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Based on document review, observation, and interview, it was determined, for 6 of 12 patients (Pts #2, 3, 4, 5, 6, and 7) on the geriatric psychiatry mental health unit (3 west), the Hospital failed to ensure patient safety rounds were conducted every 15 minutes, as required by policy.

Findings include:

1. On 4/15/14 at approximately 11:50 AM, hospital policy titled, "Nursing Rounds...Geriatric Psychiatry" (reviewed/revised 9/13/2013) was reviewed. The policy required "The charge nurse is responsible for assigning nursing staff to make Unit rounds, in order to account for the whereabouts of all patients and to ensure a safe environment. Rounds are to be made at least every 15 minutes." 5. The assigned staff member(s) are to personally locate each patient... and document the patient's location on the rounds sheet... The staff member places his/her initials at the top of the column above the time." "7. Significant behavior observations of patients and environmental problems shall be checked."

2. On 4/15/14 at approximately 9:30 AM, an observational tour of the 3 west Geriatric Psychiatry Mental Health Unit was conducted. Upon entering the unit, the 15 minute patient rounds monitoring sheet for 4/15/14 on all patients were reviewed. Six of 12 patients (Pts #2, 3, 4, 5, 6, and 7) were lacking the 8:45 AM, 9:00 AM, and 9:15 AM, checks that included patient location and behaviors (total of 18 missed checks on 6 patients).

Patients include:

- Pt # 2 was admitted on 4/7/14 with a diagnosis of bizarre/paranoid delusions and was on one to one observation.

- Pt # 3 was admitted on 4/11/14 for psychiatric issues.

- Pt # 4 was admitted on 4/12/14 for psychiatric issues.

- Pt # 5 was admitted on 3/26/14 with a diagnosis of dementia with paranoid delusions and was on close observation due to aggressive behaviors.

- Pt # 6 was voluntarily admitted on 4/7/14 for psychiatric issues.

- Pt #7 was admitted 4/7/14 with a diagnosis of confusion and was on close observation for behaviors and safety.

3. The Director of Quality & Medical Affairs (E #2) stated during an interview conducted on 4/16/14 at approximately 7:45 AM, the round sheets should have been completed every 15 minutes on all patients.

A. Based on document review, observation and interview it was determined, for 1 of 1 newborn nursery, the Hospital failed to ensure outdated formula was not available for patient use.

Findings include:

1. The Hospital policy titled "Formula" revised 4/15/2014 included, "D. All manufacturer packaged food are used or discarded by their 'use-by-date'...".

2. On 4/16/14 at approximately 1:00 PM an observational tour was conducted in the Hospital's obstetric department. During the tour of the newborn nursery there were seven (7) 2 fluid ounce bottles of Similac Advance with an expiration date of 4/1/14 available for patient consumption.

3. During the observational tour, the Director of Maternal Child Services (E #4) stated the formula was outdated and should have been discarded.


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B. Based on observational tour, document review, and interview, it was determined for 1 of 11 (Pt #18) orthopedic patients (4th floor Orthopedics), the Hospital failed to ensure a fall sign was displayed as required by policy.

Findings include:

1. On 4/15/14 at approximately 1:00 PM an observational tour was conducted on the orthopedic floor. Pt#18 was wearing a yellow fall precaution wrist band however, Pt #18's door did not have a fall sign displayed to identify Pt #18 as a fall risk patient.

2. The clinical record of Pt # 18 was reviewed on 4/15/14 at approximately 1:30 PM. Pt #18 was a 78 year old female admitted to the Hospital on 4/14/14 with diagnosis of right hip pinning. Pt #18 was assessed as a high risk for falls on 4/15/14 with a fall score of 15.

3. Hospital policy entitled, "Falls Prevention Program" (last reviewed 8/21/13) required, "...E. If the risk score is 10 or greater (High Risk): ... 2. place yellow sign on outside of door."

4. On 4/15/14 at approximately 1:30 PM, Orthopedic Nurse Manager (E #7) verified that fall sign should have been displayed on the outside of the door per Hospital policy.

Based on document review and interview it was determined for 1 of 3 patients (Pt #14) that received blood products, the Hospital failed to ensure a physician's order was received requiring the transfusion of the blood products.

Findings include:

1. On 4/16/14 Hospital policy entitled, "Administration of Blood Components" (revised date 4/8/2014) was reviewed. The Policy required " 1. Blood components must be ordered by a provider..."

2. The clinical record of Pt #14 was reviewed on 4/15/14 at approximately 1:45 PM. Pt #14 was a 63 year old male admitted on 4/7/14 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Pt #14's clinical record contained a laboratory report dated 4/13/14 at 9:39 PM, that indicated Pt#1's hemoglobin was 6.3 g/dl (grams per deciliter) (normal 13.5 - 17.5 g/dl). On 4/13/14 at 10:56 PM the patient's physician was notified of the abnormal hemoglobin. Nursing documentation entitled "Daily Assessment Inquiry" dated 4/13/14 at 10:56 PM indicated, "Type and Cross for four units of Packed red blood cells. Transfuse all four units..." The transfusion record indicated that the blood transfusion began on 4/13/14 at 11:15 PM and the fourth unit was was completed on 4/14/14 at 3:30 AM. The clinical record lacked documentation of a physician's order to transfuse the 4 units of blood.

3. The Nurse Manager of Intensive Care (E#3) was interviewed on 4/15/14 at approximately 2:00 PM. During the interview E #3 stated,"There is no physician's order for the blood transfusion."

Based on document review and interview, it was determined in 2 of 10 (Pt #1 and #2) clinical records, the Hospital failed to ensure the medical records were completed per Hospital policy.
Findings include:

1. The clinical record of Pt #1 was reviewed 4/16/14 at approximately 1:00 PM. Pt #1 was an eighty-eight year old female admitted 11/13/13 with diagnoses of delirium and confusion. Pt #1 was discharged from the Hospital on 12/16/13. The patient discharge instructions taken as a telephone order by the nurse were not dated or timed or authenticated by the physician as of review date 4/16/14. Nursing documentation (undated) included a telephone order regarding Pt #1's discharge instructions. The order was undated and un-timed. Pt #1's Emergency Room Consent Form was not dated, timed and page 1 was labeled with the patients name only and page 2 had no name

2. .An interview was conducted with the Risk Manager (E #3) 4/17/14 at approximately 2:15 PM. E #3 stated Pt #1's discharge instructions were incomplete and the nurse should have signed, dated and timed the instructions. E #3 stated the date and time on the bottom of the instructions is the date and time of when the discharge instructions were printed and not the time when received by the physician. E #3 stated the instructions could be printed at any time during the admission and does not confirm the discharge date.

3. The clinical record of Pt #2 was reviewed 4/17/14 at approximately 2:00 PM. Pt #2 was a twenty year old female admitted 12/8/13 with a diagnosis of overdose. Pt #1's clinical record contained a telephone order dated 12/10/13 for Trazadone 50 mg was not authenticated, by signing, by MD #1 until 1/2/14, 25 days later. Pt #2's discharge instructions lacked a date, time or authentication by author.

4. An interview was conducted with the Director of Behavioral Health (E #2) on 4/16/14 at approximately 1:15 PM. After reviewing Pt #1 and Pt #2's clinical record, E #2 stated the patient's discharge instructions were not dated or timed as to when the telephone order was taken or authenticated by the physician.

5. The policy "Documentation on the Medical Record (Hard Copy-Paper)" (revised 10/4/13) was reviewed 4/17/14 at approximately 1:30 PM. The policy included all notations must be preceded with the time, followed by the writer's name and the date is written at the top of the page.

6. "The Medical Staff Rules and Regulations", (revised 9/13) was reviewed 4/17/14 at approximately 11:00 AM. Section B. Medical Records 15. stated all clinical entries in the patient's medical record shall be accurately dated, timed and authenticated by the responsible practitioner within 72 hours.

7. The policy titled "Patient Authorization Form" (revised 8/23/13) was reviewed 4/17/14 at approximately 2:00 PM. The policy included the Emergency Room Consent Form will be dated and timed at the time of the patient or legal representatives signature, and the Hospital representative will complete the top section with the "patients name, medic number, physician and account number."

Based on document review, observation, and interview it was determined, for 2 of 2 patients (Pt #29 and #31) in the outpatient rehabilitation therapy department, the Hospital failed to ensure the patients' plan of care developed by the physical therapist, was signed by the physician indicating his approval for the treatment.

Findings include:

1. On 4/16/14 at approximately 2:30 PM the "Proctor Hospital Rules and Regulations of the Medical Staff" (reviewed/revised 9/13), were reviewed. The Rules and Regulation required, "20. A Physician's orders shall be reproduced on the order sheet of the patient's record by those person's authorized by the Medical Staff and shall be individualized as directed by the physician. The orders must be dated, timed and authenticated within seventy-two (72) hours."

2. On 4/16/14 at approximately 1:00 PM an observational tour of the Outpatient Rehabilitation Therapy unit was conducted. During the tour, two patients (Pt #29 and #31) were observed receiving physical therapy.

3. Pt #29's clinical record was reviewed on 4/16/14 at approximately 1:15 PM. Pt #29 was admitted to physical therapy services on 3/27/14 with a diagnosis of fractured left hip. Pt # 29 had a signed physician's referral form requiring a physical therapy evaluation and treatment. Pt # 29's physical therapy evaluation and POC (plan of care) dated 4/07/14, recommended physical therapy "2-3 time/week for 8 weeks for strengthening, neuro [neurological], re-ed [reeducation], gait training, and reduction in pain." Pt #29 began physical therapy treatment on 4/7/14. Pt # 29's treatment record lacked a signed physician's orders for physical therapy.

4. Pt. #31's clinical record was reviewed on 4/16/14 at approximately 1:20 PM. Pt #31 was admitted to physical therapy services on 3/27/14, with a diagnosis of mild to moderate arthritis to both knees. Pt # 31 had a signed physician's referral form dated 3/27/14, requiring a physical therapy evaluation and treatment. Pt #31's physical therapy evaluation and POC dated 4/07/14, recommended physical therapy "2-3 times/week for 8 weeks for strengthening, reduction in pain, gait training, and flexibility". Pt #31 began physical therapy treatment on 4/7/14. Pt #31's clinical record lacked a signed physician's orders for physical therapy.

5. The Director of Therapy Services (E #8) stated during an interview conducted on 4/16/14 at approximately 1:25 PM, that Pt #29's and Pt # 31's recommended physical therapy and POC was sent to the respective physicians for signature on 4/7/14 and have not been returned. E #8 stated the physicians had a month to sign and return the physical therapy orders.

A. Based on a review of the Hospital's Medical Staff Rules and Regulations, a review of an attestation letter from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations were reviewed on 4/16/14 at 1:30 PM. The Hospital Rules and Regulations of Medical Staff (revised and approved 9/12/13) " B. Medical records 21. The patient's medical record shall be complete at time of discharge...If after all essential reports are received and on the record, and the record remains incomplete for twenty-one (21) calendar days, the medical Records Director shall notify the physician that his/her privileges to admit and operate on patients shall be suspended seven (7) calendar days from the date of this notice, and the privileges of such practitioner shall remain suspended until the record has been completed. The appropriate areas and members of Administration and the Medical Staff shall be notified of this action. Failure to complete the medical record(s) that caused relinquishment of privileges shall constitute a voluntary resignation of appointment to the Medical Staff".

2. On 4/17/14, the Hospital presented an attestation letter from the Director, Health Information Management that included, "Today, April 16, 2014, there are 30 charts that are delinquent past 30 days."

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Based on document review, observational tour, and interview the Hospital failed in 1 of 2 (room 2) anesthesia carts in the delivery operating rooms, to ensure drugs were securely stored, as required.

Findings include:

1. The Hospital policy entitled, "Medication Storage" (revised 8/13/12) required, Policy: 1. Medication Storage ...minimize the risk of medication diversion, and reduce potential dispensing errors.6. All medications in the hospital are secured and only authorized individuals are able to obtain them..."

2. On 4/15/14 at 2:00 PM an observational tour was conducted in the OB (Obstetric) Operating Room #2. The CRNA (Certified Registered Nurse Anesthetist) epidural cart was unlocked. The 1st drawer of the unlocked epidural cart contained the following :

* four (4), 5 ml (milliliter) ampul of Lidocaine HCL 10 mg/ml 1% injectable;

* two (2), 5 ml ampul of Lidocaine HCL 1.5% & Epinephrine 1:200,000 injectable; and

* nine (9) 50 ml vials of 8.4% Sodium Bicarbonate injectable.

3. The Maternal Child Services Director stated during the observational tour on 4/15/14 at approximately 2:15 PM the CRNA epidural cart should have been locked.

Based on document review, observational tour, and interview, it was determined, for 30 of 30 immunofluorescenct study specimens, the hospital failed to properly store immunofluorescent study specimens.

Findings include:

1. On 4/17/14 at 8:30 AM, Hospital policy B 13, titled, [Blood Bank] "Freezer Inventory (Stock)", reviewed by the Hospital on 6/13/13, was reviewed. The policy included the number and types of blood products held in the blood bank freezer. Immunofluorescent study specimens were not included for blood bank freezer storage in the policy.

2. On 4/17/14 at 1:00 PM, Hospital laboratory policy titled, "Direct Immunofluorescence", reviewed by the hospital on 6/10/13, was reviewed by a surveyor. The policy required, "When the specimen is received for fluorescent studies, enter patient information into the CoPath System using the specimen type as DIF, to obtain a direct immunofluorescent number (DIF#)... (If specimen is not to be cut at this time, wrap the block in aluminum foil and put in a ziplock bag labeled with the patient's name, DIF number, and date. Place in a larger bag marked especially for DIF specimens in the ultra-cold freezer located in Chemistry.)"

3. On 4/17/14 between 8:00 AM and 8:50 AM, an observational tour was conducted in the laboratory. In the blood bank freezer, a large plastic bag was found, containing 30 ziplock bags with patient immunofluorescent study specimens. The specimens were individually bagged and labeled, but were not in the ultra-cold freezer.

4. On 4/17/14 at 8:35 AM, an interview was conducted with the laboratory director. The director stated he did not know why the specimens were in the blood bank freezer, but would find out.

5. On 4/17/14, at 12:50 PM, the laboratory director provided a list of the immunofluorescent study specimens and a note that included, "This tissue is direct immunofluoresence testing. We keep the specimens to serve as a control...were placed in that [blood bank] freezer while ultra-cold was thawing. Forgot to return to ultra-cold."

Based on document review, observational tour, and interview it was determined, for 2 of approximately 40 condiment/seasoning substances (bottle Tabasco sauce and bag of powdered sugar) in dietary services, the hospital failed to ensure condiments/seasonings packages were labeled with the open date. Thus ensuring an acceptable level of safety and quality.

Findings include:

1. On 4/17/14 at approximately 2:45 PM reviewed, hospital policy titled "Labeling & Dating" (reviewed/revised 9/27/2013). Policy required, "A. All cooked foods, pre-package open containers, protein based salads, desserts, and canned fruits are labeled, dated, and securely covered."

2. On 4/17/14 at approximately 11:00 AM an observational tour of the Dietary Services Department was conducted with Dining Services Director (E #10) During the tour, two condiments/seasonings (Tabasco sauce and powdered sugar) were observed to have no dated label.

3. The Dining Services Director (E #10) stated during an interview conducted on 4/17/14 at approximately 11:30 AM, that the two condiments/seasonings (tobacco sauce and powdered sugar) had no dated label and should have been dated.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Full Survey Due to Complaint conducted on April 15 - 17, 2014, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Full Survey Due to Complaint conducted on April 15 - 17, 2014, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 17, 2014.

Based on document review, observation, and interview it was determined in 2 of 6 laboratory department refrigerators (Specimen and Re-agent refrigerators), the Hospital failed to ensure all refrigerators were clean.

Findings include:

1. On 4/17/14 at approximately 10:00 AM the Hospital policy entitled, "Chemistry Freezer Maintenance" (reviewed/revised 4/10/13) was reviewed. The policy required, "Monthly: Clean out all outdated specimens and other materials. Clean more thoroughly if needed ... As needed: Turn off refrigerator and unplug it.... Remove the shelves and clean them with a damp towel... clean and dry the interior of the freezer..."

2. On 4/17/14 at approximately 8:00 AM an observational tour of the Laboratory Services Department was conducted with Director of Laboratory, Respiratory Care, Sleep Lab, and EEG (E #9). During the tour, two (2) refrigerators (Specimen and Re-agent refrigerators) were observed with dark debris on the bottom shelves.

3. E #9 stated during an interview conducted on 4/17/14 at approximately 8:30 AM, that the two refrigerators (Specimen and Re-agent refrigerators) bottom shelves were not clean.

A. Based on document review, observation, and interview, it was determined that for 1 of 6 staff (MD#1) observed in the Surgical Department room 8, the Hospital failed to ensure adherence to dress code.

Findings include:

1. The Hospital Policy titled "Surgical Attire" (revised date 10/2/13) required, " Policy: Masks will be worn in the restricted areas....Mask need to be tied a the back of the neck and head. Nose and mouth must be covered securely with no side venting."

2. An observational tour was conducted on 4/16/14 at approximately 9:15 AM in OR (operating room) #8. MD#1 was observed tying his surgical mask as he entered the room with sterile items open.

3. The Director of Surgical Services (E#6) was interviewed on 4/16/14 at approximately 9:30 AM. E #6 was informed of the untied surgical mask but had no response.