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This is evidenced by the Life Safety Code deficiencies identified. See tags K-11 and K-29.

Based on observation and interview the facility failed to provide a clean and sanitary environment of the ice machine, countertops in small medication room, crash cart, and intravenous pumps all located on two east resulting in the potential for the spread of disease for all patients, staff, and visitors within the facility. Findings include:

On 10/15/2012 at approximately 10:00 am while on tour of the facility it was revealed the ice machine located in the pantry area of two east had a white scaly substance on the exterior of the machine close to the grill area. Staff E was asked if regular maintenance occurred on the machine and stated "yes, the machine is cleaned on a regular basis. The buildup is from the minerals in our water."


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During tour of 2 East (Medical/Surgical unit) on 10/15/2012 at 1045, it was noted that the counter top in the small medication room was covered with a very thick layer of dust. During the observation with staff Q, when a small area of the counter top was wiped showing the amount of dust build up, she stated " Please don't do that again." When asked who was supposed to clean the area Staff Q replied "housekeeping, but it doesn't look like they have been in here in awhile." It was also noted that the staff had stored several patient care items under the sink including stuffed animals for pediatric patients. Staff Q, stated "there isn't supposed to be anything stored under the sinks."

The storage room for 2 East contained a small area of counter approximately 10 inches wide next to the ice machine where the staff were storing IV and PCA pumps. The area was right next to the intake vent for the ice machine. The vent drew air in and was very dirty and dusty and the pumps were all covered with dust from the intake of the vent.

Based on observation and interview the facility failed to discard outdated blood collection tubes resulting in the potential for inaccurate results for patients the blood tubes would be used to collect specimens. Findings include:

On 10/15/2012 at approximately 10:10 am during initial tour of the facility it was revealed the facility failed to discard of outdated blood collection tubes in the emergency crash cart. Staff E was asked what the expectation would be for securing equipment be kept current and not outdated. Staff E responded it was the expectation of those doing the monthly check of the crash cart to pull items that were close to outdate and to ensure all materials were kept current.

Based on observation, the facility failed to provide a clean and orderly facility. Findings include:

During the facility tour on 10/17/2012 between 8:30 am and 11:30 am the following was observed.

- The door from surgery to recovery was chipped/damaged exposing the wood substrate. This presents an area that cannot be easily cleaned and could also cut, scratch or injury to staff or patients if the brush up against the damaged door.

- A data line was dangling from the ceiling, down the wall and onto the floor in the OR clean supply room. This presents an area that cannot be easily cleaned and could pose a trip hazard to staff.

- A trail of blood spots were observed across the Labor and Delivery room from the bed towards the wall where the trash can was located. Housekeeping had already been in the room and turned the room over for patient use however there was still blood on the floor. The Director of Facilities confirmed that the spots on the floor appeared to be blood.


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During observation on 10/15 2012 between 0830-1200 the following was observed:
The OB Department revealed a very cluttered supply room where staff F had to move several items to get to the cabinets that contained supplies. Observations with staff F and O revealed that the nursery area was also very congested with bassinets, a rocking chair, pediatric crash cart, pediatric airway supplies and several other items. The pediatric airway supplies were in a small box way in the back of the room in an area that was difficult to get to.
When staff O was queried about to the amount of equipment in the area she stated "yeah, it is kinda packed in but we don't have anywhere else to store it."

Observation of 2 East with staff F revealed a small closet type area that contained patient supplies and personal items of staff that appeared to be just a bunch of clutter. When asked about the area staff F stated that "it is an area for staff to keep personal items." Further review of the area revealed storage of two chest tube insertion trays that staff E stated "I didn't even know those were in there."

2 East also had an antepartum room between patient rooms 286 and 284 that was stuffed with IV poles and vital sign monitors When staff F was asked about all the equipment in the room she stated "we used to use this room when we had TB patients, now we just use it for storage."



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On 10/15/2012 at approximately 10:35 am during observation it was revealed the facility failed to keep medical items separate and in a clean environment when in the medication and supply storage room it was noted the small closet within that room had a mix of medical supplies and employee purses. Staff E was asked if this was a common storage and she stated "yes, the staff use the closet area to put personal belongings."

Based on observation and record review by the Life Safety Code (LSC) surveyor on October 15, 2012, the facility does not comply with the applicable provisions of the 2000 Edition of the the Life Safety Code.

See the K-tags on the CMS-2567 dated October 15, 2012.

Based on observation, interview and policy review, the facility failed to protect patient information. Findings include:

During an interview on 10/15/2012 at 1530 with staff P, revealed that medical records were stored "in a room down the hall." An observation of the medical record storage room revealed that the room was not in sight of any staff member and was unsecured. The door contained a lock but the door was not locked at the time of the observation. It was noted that there was a doorway near the storage room that went out to a covered walkway leading over to the adjoining physician's clinics. The door was not locked from either direction at the time of the observation. When staff P was queried about the unsecured records she stated "we lock it at the end of the day before we go home." She also said that "staff are in and out of here frequently during the day and it would be difficult for everyone to have a key." Staff P also stated "there is usually someone working in here but she is on vacation today."

A review of Aspirus Grand View policy titled Controls against Loss, Destruction, Tampering of Data it reads in #5. "Medical records for discharged patients may be kept in the permanent file room or in the physician's incomplete area. These areas are maintained by the medical record department and are locked when unattended."

Based on interview, the facility failed to carry out an evaluation of it's total program. Findings include:

During an interview with staff B on 10/16/2012 at 1300, she stated that "we have not done an annual evaluation of hospital. We have monitored and carried out quality improvement projects but we do not have a documented evaluation of the services provided or the number of patients that have used the programs." She also stated that "the county is starting to put something together that identifies some specifics about the population that lives in their area and maybe they can get some information from that."