings inlcude:

During the observation tour of the facility on 8/25/2010 from 0830 - 1000 with the Director of Quality/Risk Manager #2, it was noted:

In the Emergency Department....
-Normal Saline irrigation 1000ml in the ultrasound room was opened and undated.
-Integrilin 20mg/10ml expired July 2010.

In the Stress Test clinc....
-Sodium Chloride flush 30ml was opened and undated.

In the X-ray Department....
-Sterile water 1000 ml in the x-ray department was opedned and undated.
-Barium sulfate suspension 1900 ml in the expired May 2010.
-Barium tablets were stored unlabeled. (The identity of the tablets were confrimed by the the X-ray Department manager #6).

In the Mamogram study....
-Lidocaine 1% 20ml was opened and undated.

In the Outpatient waiting unit....
-6 Sodium Chloride 30 ml flushes were opened and undated.
-1 heplock flush 30 ml was opened and undated.
-Antivert tablets were in an unsealed bottled that expired September 2008.
-Toradol 60 mg/2ml expired in July 2010.
-9 Lidocaines 1% 20 ml were opened and undated.

In the outpatient endoscopy room....
-Succinylcholine 200mg/10ml expired January 2009.
-Byetta exenatide injection 5 mcg expired Febuary 2009.
-Novalog 100 units expired january 2010.
-2 - 7Fr "Gold Probe" apparatus expired October 2008.
-2 Dexamethasone 4mg/5 ml were expired.
-4 Toradol injection 60mg/2ml were expired.
-Hydrogen peroxide bottle was labeled "5/19".


27065

On 8/25/10 from 0830-1000, during a tour of the inpatient unit with the Chief Nursing Officer, the following was observed:

1. Med Cart #2-
-Milk of Magnesia opened with no date opened marked
-Dupont Antiseptic Hand Spray, expired 5/07
-Fecal Occult Blood Developer Solution, expired 6/10

2. Inpatient Medication Room-
-stored under sink, one bottle Rubbing Alcohol, expired 12/09
-stored on shelves, two vials 0.9% Sodium Chloride, opened and no date opened marked
-stored on shelves, one opened bottle Sun Mark antacid
-stored on counter, one vial Bacteriostatic 0.9% Sodium Chloride, opened and no date opened marked

On 8/25/10 at approximately 1000, the Chief Nursing Officer stated that it was facility policy to remove expired medication from available stock and to mark the items listed above with a date opened.

Based on observation and interview, the facility failed to maintain a system for controlling infections and communicable diseases. Findings include:

During a tour of the inpatient unit, on 8/25/10 from 0820-0900, the following observations were confirmed by the Chief Nursing Officer:
1. In a recessed area of the hallway outside the soiled utility room, clean IV poles were stored next to a cart containing used eating utensils soiled with dried food.
2. In the soiled utility room, clean commodes were stored beside dirty laundry bags.
3. In the Suture Basket container, one pair of scissors with a dried red-brown substance on the blades.
4. In the hallway, one pair of scissors soiled with a brown substance.



26222

Based upon observation and interview, the facility failed to monitor flash sterilization rates and clean supply storage.

Findings include:
On 8/26/10 at 8:25 AM, clean housekeeping towels and enzymatic sponges used to clean endoscopes were observed stored in the cabinet beneath the hand sink in the soiled utility room. Unprotected sewage drain lines are located in this cabinet.
On 8/26/10 at 8:40 AM, based upon interview with the OR Supervisor, it was discovered that there is no record kept of dates, times, and what instruments are flash sterilized.


18299

During the observation tour of the facility on 8/25/2010 from 8:30 am - 10:00am with the Director of Quality/Risk Manager #2, it was noted:

In the Emergency Department....
-Clean utility room and dirty utility room were housed in the same small area with splash from the commode being close enough to contaminate clean supplies used for the ER.
-Storage under the clean utility/dirty utility sink where unprotected sewage drain lines are located.

The facility failed to ensure that a current nursing care plan was kept current for one of three patients. Finding include:

On 8/25/10 at 1630, review of patient #16's medical record revealed that she was admitted on was admitted 6/30/10 following a suicide attempt. At 0800 on 7/2/10 the attending physician's progress note states: "very depressed...wanting to go back to Rehab...will consult Social Services." At 1701 on 7/2/10, the Social Worker (employee #4) noted: "By the end of the business day nothing has been resolved" in regard to discharge plans. The Social Worker's note also states: "It appears that the patient will be staying in the hospital another night, as the attending physician is not at all reassured that [patient #16] will not again attempt suicide as soon as she is released, if left on her own."

There was no documentation that the physician (employee #13) saw the patient after 0800 on 7/2/10. At 0130 on 7/3/10 the attending physician wrote an order for discharge. In the Discharge Summary the Attending Physician states: "she (patient #16) feels that she was not in rehab long enough. She was having a very difficult time." The physician states that "she was stable from a medical standpoint." The Discharge Summary concludes with the statement that a mental health agency cleared her for discharge (from the hospital) from a mental health standpoint and picked the patient up at 0130 to take a bus to Minnesota.

A 7/3/10 Social Services note, written by employee #12, states: "This Worker arrived to find that patient had been discharged. Called (mental health agency) to find out facility name and phone number....Worker stated that patient was taken to the bus stop and sent home to Minnesota, not a treatment facility." Post-discharge documentation by staff indicates that other members of the treatment team were unaware of patient #14's discharge plan prior to discharge.

Record review revealed that patient #14's discharge care plan was not updated prior to discharge. Facility policy NE-046, dated 10/26/09, titled Discharge Planning, states: "Coordination and evaluation of post-discharge needs should be communicated and facilitated by the RN and social worker under the direction of the physician, and in collaboration with the patient and/or family." On 8/27/10 at approximately 0930, these findings were confirmed by the Director of quality and Risk Management.

Based on records reviewed and policy review the facility failed to ensure before discharge each person was evaluated for proper anesthesia recovery by a qualified practitioner as specified in paragraph (c) of this section for 3 of 3 patient's receiving surgical services. Findings include:

The Facility's "Med Staff By-Laws" section 7.13 states: "The medical record shall contain a record of post anesthetic visits including at least one note describing the apparent presence or absence of anesthesia-related complications...."

For MR #'s 11,12 and 14 there was no documented evidence a post anesthesia assessment including cardiopulmonary status, level of consciousness, follow up care/observations, or complications noted during recovery had been performed by the CRNA.

Based upon medical record review, policy review and interview, the facility failed to ensure the development of a comprehensive care plan for each resident. Finding include:

There is not a comprehensive care plan in 1 of 10 swing bed patient medical records (pt. #20) reviewed. These findings were verified on 8/25/10 at approximately 1135 in the conference room with the Medical Records Supervisor.

There was no physicians order for admission to the Swing Bed Program in 2 of 10 swing bed patient medical records reviewed (pt. #18 and pt. #24). These findings were verified on 8/25/10 at approximately 1135 in the conference room with the Medical Records Supervisor.

There was no physicians order for services to be provided to the patient at the time of admission to the Swing Bed Program in 3 of 10 swing bed patient medical records reviewed (pt. #17, pt. #18 and pt. #24).
These findings were verified on 8/25/10 at approximately 1135 in the conference room with the Medical Records Supervisor.

Based upon medical record review, policy review and interview, the facility failed to ensure that the comprehensive care plan for each resident was prepared by an interdisciplinary team that includes the attending physician and the registered nurse. Finding include:

Review of 3 of 10 swing bed patient medical records (pt. # 17, pt. #18 and pt. #25) reveals that there is no documentation of physician participation in the Interdisciplinary Plan Update (comprehensive care plan). These findings were verified on 8/25/10 at approximately 1330 in the conference room with the Risk Manager.

Review of 1 of 10 swing bed patient medical records (pt. # 17) reveals that there is no documentation of registered nurse participation in the Interdisciplinary Plan Update (comprehensive care plan). These findings were verified on 8/25/10 at approximately 1330 in the conference room with the Risk Manager.

Based upon medical record review, policy review and interview, the facility failed to ensure that Specialized Rehabilitative Services are provided under the written order of a physician.
Finding include:


Review of 7 of 10 swing bed patient medical records (pt. # 19, pt. #20, pt. #21, pt. #22, pt. #23, pt. #25 and pt. #26) reveals that there is not documentation of a physicians order for the Specialized Rehabilitative services for Occupational Therapy and Physical Therapy services being provided. These findings were verified on 8/26/10 at approximately 1015 in the Nursing Supervisors Office with the PT/Rehabilitation Supervisor, Staff Social Worker, Social Work Supervisor, and the Nursing Supervisor.