HospitalInspections.org

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services. Based on document review and staff interview the hospital failed to provide the patient or patient representative notice of the patient's rights for 29 of 31 patients receiving services from the hospital (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, and 31).

Findings included:

- The hospital ' s policy " Patient Responsibilities " reviewed on 5/16/13 at 11:20am revealed the document informs patients of patient's rights. The hospital failed to provide this bill of rights to the patient or patient representative.

- Patient #1's closed medical record reviewed on 5/14/13 revealed an admission date of 2/12/13 for opiate pump implant (a pain dispensing device implanted in the body). The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

- Patient #22's closed medical record reviewed on 5/13/13 revealed an admission date of 3/1/13 for chronic low back pain and bilateral leg pain. The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

- Patient #24's closed medical record reviewed on 5/14/13 revealed an admission date of 4/4/13 for spondylosis (arthritis in the spine) and allied disorders The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

Staff F, office staff, interviewed on 5/14/13 at 2:30pm explained they did not know to provide each patient with a copy of patient rights.

Staff C, chief operations officer, on 5/15/13 at 5:35pm acknowledged the hospital failed to provide the patient or patient representative their rights for each patient.

Non-compliance with this regulation also affected patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 26, 27, 28, 29, 30 and 31.

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services. Based on document review and staff interview the hospital failed to provide the patient or patient representative notice of the toll free hotline complaint number for 31 of 31 patients receiving services from the hospital (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31).

Findings included:

- The hospital ' s policies " Patient Rights: Patient Grievance Policy " and " Patient Grievance Resolution " reviewed on 5/15/13 at 5:35pm revealed the document guides the grievance process. The hospital failed to provide the state toll free hotline phone number to patients.

- Patient #1's closed medical record reviewed on 5/14/13 revealed an admission date of 2/12/13 for opiate pump implant. The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Patient #22's closed medical record reviewed on 5/13/13 revealed an admission date of 3/1/13 for chronic low back pain and bilateral leg pain. The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Patient #24's closed medical record reviewed on 5/14/13 revealed an admission date of 4/4/13 for spondylosis (arthritis in the spine) and allied disorders The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Staff C, chief operations officer, on 5/15/13 at 5:35pm acknowledged the hospital failed to provide the patient or patient representative the state toll free hotline phone number.

Non-compliance with this regulation also affected patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 25, 26, 27, 28, 29, 30, and 31.

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services.
Based on observation, documentation, and staff interview, the hospital failed to implement systems to achieve and then maintain a sanitary environment in the surgical suite area when the infection control officer failed to ensure hospital staff separated soiled lines and trash from the surgical staff changing area and clean supplies in the sub-sterile area, and failed to ensure surgical staff followed acceptable standards for surgical attire. The infection control officer failed to ensure two nursing staff providing dressing changes prior to patient dismissal and laboratory procedures followed infection control policies and acceptable standards of practice with hand hygiene by cleaning their hands between glove changes.

Findings include:

- The hospital policy " Clinical-Surgical Dress Code " reviewed on 5/14/13 at 9:55 am directed " ...all hair is to be completely covered ... " , " ...any employee involved in patient care may no wear artificial nails of any kind ... " , " ...jewelry ...should not be worn in the Operating Room ... " .

- Staff E, circulating surgical nurse, observed on 5/14/13 at 8:50am in the operating room (OR) wore artificial fingernails on hands, wore a surgical cap that failed to cover all their hair, and wore dangling earrings.

- Staff I, surgical sales representative, observed in the OR on 5/14/13 at 8:50am wore a surgical cap that failed to cover all their hair and sideburns.

- Staff E, circulating surgical nurse, interviewed on 5/14/13 at 1:05pm acknowledged she wore artificial fingernails in the OR during surgery.

- Staff B, director of nursing, interviewed on 5/14/13 at 6:00pm acknowledged staff and surgical representative failed to follow hospital policy for surgical dress code.

- American Operating Room Nurses (AORN) guidelines " Recommended Practices for Traffic Patterns in the Perioperative Practice Setting " reviewed on 5/15/13 at 5:30 pm revealed " ...soiled supplies, instruments, and equipment should not re-enter the clean core area ...soiled linen and trash collection areas should be separated from personnel and patient traffic areas ...Separation of clean and sterile supplies and equipment from soiled materials by space, time, and traffic patterns decreases the risk of infection. "

- Sub sterile operating room (OR) area observed on 5/13/13 at 2:25pm revealed two large bins; one with trash and one with soiled linen within 40 inches of a cart stocked with clean surgical attire and supplies. The location of the trash and soiled linen created the potential for cross contamination of the clean surgical attire and supplies.

- The hospital admitted patient #3 on 5/13/13 for a posterior spinal fusion of L4-5 (a surgical procedure that joins two or more bones of the spine for spinal stenosis and pain treatment). Registered Nurse staff H on 5/14/13 at 11:10am changed patient #3 ' s dressing and removed a surgical drain prior to the patient ' s dismissal. Staff H washed their hands, put on a pair of gloves, removed the soiled dressing, cleaned the surgical site and removed the drain tube. Staff H changed their gloves without performing hand hygiene between glove changes and redressed the surgical site. The failure to perform hand hygiene between glove changes failed to meet acceptable standards of practice for hand hygiene. The infection control officer failed to ensure staff followed nationally recognized infection prevention and control precautions, such as current Centers for Disease Control (CDC) guidelines and recommendations, for infections/communicable diseases.


- The hospital provided laboratory services to outpatient #31 in preparations for a future surgery and pain management and patient #21 after a lysis procedure on the spine (a procedure to dissolve scar tissue on the spine) to alleviate pain. Registered nurse staff H on 5/15/13 obtained blood from each patient in a syringe then brought the blood to the I-Stat machine (point of care blood testing/analysis machine) located in a work area behind the nurse ' s station. Staff H consistently failed to perform hand hygiene between glove changes when testing each patient ' s blood. The failure to perform hand hygiene between glove changes failed to meet acceptable standards of practice for hand hygiene. The infection control officer failed to ensure staff followed nationally recognized infection prevention and control precautions, such as current CDC guidelines and recommendations, for infections/communicable diseases.

- Staff C, the Chief Operations Officer responsible for nursing services and the Infection Control Practitioner for the hospital verified on 5/15/13 and 5/16/13 the hospital followed CDC guidelines for hand hygiene and expected staff providing patient care to perform hand hygiene (either alcohol rub or hand washing) between glove changes.

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services. Based on document review and staff interview the hospital failed to provide the patient or patient representative notice of the patient's rights for 29 of 31 patients receiving services from the hospital (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, 30, and 31).

Findings included:

- The hospital ' s policy " Patient Responsibilities " reviewed on 5/16/13 at 11:20am revealed the document informs patients of patient's rights. The hospital failed to provide this bill of rights to the patient or patient representative.

- Patient #1's closed medical record reviewed on 5/14/13 revealed an admission date of 2/12/13 for opiate pump implant (a pain dispensing device implanted in the body). The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

- Patient #22's closed medical record reviewed on 5/13/13 revealed an admission date of 3/1/13 for chronic low back pain and bilateral leg pain. The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

- Patient #24's closed medical record reviewed on 5/14/13 revealed an admission date of 4/4/13 for spondylosis (arthritis in the spine) and allied disorders The medical record lacked documentation the hospital informed the patient or patient representative of their rights.

Staff F, office staff, interviewed on 5/14/13 at 2:30pm explained they did not know to provide each patient with a copy of patient rights.

Staff C, chief operations officer, on 5/15/13 at 5:35pm acknowledged the hospital failed to provide the patient or patient representative their rights for each patient.

Non-compliance with this regulation also affected patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 26, 27, 28, 29, 30 and 31.

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services. Based on document review and staff interview the hospital failed to provide the patient or patient representative notice of the toll free hotline complaint number for 31 of 31 patients receiving services from the hospital (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31).

Findings included:

- The hospital ' s policies " Patient Rights: Patient Grievance Policy " and " Patient Grievance Resolution " reviewed on 5/15/13 at 5:35pm revealed the document guides the grievance process. The hospital failed to provide the state toll free hotline phone number to patients.

- Patient #1's closed medical record reviewed on 5/14/13 revealed an admission date of 2/12/13 for opiate pump implant. The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Patient #22's closed medical record reviewed on 5/13/13 revealed an admission date of 3/1/13 for chronic low back pain and bilateral leg pain. The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Patient #24's closed medical record reviewed on 5/14/13 revealed an admission date of 4/4/13 for spondylosis (arthritis in the spine) and allied disorders The medical record lacked documentation the hospital informed the patient or patient representative of the state toll free hotline phone number.

- Staff C, chief operations officer, on 5/15/13 at 5:35pm acknowledged the hospital failed to provide the patient or patient representative the state toll free hotline phone number.

Non-compliance with this regulation also affected patient #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 25, 26, 27, 28, 29, 30, and 31.

The hospital data base worksheet completed by hospital administration identified the hospital staffed 10 beds with an average daily census of one, and an operating suite with four operating rooms for inpatient and outpatient services.
Based on observation, documentation, and staff interview, the hospital failed to implement systems to achieve and then maintain a sanitary environment in the surgical suite area when the infection control officer failed to ensure hospital staff separated soiled lines and trash from the surgical staff changing area and clean supplies in the sub-sterile area, and failed to ensure surgical staff followed acceptable standards for surgical attire. The infection control officer failed to ensure two nursing staff providing dressing changes prior to patient dismissal and laboratory procedures followed infection control policies and acceptable standards of practice with hand hygiene by cleaning their hands between glove changes.

Findings include:

- The hospital policy " Clinical-Surgical Dress Code " reviewed on 5/14/13 at 9:55 am directed " ...all hair is to be completely covered ... " , " ...any employee involved in patient care may no wear artificial nails of any kind ... " , " ...jewelry ...should not be worn in the Operating Room ... " .

- Staff E, circulating surgical nurse, observed on 5/14/13 at 8:50am in the operating room (OR) wore artificial fingernails on hands, wore a surgical cap that failed to cover all their hair, and wore dangling earrings.

- Staff I, surgical sales representative, observed in the OR on 5/14/13 at 8:50am wore a surgical cap that failed to cover all their hair and sideburns.

- Staff E, circulating surgical nurse, interviewed on 5/14/13 at 1:05pm acknowledged she wore artificial fingernails in the OR during surgery.

- Staff B, director of nursing, interviewed on 5/14/13 at 6:00pm acknowledged staff and surgical representative failed to follow hospital policy for surgical dress code.

- American Operating Room Nurses (AORN) guidelines " Recommended Practices for Traffic Patterns in the Perioperative Practice Setting " reviewed on 5/15/13 at 5:30 pm revealed " ...soiled supplies, instruments, and equipment should not re-enter the clean core area ...soiled linen and trash collection areas should be separated from personnel and patient traffic areas ...Separation of clean and sterile supplies and equipment from soiled materials by space, time, and traffic patterns decreases the risk of infection. "

- Sub sterile operating room (OR) area observed on 5/13/13 at 2:25pm revealed two large bins; one with trash and one with soiled linen within 40 inches of a cart stocked with clean surgical attire and supplies. The location of the trash and soiled linen created the potential for cross contamination of the clean surgical attire and supplies.

- The hospital admitted patient #3 on 5/13/13 for a posterior spinal fusion of L4-5 (a surgical procedure that joins two or more bones of the spine for spinal stenosis and pain treatment). Registered Nurse staff H on 5/14/13 at 11:10am changed patient #3 ' s dressing and removed a surgical drain prior to the patient ' s dismissal. Staff H washed their hands, put on a pair of gloves, removed the soiled dressing, cleaned the surgical site and removed the drain tube. Staff H changed their gloves without performing hand hygiene between glove changes and redressed the surgical site. The failure to perform hand hygiene between glove changes failed to meet acceptable standards of practice for hand hygiene. The infection control officer failed to ensure staff followed nationally recognized infection prevention and control precautions, such as current Centers for Disease Control (CDC) guidelines and recommendations, for infections/communicable diseases.


- The hospital provided laboratory services to outpatient #31 in preparations for a future surgery and pain management and patient #21 after a lysis procedure on the spine (a procedure to dissolve scar tissue on the spine) to alleviate pain. Registered nurse staff H on 5/15/13 obtained blood from each patient in a syringe then brought the blood to the I-Stat machine (point of care blood testing/analysis machine) located in a work area behind the nurse ' s station. Staff H consistently failed to perform hand hygiene between glove changes when testing each patient ' s blood. The failure to perform hand hygiene between glove changes failed to meet acceptable standards of practice for hand hygiene. The infection control officer failed to ensure staff followed nationally recognized infection prevention and control precautions, such as current CDC guidelines and recommendations, for infections/communicable diseases.

- Staff C, the Chief Operations Officer responsible for nursing services and the Infection Control Practitioner for the hospital verified on 5/15/13 and 5/16/13 the hospital followed CDC guidelines for hand hygiene and expected staff providing patient care to perform hand hygiene (either alcohol rub or hand washing) between glove changes.