HospitalInspections.org

Based on review of facility policies and procedures, department policy and procedure manuals, observations and interviews with staff, the facility failed to:

1. Review and approve all departmental policy and procedure manuals annually.

2. Follow facility policy for completing quality control for glucose meters

3. Follow the facility policy for checking the crash cart each shift in the nursing services department.

This had the potential to affect all patients served in this facility.

Findings include:

Policy and Procedure:
Subject: Microdot Controls

Procedure:
"Controls will be performed on the Microdot meter to ensure that the meter and test strips are working correctly...patient results are accurate.

A Control Solution test will be performed when any of the following conditions occur:
When you open a new vial of strips
Once every 24 hours on the 11 p (PM) to 7 AM shift...
It is the responsibility of the RN (Registered Nurse) to ensure...the control is completed...

Test Procedure:
11. Document control testing on the Control Log. Document: Date, Time, Initials, low Range results, Low control range, Hi (high) control range, High control range and Expiration date..."

Date of Origin:03/16

***

Policy & Procedure:
Crash Cart

Procedure:
1. The defibrillator, monitor and tab will be checked each shift.
2. The pharmacy staff will maintain a "first drug to expire" date sticker on the drug box. Drugs will be inventoried each time the cart is broken."

Date of Origin: 8/93
Date of Review: 01/16

***

During a tour of the radiology department on 3/22/16 at 12:30 PM with Employee Identifier (EI) # 4, Radiology Technician, the policy and procedure book for the radiology department was reviewed. The surveyor noted the last review and revision date in the front of the manual was 12/24/2014.

EI # 4 reported during an interview on 3/22/16 at 12:40 PM, the policy manual would be reviewed and updated if policies and procedures had changed.

An interview on 3/24/16 at 4:00 PM with EI # 10, Administrator reported all policy manuals are reviewed and approved annually. The front page of the manual reflects signatures and date(s) of the last review and approval.

***

On 3/22/16 at 2:30 PM during a tour of the Surgical Services area, an interview was performed with EI's # 5 and # 6, Registered Nurses (RN) who reported the surgical department had a glucometer, currently in use on the medical floor for an outpatient infusion procedure. A request to observe the glucometer was made to EI # 5 and # 6.

On 3/23/16 at 8:10 AM, observations of care were performed on the Medical Unit.

The surveyor observed 2 Microdot glucometers, SN0020853 and SN00237134. There was one set of quality controls in use. Review of the 2015 and 2016 glucometer quality control log revealed daily monitoring was performed. There was no documentation as to which Microdot glucometer control tests were performed on.

In an interview on 3/23/16 at 8:20 AM, EI # 1, Director of Nursing confirmed control documentation did not reveal the specific monitor quality control testing was performed on.

At 8:45 AM on 3/23/16 in the Surgical services/Outpatient services department, an interview with EI # 6 was conducted. EI # 6 provided the surveyor with the OR Microdot glucometer, SN00259134 used in the surgery and outpatient department. EI # 6 reported she was not aware the glucometer required quality control monitoring.

The facility staff failed to perform and document quality control monitoring in 2015 and 2016 using the Microdot glucometer SN00259134.

***


32470

A tour was conducted on 3/22/16 between 1:30 PM and 2:15 PM of the Laboratory area. The Policy and Procedure Manuals were reviewed by the surveyor. During the review of the Policy and Procedure manuals it was revealed the Laboratory manuals had not been updated since 3/5/14.

An interview was conducted on 3/24/16 at 9:30 AM with EI # 15, Laboratory Director, who confirmed the above mentioned findings.




36271

Review of the Crash Cart Inventory record for March 2016 revealed the monitor was not verified as in working order on 3/11/16 for both the AM and NOC (night) shifts and the defibrillator was not verified as in working order on the NOC shift.

Further review of the Crash Cart Inventory record revealed the monitor and defibrillator were not verified as in working order on 3/19/16 and 3/20/16 for both the AM and NOC shifts.

The facility policy states the monitor, defibrillator and tab will be checked each shift.

An interview was conducted on 3/24/16 at 4:00 PM with EI # 1, who verified the nursing staff was responsible for checking the crash cart each shift.

Based on review of facility policy, medical record (MR) and interview, it was determined the facility failed to ensure staff followed their own policy and procedure for use of restraints. This affected MR # 31, 1 of 1 patient with restraints reviewed. This had the potential to affect all patients treated in the facility.

Subject: Restraints
Policy: "A restraint is defined as a device to restrict freedom from movement...used to provide a safe environment for patients...

Procedure:
2. A time-limited physician's order is necessary for the use of restraints....

General Information:
...Restrained areas are to be inspected every two hours and appropriate space (circulation checks) performed and documented on the Restraint Flow Sheet...
Restraints are to be removed every two hours and more often as indicated, for ROM (range of motion) and ADL's (activities of daily living) to be administered (fluids and bathroom privileges). This is to be documented on Restraint Flow Sheet....

Findings include:

MR # 31 was admitted to the facility 1/10/16 with diagnoses including Altered Mental Status.

Review of Physician Admission Orders dated 1/10/16 included Posey Restraint with Mittens. The 1/10/16 physician orders did not include the time the restraint order was written.

Review of the Nurse's Initial Interview documentation dated 1/11/16 at 1:30 AM included the following: "...Nurse's Notes, PT (patient) arrived on unit via stretcher and restraints at 0115 (1:15 AM). PT is slightly agitated and attempted to trash and then drowsy after a few moments...PT had posey vest and mitten restraints on at this time...SR (siderails) up...call light within reach...posey vest and mittens. All 4 Rails UP..."

Review of the 1/11/16 3:30 AM nurse documentation included resting comfortably in bed...Restraints released. CSM (comfort, safety measures)WNL (within normal limits).

There was no documentation circulation checks were performed or fluids offered.

Record review failed to reveal restraints were released and restrained areas inspected at 5:30 AM, every 2 hours per facility policy.

Review of the 1/11/16 6:05 AM nurse documentation included PT slightly agitated. Ativan given. See MAR (medication administration record). Restraints released. CSM WNL.

There was no documentation circulation checks were performed or fluids offered at 6:05 AM.

Record review revealed MR # 31's respirations increased, fingers and nail beds noted to be purple in color. All restraints were removed at 7:30 AM on 1/11/16.

Staff failed to perform and document restraint monitoring on the Restraint Flowsheet as per facility policy.

In an interview on 3/24/16 at 3:13 PM with Employee Identifier # 1, Director of Nursing, the above findings were confirmed.

Based on review of facility 2016 Quality Assurance/Performance Improvement Plan, review of the facility services, Centers for Medicare and Medicaid (CMS) Hospital Quality Assessment Performance Improvement (QAPI) worksheet and interview, it was determined the facility failed to ensure:

a) Quality data collection was performed and program improvement opportunities were identified and implemented for all facility departments including all contracted services.

b) Approval of the specific quality performance improvement projects chosen by the facility to be conducted and reviewed annually was documented.

Refer to 0283, 0308 and 0309 for additional findings.

Based on review of facility 2016 Quality Assurance/Performance Improvement Plan, review of the facility services, Centers for Medicare and Medicaid (CMS) Hospital Quality Assessment Performance Improvement (QAPI) worksheet and interview, it was determined the facility failed to ensure quality data collection was performed and program improvement opportunities were identified and implemented for all facility services.

This had the potential to affect all patients treated at the facility.

2016 Quality Assurance/Performance Improvement Plan
Revision Date 12/21/2015

I. Mission/Goals
"...To provide high quality patient and acute care in a rural setting...
II. Vision
...3. Establish a culture that fosters safety as a priority...
III. Goals
A. Incorporate the performance improvement process into the structure of all departments and services existing quality programs...
B. Improve safety and quality of care and utilization of hospital resources through the incorporation of best practices...
E. Continue to perform monitoring to comply with requirement of...regulatory agencies and standards.
F. Coordinate and integrate medical staff, hospital committee, and departmental monitoring and evaluation activities.
I. To provide a system for managing the data required to improve quality and safety of patient care...
IV. Principles of Performance Improvement
...B. Measuring these process and their outcomes...
C. Assess, aggregate and analyze collected data to identify key areas for improving patient care...

I. Maintain accurate records on all activities.

X. Annual Program Evaluation Plan
The Performance Improvement plan will be reviewed annually, and revised as necessary. A summary of evaluation results will be presented to Administration and Medical Staff. The PI (performance improvement) Director is responsible for coordinating the presentation of the annual review..."

Findings include:

An interview with Employee Identifier (EI) # 3, Director of Case Management on 3/24/16 at 1:00 PM was conducted and incorporated the CMS Hospital QAPI worksheet.

During the interview with EI # 3, the surveyor requested data collection, analysis and evaluation of all contracted services and hospital departments.

EI # 3 was unable to provide documentation all departments including Maintenance, Human Resources, and Surgery/Outpatient departments participated in 2015 QAPI projects.

During an interview on 3/24/16 at 2:45 PM, EI # 3 confirmed the facility failed to ensure staff from all departments assessed, collected, aggregated and analyzed data required to identify key areas for improving patient care.

Based on review of the facility 2016 Quality Assurance/Performance Improvement Plan, review of facility contracted services list, the Centers for Medicare and Medicaid (CMS) Hospital Quality Assessment Performance Improvement (QAPI) worksheet and interview, it was determined the facility failed to ensure quality data collection was performed and program improvement opportunities identified for all contracted facility services. This had the potential to affect all patients treated at the facility.

2016 Quality Assurance/Performance Improvement Plan
Revision Date 12/21/2015

I. Mission/Goals
"...To provide high quality patient and acute care in a rural setting...
II. Vision
...3. Establish a culture that fosters safety as a priority...
III. Goals
A. Incorporate the performance improvement process into the structure of all departments and services existing quality programs...
B. Improve safety and quality of care and utilization of hospital resources through the incorporation of best practices...
E. Continue to perform monitoring to comply with requirement of...regulatory agencies and standards.
F. Coordinate and integrate medical staff, hospital committee, and departmental monitoring and evaluation activities.
I. To provide a system for managing the data required to improve quality and safety of patient care...
IV. Principles of Performance Improvement
...B. Measuring these process and their outcomes...
C. Assess, aggregate and analyze collected data to identify key areas for improving patient care...

I. Maintain accurate records on all activities.

X. Annual Program Evaluation Plan
...The PI (performance improvement) Director is responsible for coordinating the presentation of the annual review..."

Findings include:

An interview with Employee Identifier (EI) # 3, Director of Case Management on 3/24/16 at 1:00 PM was conducted. This interview incorporated the CMS Hospital QAPI worksheet.

During the interview with EI # 3, the surveyor requested 2015 and 2016 data collection, analysis and evaluation of all contracted hospital departments services.

EI # 3 reported there was no QAPI projects documentation for contracted services including inpatient Physical Therapy evaluations, Nuclear Medicine Services including Thallium Stress Tests, Ultrasound Services and Anesthesia services.

In an interview on 3/24/16 at 2:45 PM, EI # 3 confirmed the facility failed to ensure contracted services and services provided under arrangement participated in and demonstrated evidence of a QAPI program.

Based on review of the facility 2016 Quality Assurance/Performance Improvement Plan, 2014 to 2016 Board of Directors Meeting Minutes and Medical Staff Meeting Minutes, Centers for Medicare and Medicaid (CMS) Hospital Quality Assessment Performance Improvement (QAPI) worksheet and interview, it was determined the facility failed to document approval of the specific quality performance improvement projects chosen by the facility to be conducted and reviewed annually.

This had the potential to affect all patients treated at the facility.

2016 Quality Assurance/Performance Improvement Plan
Revision Date 12/21/2015

I. Mission/Goals
"...To provide high quality patient and acute care in a rural setting...
III. Goals
A. Incorporate the performance improvement process into the structure of all departments and services existing quality programs...
E. Continue to perform monitoring to comply with requirement of...regulatory agencies and standards.
F. Coordinate and integrate medical staff, hospital committee, and departmental monitoring and evaluation activities.
IV. Principles of Performance Improvement
...B. Measuring these process and their outcomes...
C. Assess, aggregate and analyze collected data to identify key areas for improving patient care...

I. Maintain accurate records on all activities.

X. Annual Program Evaluation Plan
The Performance Improvement plan will be reviewed annually, and revised as necessary. A summary of evaluation results will be presented to Administration and Medical Staff. The PI (performance improvement) Director is responsible for coordinating the presentation of the annual review..."

Findings include:

An interview with Employee Identifier (EI) # 3, Director of Case Management on 3/24/16 at 1:00 PM was conducted that incorporated the CMS Hospital QAPI worksheet.

Review of the 12/8/14 and 4/27/15 Medical Staff Meeting minutes, the 7/6/15 and 10/5/15 Board of Director Meeting Minutes and Medical Staff Meeting minutes did not reveal the number of and specific quality indicators or performance improvement projects approved by the governing body and evidence improvement projects actions were evaluated annually by the governing body.

The surveyor requested documentation of the facility's Governing Body and Medical Staff leaderships' annual approval of the number of and facility specific quality indicators chosen for 2016.

Review of the 2016 Quality Assurance/Performance Improvement Plan for the facility was revised 12/21/15 and approved by EI # 10, Administrator, EI # 17, Chief Executive Officer and EI # 18, the 2016 Medical Director.

Review of January 26, 2016 Board of Directors Meeting Minutes and January 26, 2016 Medical Staff Minutes did not include documentation of specific 2016 QAPI projects or indicators of performance improvements projects for 2016, the frequency of data collection or an annual presentation of facility QAPI projects to hospital leadership.

In an interview conducted on 3/24/16 at 2:50 PM, EI # 3 confirmed there was no documentation of the above in the 2014 to 2016 documents referenced above.

Based on review of facility bylaws, medical records (MR) documentation, policy and interviews, it was determine the facility failed to ensure medical staff:

a) Completed history and physicals within 24 hours of admission.

b) Documented the date consultations were completed.

c) Performed consultations as ordered.

This affected MR's # 26, # 30 and # 29, 3 of 13 patients admitted for inpatient services and had the potential to affect all patients treated at the facility.

Regulations Governing the Medical Staff of Lakeshore Community Hospital

"...12. A complete history and physical examination shall, in all cases, be on the chart within 24 hours after admission of the patient. If dictated, it shall be so indicated on the progress sheet at the time of dictation...This applies to the work of both the attending physician, the dentist, and /or the affiliate staff...
13. Consultations should be promptly recorded in the medical record in the same manner and timely fashion as the history and physical, as noted in the # 12 above...

Bylaws amended 7/1/01


Medical Record Documentation

Policy Statement
A. The medical record contains sufficient information, recorded in both electronic and paper format, to identify...support the diagnosis, justify the treatment...document the ...hospital course. The record is accessible to authorized persons. authenticated...current, and complete.

Definitions
A. Authentication: The process of identifying the author of an entry...
D. Medical Staff: The formal organization of all licensed physicians and dentists...granted authority by the Governing Board to provide care at LMCH (Lake Martin Community Hospital)...

J. Medical Record Content Requirements:

b. The H & P (history and physical) is completed within 24 hours of admission...."

Findings include:

1. MR # 26 was admitted to the facility 2/21/16 with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure (CHF)and Sepsis.

Record review revealed a History and Physical signed by the admitting physician on 2/23/16, 48 hours after admission.

Review of the History and Physical revealed a cardiac consultation was indicated due to CHF.

Record review revealed a document from the referring physician to the cardiologist titled "Report of Consultation". There was no date on the report of consultation.

Record review revealed the presence of the cardiac consultation. However, the consulting cardiologist did not document the date the consult was performed.

In an interview conducted on 3/24/16 at 3:45 PM, Employee Identifier (EI) # 1, Director of Nursing confirmed the finding above.

2. MR # 30 was admitted to the facility 3/15/16 with diagnoses including Diverticulitis and Urinary Tract Infection

Record review revealed a History and Physical signed by the admitting practitioner on 3/19/16, which is greater than 48 hours after admission.

In an interview conducted on 3/24/16 at 3:45 PM, EI # 1, confirmed the finding above.

3. MR # 29 was admitted to the facility 2/7/16 with diagnoses including Anemia, Bilateral Hip Decubiti (ulcers) and Failure to Thrive.

Record review revealed an admit history and physical that revealed the presence of 2 large decubitus to each hip, will ask surgeon (named) to evaluate.

Review of physician's orders dated 2/7/16 at 9:17 AM included Consult: Dr. (doctor)[named, a General Surgeon].

Review of the medical record failed to reveal the above consult was performed. There was no order to dismiss the General Surgeon consult which was ordered 2/7/16. MR # 29 was discharged 2/10/16. No consult was performed.

In an interview conducted 3/24/16 at 3:13 PM, EI # 1 confirmed MR # 29 did not receive the ordered consult.

Based on review of medical records (MR), policies and procedures and staff interviews, it was determined staff failed to ensure:

a) Laboratory tests were performed as ordered.

b) Wound care orders included specific solution to cleanse wound sites.

c) Wound care was performed as ordered.

d) Wound sites were assessed to reflect appearance and progress/deterioration of the wound.

e) Nutritional supplements were administered as ordered.

f) Anti-embolism stockings were applied as ordered.

g) Physician orders for hypoglycemia (low blood glucose) were followed.

h) PEG (percutaneous enteral gastrostomy) tube was flushed as ordered.

This affected 3 of 31 records reviewed and included MR's # 29, # 24 and # 30. This had the potential to affect all patients treated at the facility.

Policy and Procedure:

Subject: Wound/Decubitus Dressing Changed
Policy:
...A wound/ostomy flowsheet ...completed on all patients with impaired skin integrity. The attending physician will be notified on all other patients admitted...with decubitus for treatment orders.

Subject: Sterile Dressing Change
Policy: Dressing will be changed upon order of the physician...

Chart:
1. Time of dressing change.
2. Amount and description of drainage and appearance of wound.

Findings include:

1. MR # 29 was admitted to the facility 2/7/16 with diagnoses including Anemia, Bilateral Hip Decubiti (ulcers) and Failure to Thrive.

Record review included a history and physician that revealed the presence of 2 large decubiti to each hip, found packed with sponges, patient has a declining appetite and not drinking well. Physician plans included wound care daily with Dakin's wet to dry. Will ask surgeon (named) to evaluate.

Review of physician's orders dated 2/7/16 at 9:17 PM included the following:

Transfuse 2 units of PRBS's (packed red blood cells)

H&H (hemoglobin and hematocrit) 6 hours after unit # 2 transfusion complete

Obtain occult blood stool

Consult Dr. (doctor) [named].

Dakin's solution (FULL) 0.5 % topical every day.

Record review revealed the 2nd unit of PRBS was complete 2/8/16 at 6:00 AM.

Review of medical record laboratory results revealed H&H results were completed on 2/8/16 at 8:08 AM, less than 2 hours post transfusion of the 2nd unit. The H&H was not performed 6 hours post transfusion as ordered.

Review of physician orders dated 2/9/16 at 8:41 AM included a nutritional consult this am (morning).

The nutritional assessment, completed 2/9/16 revealed MR # 20's Albumin level (evaluation of protein stores) was 1.8 (3.0-5.0 within normal range). The Registered Dietician's recommendation were to provide Ensure Supplement three times daily between meals for caloric increase and protein.

Record review failed to reveal MR # 29 was provided Ensure supplements.

There was no documentation in the review to reveal stool for occult blood was collected as ordered.

Review of the 2/7/16 6:21 PM Initial nurse documentation revealed "...PT [patient] has 2 Decub [decubitus] with tunneling on bilat [bilateral] hips. measuring 2 IN (inches) [wide-W] x (by) 4 IN round with pink wound bed, no slough noted. Dressing is clean, dry and intact..."

Further review revealed 2/7/16 at 22:11 (10:11 PM) ...Dressing changed" The wound flowsheet revealed serosanguineous drainage to both wounds. The amount of drainage was not documented.

There was no documentation of the specific wound care provided on the 2/7/16 10:11 PM dressing change.

Review of the nurse documentation dated 2/8/16 did not include wound care to bilateral stage 4 decubitus daily as ordered.

Review of nursing documentation dated 2/9/16 at 5:35 PM revealed wound care performed to bilateral hips. Site cleaned with NS (normal saline) with Dakins wet to dry dressings applied. Secured with tape.

There was no order for NS cleaning to bilateral hips. The documentation was not specific as to the strength Dakins solution applied.

Review of the 2/9/16 wound assessment revealed a right hip stage 4 decubitus that measured 4.5 cm (centimeters) [length] X (by) 4.5 cm [width] x 2 cm tunneling. Left hip 4 cm (L) x 4 cm (w) x 5 cm tunneling distal.

There was no documentation as to the location of the tunneling to the right and left stage 4 decubiti.

There was no documentation of the appearance of the wound beds, skin surrounding the wound or presence/absence of type drainage.

There was no consult completed by the surgeon (named) prior to MR # 29's discharge on 2/10/16 at 12:30 PM.

In an interview on 3/24/16 at 3:13 PM with Employee Identifier (EI) # 1, Director of Nursing, the above findings were confirmed.

2. MR # 24 was admitted to the facility 2/9/16 with diagnoses including Altered Mental Status, Generalized Weakness and Chronic Dementia.

Review of the Initial interview dated 2/9/16 at 1:44 PM revealed the following: Abrasion right knee approx (approximately) 3 in (inch) long, 1/2 in wide, friction sheers to bil (bilateral) heels skin remains partially intact wound bed pink in color, scant sanginous drainage, buttocks dark red in color.

Review of physicians' orders dated 2/9/16 12:12 PM included anti-embolism stockings and decubitus precautions on 2/9/16 at 4:34 PM.

Review of the nurse note documentation dated 2/9/16 at 12:36 PM revealed friction sheers to bil heel, duoderm applied, TED hose not placed due to wounds to heels. Buttocks dark red, skin intact, turning q 2 hours.

There was no physician's order for Duoderm application to bilateral heels. The staff failed to apply TED hose (anti-embolism stockings) as ordered.

In an interview on 3/24/16 at 3:45 PM with EI # 1, the above findings were confirmed.

3. MR # 30 was admitted to the facility 3/15/16 with diagnoses including Diverticulitis and Urinary Tract Infection. Past medical history included IDDM (Insulin Dependent Diabetes).

Review of physicians' orders dated 3/16/16 at 4:13 PM included Dextrose 50 % INJ (injectable) 25 ml (milliliter) IV (intravenous) route prn (as needed) if BS (blood sugar) < (less than) 70 [milligram/deciliter].

Review of nurse documentation dated 3/16/16 at 21:00 (9:00 PM) revealed the "...FSBS (finger stick blood sugar) 58. Gave pt. (patient 8 oz (ounce) orange juice via her/his PEG. pt was repositioned...

There was no documentation the nurse administered Dextrose 50 % INJ 25 ml IV route prn for BS < 70 as ordered.

Review of physicians' orders dated 3/17/16 at 8:16 AM included Glucerna at 40 cc (cubic centimeter)/hr (hour) and flush PEG with 100 cc H20 (water) Q (every) 4 hours.

Review of the 3/17/16 10:30 AM nurse documentation revealed "tube feeding started Glucerna at 40 cc/hr, with 100 cc H20 Q 4 hr".

Review of the 3/17/16 12:08 PM nurse note documentation included flushed PEG tube with 100 cc H20, residual checked prior..."

Review of the medical record documentation did not reveal staff administered H20 flush, 100 cc q 4 hr to PEG as ordered after 12:08 PM on 3/17/16.
An interview with EI # 1 on 3/24/16 at 3:23 PM confirmed the above findings.

Based on review of medical records (MR), policy and procedure and interviews, it was determined the facility failed to ensure staff provided care to patients receiving blood transfusions according to physician orders and facility policy.

This affected 2 of 2 records reviewed with blood transfusions, including MR's # 20 and # 25. This had the potential to affect all patients treated at the facility.

Policy and Procedure:
Subject: Blood Administration for inpatients and outpatients

Policy: Blood will be administered...on an order from physician. A registered nurse will administer blood after proper orientation to procedure...

Procedure:

Nursing care:
1. Blood should be initiated at rate of 50-75 cc (centimeters)/hr (hour) to observed for untoward reaction. Rate may be increased at intervals based on tolerance ....up to 100 cc /hr...not to exceed 150 cc/hr
2. Vital signs, including temperature will be taken and recorded in the patient's...blood transfusion record.
a. Prior to the start of transfusion.
b. At 5 minute, 10 minute and 15 minute intervals, and then hourly until...completed...

f. Charting:
2. Charting to be done on the Blood Administration flow chart..."

Findings include:

1. MR # 20 was admitted to the facility 2/7/16 with diagnoses including Anemia, Decubitus Ulcers and Failure to Thrive.

Review of physician's orders dated 2/7/16 at 9:17 PM included transfuse 2 units of PRBS's (packed red blood cells) and obtain a H&H (hemoglobin and hematocrit) 6 hours after unit # 2 transfusion complete.

Record review revealed PRBC unit # 1 was initiated at 12:00 AM with vital signs documented. The blood products flowchart revealed the blood flow rate on 2/8/16 at 12:21 AM was 100 ml (milliliter)/hr.

The facility policy is to initiate the transfusion rate at 50-75 cc/hr then may increase to 150 ml/hr.

Staff did not follow transfusion rate policy at initiation of the transfusion.

There were no vital signs documented 5 minutes, 10 minutes and 15 minutes after transfusion initiation per policy. The next vital signs taken post infusion initiation was 21 minutes after transfusion initiation at 12:21 AM.

There was no documentation vitals signs were taken at 1:21 AM, 1 hour after initiation, but taken at 1:30 AM instead, 70 minutes later. The vital signs were not monitored at specified timeframes per the facility policy.

Record review revealed unit # 1 was complete at 3:30 AM. Unit # 2 was initiated at 3:45 AM with vital signs documented. There were no documented vitals signs 5 minutes post infusion at 3:50 AM. The next vital signs were documented at 4:00 AM, 15 minutes after transfusion initiation.

The facility failed to perform and document vital signs at designated timeframes during blood transfusions and initiate the flow rate per policy.

In an interview on 3/24/16 at 3:13 PM with Employee Identifier (EI) # 1, Director of Nursing, the above findings were confirmed.



36271

2. MR # 25 was admitted to the facility 3/2/16 with diagnoses including Anemia.

Review of the physician's order dated 3/2/16 at 5:55 PMrevealed the following orders:

a. Benadryl 25 mg (milligrams) po (oral) prn (as needed) Q (every) 8 H (hours) - give a dose prior to transfusion.

b. Tylenol 325 mg tablet 650 mg po prn Q 4 H - give a dose prior to transfusion.

Review of the Medication Record revealed no documentation these medications were administered prior to the transfusion.

Review of the MR revealed the first unit of blood was started at 8:50 PM and completed at 11:15 PM on 3/2/16.

Review of the blood products flowchart dated 3/2/16 at 8:57 PM revealed the blood product was infusing at 100 ml/hr. The facility policy is to initiate the transfusion rate at 50-75 cc/hr then may increase to 150 cc/hr.

Review of the MR revealed a second unit of blood was started at 11:45 PM on 3/2/16 and completed 3/3/16 at 2:45 AM.

Review of the blood product flowchart dated 3/2/16 at 11:42 PM revealed the blood flow rate was 100 cc/hr. The facility policy is to initiate the transfusion rate at 50-75 cc/hr then may increase to 150 cc/hr.

Review of the MR revealed a third unit of blood was started at 10:15 AM and ended at 12:30 PM on 3/3/16.

Review of the blood product flowchart dated 3/3/16 at 10:15 AM revealed a blood flow rate of 125 cc/hr. The facility policy is to initiate the transfusion rate at 50-75 cc/hr then may increase to 150 cc/hr.

Review of the MR revealed a fourth unit of blood was transfused on 3/4/16.

Review of the blood product flowchart revealed the blood was started at 11:15 PM and the blood flow rate was 110 cc/hr. The facility policy is to initiate the transfusion rate at 50-75 cc/hr then may increase to 150 cc/hr.

An interview was conducted on 3/24/16 at 3:20 PM with EI # 1, who verified the Benadryl and Tylenol was not administered prior to the transfusion and the facility policy was not followed regarding the rate of administration of blood products.

Based on review of facility policies and procedures, medical records (MR) and interviews, it was determined the facility failed to ensure staff documented care performed during procedures and treatments. This affected MR's # 21 and # 31, 2 of 13 patients admitted for inpatient treatments. This had the potential to affect all patients treated at the facility.

Findings include:

Policy:

Medical Record Documentation

Policy Statement

"A. The medical record contains sufficient information, recorded in both electronic and paper format, to identify...support the diagnosis, justify the treatment...document the ...hospital course. The record is accessible to authorized persons. authenticated...current, and complete.

B. The medical record includes...findings from relevant physical ...assessments...therapeutic orders...clinical observations...

J. Medical Record Content Requirements:

4. Progress and Procedure Notes:
a. Results of invasive procedures are specifically noted..."

Policy:
Subject: Intravenous (IV) Therapy

"...Procedure
1. Gather needed equipment
8. Cleanse site with Chloraprep preparation, circular motion...Allow to air dry at lease 30 seconds.
9. insert the catheter or butterfly into the vein...
12. Flush gently with normal saline...
13. Apply occlusive dressing...and secure the site.
14. Label site with date, catheter size and nurses' initials.
15. Document in the nurse's notes and EMAR (electronic medical record)..."

Findings include:

1. MR # 21 was admitted to the facility 2/9/16 with diagnoses including Leukemia.

Review of physician orders dated 2/9/16 6:42 PM include "Foley Catheter".

Review of nurse note documentation dated 2/9/16 at 6:43 PM revealed the following: "...16 French (foley) placed related to patient has noted [not]had any urine output since arrival. Abdomen slightly swollen and tender to touch..."

The nurse failed to document that sterile/aseptic technique was used during insertion, the catheter balloon size, the solution type and amount instilled into the balloon, whether urine was returned, the amount and character of urine and patient tolerance of the procedure.

In an interview with Employee Identifier (EI) # 1, Director of Nurses on 3/24/16 at 3:20 PM, the above finding was confirmed.

2. MR # 31 was admitted 1/10/16 with diagnoses including Altered Mental Status and Dementia.

Review of the nurse note documentation dated 1/11/16 at 6:13 PM revealed the following: "IV (intravenous) site infiltrated, site D/C'D (discontinued) with cath tip intact. 2 x 2 gauze applied. cold pack applied. IV restarted left FA (forearm) x (by) 1 stick..."

There was no documentation of the appearance of the infiltrated IV site, the size/gauge of the catheter removed, how the IV site was prepared, the size IV catheter reinserted, type dressing applied and how the patient tolerated both procedures.

In an interview with EI # 1 on 3/24/16 at 3:49 PM, the above findings were confirmed.

Based on review of policy and procedure, Centers for Disease Control and Prevention, observations and interview, it was determined the facility failed to ensure:

a) All medications in patient treatment areas were not expired.

b) All medications and biologicals in use were correctly labeled.

This had the potential to negatively affect patients receiving care at this facility.

Centers for Disease Control and Prevention

4. "When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

Findings include:

During a tour of the Surgical Services department on 3/22/16 at 2:00 PM with Employee Identifier's (EI) # 5 and # 6, Registered Nurses, the following was observed:

On the Surgery Emergency Cart located between surgical suites were 3 Sure Scope single-use laryngoscope with built in light source, expired 02/2016.

In the blanket warmer (temperature 109.5 degrees Fahrenheit) were 5 bags of 1000 milliliter (ml) 0.9 % Sodium Chloride. One bag had a sticker, labeled "use by 2/19/16" and bag two was labeled "use by 2/5/16". The 3 other bags were not labeled.

Found in the Recovery Room, used by the general surgeon to perform minor procedures according to EI # 5 was one 8 ounce bottle of PVP Prep solution, expired October 2015.

Also in the Recovery Room was a prefilled normal saline syringe, expired 4/2015.

In the locked medication cabinet in the Surgical department was one Atropine Sulfate 1 mg(milligram)/10 ml injectable syringe, expired 1/2016 and thirteen 10 ml vials 0.9 % vials, expired 12/2015.

In the Holding Room was an open blade on top of a blade dispenser located on the top of a supply cart.

The supply cart also contained an open bottle of hydrogen peroxide 3%, expiration date 01/16 and an open bottle of Betadine solution with no label to indicate the date opened.

Inspection of the emergency crash cart located in the nursing unit on 3/22/16 at 10:20 AM revealed 2 Epinephrine 1:10,000 1 mg per 10 ml prefilled syringes, expiration date 01/16.

Further review of the supplies revealed Resting Electrocardiogram Tab Electrodes with a Use By Date of 10/2015.

An interview conducted on 3/23/16 at 9:00 AM with EI # 2, Director of Pharmacy, who verified the pharmacy was responsible for checking the crash carts for expired medications.

Based on observations, United States Health Public Food Code 2009 regulations, review of the sanitizer and dish washer log and interviews, it was determined the facility failed to ensure dietary products were stored with proper labels and dated, food items in the refrigerator were stored properly and the sanitizer and dishwasher logs were up to date.

This had the potential to negatively affect all patients served by the facility.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

A tour of the Dietary Department was conducted on 3/23/16 at 10:15 AM with Employee Identifier (EI) # 11, Dietary Manager. During the tour, the dry food storage was observed. While touring the dry food storage area the surveyor observed 2 large bags of tortilla chips had been opened, were resealed and were not labeled with the date the bags were opened. The surveyor observed a lager bags of pasta noodles and macaroni on the shelf which had been opened, resealed and did not contain a proper label of date product was opened.

While touring the dry food storage area a large plastic tote was on the bottom shelf of one area with a paper on the front labeled "Chicken Batter". The surveyor opened the container and observed a flour type substance in the tote which had multiple spices in it. Also in the container was a plastic cup that was used to scoop the chicken batter out. Further observation of the tote revealed no label of when the flour product was placed into the plastic tote or when the product was to expire.

A tour of the walk-in refrigerator revealed gallon containers of ranch dressing and a gallon container of Caesar dressing opened. There were no label of the date(s) when the containers were opened.

The cooler was observed during the tour of the dietary department. The following items had been opened and did not contain a label of the date each item was opened:

1- 5 pound container of sour cream
1- gallon container of dill pickle slices
2- gallon container of mayonnaise
1- gallon container of mustard
1- gallon container of Sweet Baby Rays BBQ sauce
1- container of sweet pickle relish

The tour of the kitchen area revealed an area of spices on the counter. Review of the spice containers revealed each of the following containers had been opened and were not properly labeled with the date each container was opened and contained no expiration dates:

1- Black pepper 4.5 pounds
2- Garlic Powder 6 pounds
1- Sage 6 pounds
1- Parsley Flakes 11 ounces

A tour of the 3 compartment sink area revealed the middle compartment was used for the sanitizer area for the pots and pans. Review of the log for checking the sanitizer with strips revealed the sanitizer was checked only once during the day.

Review of the dishwasher area revealed the dishwasher log for temperatures and chemical test strips was complete. Further review of the log revealed the temperature and chemicals were only checked once a day.

On 3/23/15 at 12:00 PM plating of the food was observed. Once the plating was complete, trays were placed on the cart for delivery to the patient area.

EI # 16, Food Service Assistant, was observed loading each tray onto the cart. EI # 16 was wearing gloves, a hair net, and an apron. EI # 16 rolled the cart out the door with the same gloves and apron on. When EI # 16 returned he/she removed the gloves, washed hands, donned clean gloves and was observed wearing the same apron.

During observation of the use of the dishwasher at 1:30 PM, EI # 16 checked the temperature and used the chemical strip. The strip was compared to the manufactures recommended safe levels and the chemicals in the dishwasher registered too low. Another test was taken approximately 5 minutes later. The results had improved but continued to remain low according to the manufacturers recommendations. The surveyor was told if it remains low a thorough check of the chemical lines and dishwasher would be conducted.

An interview was conducted on 3/24/16 at 9:45 AM with EI # 11 who confirmed the above mentioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of the facility policies and procedures, facility training documentation and material, Centers for Disease Control (CDC) and Prevention information for respirator fit testing, facility Endoscope Disinfection Guide documentation, review of Surgical Center Cleaning Standards Using the Association of PeriOperative Registered Nurses (AORN) recommended practice, and interviews, it was determined the facility failed to ensure:

a) Staff performed handwashing and hand hygiene per facility policy.

b) Sharps used in the surgery department were placed in a sharps container after use.

c) Properly trained staff are available for access and maintenance of central vascular catheters.

d) Employees are fit tested for respirator use according to Occupational Safety and Health Administration requirements.

e) Endoscopes are cleaned and disinfected according to manufacturers' recommendations.

f) All required areas were monitored for appropriate temperature and humidity to ensure environmentally controlled conditions were present.

g) A hospital wide infection control and prevention program was implemented with documentation of identification, investigation, reporting, prevention and controlling of infections.

h) A process was in place to ensure patients admitted with known infections were placed on the appropriate infection control precautions and/or isolation.

i) Infection control and prevention data was incorporated into the facility Continuous Quality Improvement and Performance Improvement (CQI/PI) program.

j) An annual Risk Assessment was performed.


This had the potential at affect all patients served by this facility and the staff.

Refer to A 749 and A 756 for additional findings.

Based on observations, review of the facility policies and procedures, facility training documentation and material, Centers for Disease Control (CDC) and Prevention information for respirator fit testing, facility Endoscope Disinfection Guide documentation, review of Surgical Center Cleaning Standards Using the Association of PeriOperative Registered Nurses (AORN) recommended practice, and interviews, it was determined the facility failed to ensure:

a) Staff performed handwashing and hand hygiene per facility policy.

b) Sharps used in the surgery department were placed in a sharps container after use.

c) Properly trained staff are available for access and maintenance of central vascular catheters.

d) Employees are fit tested for respirator use according to Occupational Safety and Health Administration requirements.

e) Endoscopes are cleaned and disinfected according to manufacturers' recommendations.

f) All required areas were monitored for appropriate temperature and humidity to ensure environmentally controlled conditions were present.

Findings include:

Policy and Procedure
Hand Hygiene for all Healthcare Workers
Date of Origin: 03/16

Purpose: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare workers.

Policy:

Hand hygiene shall be practiced before and after each patient contact (even if gloves are worn)...

Gloves shall be worn when exposure to blood or any other body fluids, excretions or secretions is likely...

Routine Handwashing Procedure...

Dry well with paper towels and use the paper towels to turn off the faucet.

****

Recommendations for Hand Hygiene
Reference # 4009 Infection Prevention and Control

Indications for Handwashing and Hand Antisepsis...

Decontaminate hands after removing gloves.

(This document was provided to the surveyor by the Infection Control Director on 3/23/16 and was used for employee training)

****

Centers for Disease Control and Prevention
Respirator Trusted-Source Information
Section 3: Ancillary Respirator Information

Are respiratory fit tests required?

Yes. The Occupational Safety and Health Administration...requires a respirator fit test to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is to be used in the workplace...

****
"Olympus...

Endoscope Disinfection Guide...

GI (gastrointestinal) Endoscopes

...Summary of the steps necessary to properly disinfect your endoscope

High Level Disinfection...Rinsing...Drying

11. Remove endoscope from rinse water. Use syringe to inject air through air, water and suction channels expelling the rinse water.

12. Inject air to flush water from elevator-wire channel/auxiliary channel.

13. Use syringe to flush 70 % alcohol through air, water and suction channels. Inject air to remove retained alcohol.

14. For endoscope with elevators or auxiliary-water feeding only; flush 70 % alcohol into elevator-wire/auxiliary water channel. Inject air to remove alcohol.

15. Disconnect all accessories from the endoscope. Dry endoscope and accessories with an alcohol-moistened cloth. Make sure equipment is completely dry prior to storage...

****

2015 Edition
Guidelines for PeriOperative Practices
AORN

Guidelines for Selection and use of Packaging Systems for Sterilization
pages 651, 654

"...Recommendation III

III.d.

The shelf life of a packaged sterile item is event related...

The sterility of an item does not change with passage of time, but may be affected by particular events [eg, amount of handling] or environmental conditions [eg, humidity]..."

****

1. Observation of terminal cleaning of a patient room was conducted on 3/22/16 at 1:00 PM to observe the process performed by Employee Identifier (EI) # 13 Environmental Services # 1, and EI # 14, Environmental Services # 2.

EI # 13 donned the appropriate PPE (personal protective equipment) and proceeded to clean the bathroom starting with the sink, mirror and paper towel dispenser. Using the same cleaning cloth EI # 13 then cleaned the toilet starting with the outside and finishing with the inside of the toilet bowl placing gloved hand and cleaning cloth into the bowl to wipe clean. EI # 13 then placed the soiled cloth in the dirty linen bag on the cleaning cart, reached into the pocket of his/her uniform to retrieve a clean cloth and proceeded to clean the shower without changing gloves.

EI # 14 was observed cleaning the bed, mattress, and furniture, removed gloves and did not perform hand hygiene. EI # 14 then went to the clean linen closet, retrieved linens for the bed and returned to the room to finish cleaning the room.

EI # 13 and # 14 failed to change gloves after contact with contaminated surfaces and failed to perform hand hygiene immediately after glove removal.

2. An observation was conducted on 3/23/16 at 8:15 AM with EI # 8, Registered Nurse (RN) to observe medication administration. EI # 8 was observed performing handwashing at the sink in the patient's bathroom. EI # 8 washed hands, then turned the faucet off with clean hands. EI # 8 failed to use paper towels to turn off the faucet.

3. During a tour of the Operating Room (OR) Holding Room, the surveyor observed an open razor blade lying on top of a razor blade dispenser on the top shelf of a clean supply cart.

An interview was conducted on 3/23/16 at 1:00 PM with EI # 2, Infection Control Coordinator, and on 3/23/16 at 2:30 PM with EI # 1, Director of Nursing, who both verified the hand hygiene policy was not followed and sharps were to be disposed of in a sharps container.

An interview was conducted on 3/23/16 at 2:30 PM with EI # 1, Director of Nursing, to review the Infection Control Program as related to nursing service.

When inquiring about respirators and fit testing for protection against droplet transmission EI # 1 stated respirators were available but EI # 1 had no knowledge of the fit testing requirement.

Review of 5 RN Human Resource files on 3/24/16 at 12:35 PM revealed no documentation of training and competency for access and maintenance of central venous catheters.

An interview conducted with EI # 1 on 3/23/16 at 2:30 PM confirmed the RNs had no training and education or competency verification for access and maintenance of central venous catheters.



30952

4. During a tour of the Surgical suites and Outpatient service departments on 3/22/16 at 2:00 PM, an interview with EI # 5, RN Surgery/Outpatient Departments was conducted.

In a verbal simulation of scope cleaning as no procedures were scheduled for the week, EI # 5 reported surveyor the facility followed the "Endoscope Disinfection Guide posted on the wall in the scope/surgical instrument cleaning room.

EI # 5 verbalized that after the scope soaked in Cidex for 12 minutes, the scope was removed, put in clean rinse water, then flushed with air via a syringe thorough the channels, dried and hung from the scope cabinet.

The surveyor asked if alcohol was injected following injection of air. EI # 5 reported she did not inject 70 % alcohol into the air, water and suction channels.

The surveyor asked if alcohol was kept in the scope cleaning room. EI # 5 answered, No, and reported "alcohol flush may be used, but is not a requirement".

In the 3/22/16 2:35 PM interview, EI # 5 confirmed she did not follow the facility posted "Endoscope Disinfection Guide" directions high level disinfection of facility endoscopes.

****

5. While touring the Surgical Department, the surveyor asked EI # 5 and 6 where the Sterile Supply room was located?

EI # 5 and # 6 reported "we don't have a central supply storage room, we don't do surgical cases here". EI # 5 and # 6 confirmed the Amsco 2011 Gravity (Steam) sterilizer was in use at the facility.

The surveyor observed 2 sterile packaged laceration tray packs, 1 Implant procedure tray, 1 toe nail removal tray and 10 sterile packs with various sterilized instruments lying on the cabinet across from the surgery medication room in the surgical department.

The surveyor asked EI # 6 for the Temperature and Humidity Log documentation in the area where the sterilized instruments/trays are stored.

EI # 5 reported there was no temperature and humidity monitoring in that area of the surgical department.

On 3/24/16 at 9:34 AM, EI # 7, Maintenance Director confirmed in an interview facility staff could not monitor temperature and humidity in the hallway area of the surgery department where sterilized packs were stored.

There was no documentation the facility monitored temperature and humidity in the area where sterilized supplies used for surgical procedures were stored.

Based on review of facility policies and procedures and interviews with department directors it was determined the facility failed to ensure:

a) A hospital wide infection control and prevention program was implemented with documentation of identification, investigation, reporting, prevention and controlling of infections.

b) A process was in place to ensure patients admitted with known infections were placed on the appropriate infection control precautions and/or isolation.

c) Infection control and prevention data was incorporated into the facility Continuous Quality Improvement and Performance Improvement (CQI/PI) program.

d) An annual Risk Assessment was performed.

Findings include:

Infection Prevention and Control Program
Reference #1001
Effective: 01/01/2015
Revised: 02/17/2015

Policy:

(Facility Name) Infection Prevention and Control Program shall ensure that this organization develops, implements and maintains an active, organization program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers...

(Facility Name) Infection Prevention and Control Program shall be integrated into the hospital-wide CQI/PI program...

The Infection Preventionist(s) and the Infection Prevention and Control Committee shall be responsible for identifying, investigating, reporting, preventing and controlling infections and communicable diseases through the following activities...

Mitigation of risks associated with patient infections present upon admission:

Development of systems for early detection and management (i.e., use of appropriate infection prevention and control measures, including isolation precautions, PPE [personal protective equipment]) of potentially infectious persons at initial points of patient encounter...

Measures specific to prevention of infections caused by organisms that are antibiotic-resistant...

...shall incorporate and document the following on an ongoing basis...
Surveillance...conducted to determine rate of infections so that trends can by identified and investigated, and appropriate prevention strategies can be initiated...
and shall include infection detection, data collection and analysis, monitoring and evaluation of preventive interventions...

Performance measures will be identified based on the infection risk assessment and shall be approved by the Infection Prevention and Control Committee.

Performance measures with related performance outcomes shall be reported to the Infection Prevention and Control Committee...Performance Improvement Committee and the Medical Executive Committee...

An interview was conducted with the Infection Control Coordinator on 3/23/16 at 1:00 PM to review the facility's infection control program.

There was no documented evidence:

a) The facility followed its own policy for maintaining an active, organization-wide program for the prevention, control and investigation of infections.

b) Data regarding the facility infection rate was completed or reported to the Infection Prevention and Control Committee.

c) Infections were tracked to ensure appropriate infection control measure and/or isolation precautions were implemented.

d) Tracking and trending data regarding infections including Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, Clostridium difficile and pneumonia's was completed and reported to the Infection Prevention and Control Committee.

e) Performance measures with related performance outcomes were reported to the Infection Prevention and Control Committee.

f) An annual risk assessment was completed.

g) The Infection Control program data was reported to the CQI/PI committee.

In an interview on 3/24/16 at 4:00 PM, EI # 1, Director of Nurses, EI # 2, Director of Pharmacy/Infection Preventionist, EI # 3, Director of Case Management confirmed the above findings.

Based on review of facility OR (operating room) control and temperature and humidity logs and interview with staff, the facility failed to ensure temperature and humidity levels in the OR suites were maintained within facility range. This had the potential to affect all patients treated in the OR's.

Findings include:

Facility "OR Temperature and Humidity Log"

"Relative Humidity-range of greater than or equal to 20-less than or equal to 60 percent in all anesthetizing locations
AORN (American Operative Registered Nurses) recommended temperature range between 68 degrees Fahrenheit and 73 degrees Fahrenheit"

During a tour of the surgical suites on 3/22/16 between 2:00 PM and 3:15 PM, a review of the OR Temperature and Humidity Log documentation was observed and revealed the following:

OR # 2-December 2015- 12/28/15; Humidity 66%. here was an asterisk and note that revealed "adjusted heat".

The 12/28/16 relative humidity was greater than the facility's acceptable range at 66 %. There was no documentation staff monitored the relative humidity following the "heat adjustment".

OR # 1-March 3, 2016-Humidity; 12%-"maintenance notified". There was no documentation of maintenance's response and/or actions taken and results.

March 2016- 3/22/16 Temperature 74.8 degrees Fahrenheit; Humidity 10%. "maintenance called". There was no documentation maintenance responded and/or actions taken or results.

The March 2016 above temperature and relative humidity levels were outside acceptable facility range. There was no documentation staff monitored the temperature and humidity after levels outside acceptable ranges were identified.

In an interview on 3/24/16 at 9:24 AM, EI # 7, Maintenance Director confirmed there was no documentation staff re-evaluated the OR suites for temperature and humidity levels on the above dates.