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Based on the facility medical record statistics, staff interviews, and policy review the facility failed to ensure medical records were completed within 30 days of discharge. This affected 1026 medical records reported in March 2014. The facility's average delinquency rate for the past 12 months was 21 percent with an average monthly rate of 5578 discharges.

Findings include:

On 04/21/14 from 1:30 PM to 2:15 PM the facility's medical record department was reviewed including interviews with the Health Information Director of Operations (Staff D) and the Health Information Supervisor (Staff C). Staff D provided the facility's medical record statistics for the past 12 months. Staff D explained the delinquent medical record count for March 2014 was 1026.

On 04/23/14 at 1:45 PM Staff C verified the medical record statistics including the facility's average monthly discharge rate of 5578, the medical record delinquency timeframe of 30 days, the delinquent medical record totals for March 2014 of 1026, and the first quarter 2014 delinquency rate of 18 per cent. On 04/23/14 at 2:10 PM the Director of Quality & Case Management (Staff A) stated the facility's ultimate goal was no delinquencies and the 2014 quality assurance/performance improvement goal was set at "ten percent and below".

On 04/24/14 the facility policy, Practitioner Suspension, dated 02/17/14 was reviewed. The policy documented a medical record not complete within 30 days of discharge was considered delinquent. In accordance with Medical Staff Governance Documents, practitioners would be notified and privileges suspended due to delinquent medical record. Reinstatement of privileges would then be based upon completion of all delinquent records.

Based on observations during tour, review of policies, and staff interview, the facility failed to ensure staff followed the current facility policy for the requirement of emergency medications to be stored in a locked cabinet and/or locked medication rooms or under continuous surveillance. The facility also failed to ensure staff segregated expired medications until they could be wasted or sent to pharmacy.

Findings include:

The facility's Maternity Unit was toured on 04/22/14 at 11:00 AM. A clear tackle box labeled with signage reading Emergency Medication was attached to the side of the Pyxis Anesthesia System in Cesarean Delivery Room #2. Although the tackle box had a break away tie visible inside the box, the tie was not secured on the box, leaving medications inside accessible to unauthorized staff, patients, and visitors. One vial of Succinycholine, one bottle of Propofol, and one vial of Atropine, all medications used during the induction and maintenance of general anesthesia, were contained in the tackle box. The bottle of Succinylcholine was also labeled with a sticker indicating the medication expired on 04/15/14. Although the break away tie was secured on the identical box in Cesarean Delivery Room #2, the bottle of Succinylcholine was labeled with a sticker indicating the medication expired on 04/15/14. Staff B was interviewed on 04/22/14 at 12:10 PM and asked if it was customary for the tackle box with emergency medications to be unsecured. Staff B reported that it was facility policy for all medication to be secured. The facility policy entitled Storage of Medications was reviewed on 04/22/14 at 01:30 PM. According to the policy, emergency medications must be stored in a locked cart or under continuous surveillance. The policy also indicated that all expired medication should be segregated until they can be wasted and/or sent to pharmacy for removal from the hospital. These facts were confirmed with Staff A on 04/22/14 at 02:45 PM.

Based on observation, record review and interview, the facility failed to maintain the ratings of its smoke and/or fire barriers, failed to have doors resist the passage of smoke into the corridor, failed to have fire drills under varying, random times, failed to sensitivity test smoke detectors, failed to ensure sleeping areas were free from space heaters, failed to ensure trash containers did not exceed 32 gallon capacity, failed to ensure medical gas shut off valves were readily accessible, failed to ensure proper suite sizes and failed to have emergency lighting tested in accordance with NFPA 101 7.9, 2000 edition. This has the potential to affect all patients, staff and visitors to the facility. The facility's census was 117 patients.

Findings include:

See A709.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients, staff, and visitors to the facility. The facility ' s census was 117 patients.

Findings include:

K18 Failed to have doors protect corridor openings from smoke
K25 Failed to maintain the ratings of its fire and/or smoke barriers
K29 Failed to have soiled utility room door on self closer
K30 Gift shop opened onto corridor
K46 Emergency lighting not tested in accordance with NFPA 101 7.9, 2000 edition
K50 Fire drills not held under varying conditions on the third shift
K52 90 second test signal not performed on alarm system
K54 Lacked documentation of smoke detector sensitivity
K70 Portable space heaters found in patient care smoke compartment
K75 Mobile soiled linen carts of greater than 32 gallons found stored in a corridor
K78 Paraphenalia stored in front of the medical gas shut off valves
K114 Rating of barrier between main hospital and ambulatory surgery center not maintained
K130 Emergency department suite size greater than 10,000 square feet
K154 Fire watch policy for sprinkler system with exceptions
K155 Fire watch policy for alarm system with exceptions.