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Based on interview with the Director of Plant Operation and tour of the CAH on November 4-5, 2014, it was determined that the CAH is not constructed, arranged and maintained to ensure access to and safety of patients, and provide adequate space for the provision of services.

The findings include:

1. The Laboratory Department had nine (9) soiled phlebotomy trays that are taken to patient areas throughout the hospital. In addition, there was no system for routine cleaning of the trays.

2. The kitchen entry area had soiled, ill-fitting ceiling tiles and walls that were gouged, with chipped paint.

3. The Laundry Room and Operating Room (OR) had door frames that were gouged, with chipped paint, not easily sanitized.

4. The doors on the Medical Surgical Unit were gouged with worn varnish surfaces, not easily sanitized.

5. The OR had flooring that was separating from the wall, two scrub sinks with torn vinyl surfaces and rusted feet. In addition, the ceiling tiles in OR 1&2 were discolored, with what appeared to be rusted areas on the metal ceiling grids in OR 1.

6. The above findings were confirmed with the Director of Plant Operations on November 4 & 5, 2014.

Based on document review and interviews with key personnel on November 4-5, 2014, it was determined that the Chief Executive Officer failed to ensure that all facility policies were followed.

The findings Include:

1. The Employee Performance Evaluation policy states "...Periodic evaluations are to be completed within no later than 1 year of the last evaluation."

2. A review of twelve (12) personnel files was conducted. Two (2) employee files contained periodic evaluations that exceeded the required time frame (Employee File A&B).

3. Employee A was last evaluated during "September 2013".

4. Employee B was last evaluated during "May 2013".

5. These findings were confirmed with the Human Resources Manager on November 4, 2014, at 1400. She stated that she had requested that the managers complete the evaluations in a timely manner on "multiple occasions." Additionally, she reported that she had requested that the documents contain the actual date of the evaluation.

6. The Stephen Memorial Hospital "Code Cart, Checking and Restocking" policy specifies that "Once a day the integrity of the locked system, portable O2 tank and portable monitor/defibrillator are to be checked. This will be documented on the checklist located in each cart".

7. A tour was conducted on November 5, 2014 indicated that three (3) of six (6) crash carts failed to have daily documentation of code cart checks. Two code carts on the Medical Surgical Unit and one Code cart on the Endoscopy Unit failed to document the safety checks on the following dates:
A. Medical- Surgical Pediatric Code Cart: 10/2, 10/10, 10/28, 10/31, 9/22, 8/29, 7/17 & 7/2/2014.
B. Medical Surgical Adult Code Cart: 10/22, 10/11, 10/10, 9/28, 8/14, 8/15 & 7/2/2014.
C. Endoscopy Code Cart: 10/22, 10/15, 9/24, 8/11, 6/23, 6/24, 6/30 & 5/28/2014.

8. These findings were confirmed with the Director of Pharmacy on November 5, 2014 at approximately 1530.

Based on review of medical records and interviews with key personnel on November 4, 2014, it was determined that the facility failed to ensure that each medical record was complete and accurately documented.

Findings include:

The Stephens Memorial Hospital Patient Rights policy states, "8. Consent to Care and Treatment. To the degree possible, patients shall be provided by their physician with a clear explanation of their medical condition, the proposed technical procedures ...Those responsible for authorizing and performing procedures/treatments shall be made known to the patient."

1. On November 4, 2014, five (5) surgical records were reviewed with the Lead Surgical Services Registered Nurse. One (1) surgical record did not contain a properly executed informed consent


The Stephens Memorial Hospital Medical Record Department Informed Consent policy states, "A. Written, signed, informed, surgical and anesthesia consent must be obtained and documented in the medical record prior to the operative procedure ...A properly executed consent form contains at least the following: Date and time consent is obtained and signature of professional person witnessing the consent..".

2. RECORD D was missing the date and time that the consent was signed and the professional witness signature. This finding was confirmed at 1140, on November 4, 2014, by the Lead Surgical Services Registered Nurse.

The Stephens Memorial Hospital Medical Records Department Statement states, "Mission: To provide a complete, timely, accurate, and readily accessible unit record including in-patient, ambulatory surgery, observation and Emergency Services reports for each patient treated in the hospital and to protect the patient's rights to confidentiality at all times. Goals: Medical Records personnel are responsible for: Assuring the completion of each patient's medical record and for the filing and maintenance of that record."

The Stephens Memorial Hospital Emergency Services Triage policy states, "Procedure: 1. All patients presenting to Emergency Services will be triaged by: a. A Registered Nurse with documented training in triage. 2. Triage is performed utilizing the Emergency Services Index (ESI) five level triage algorithms that categorize emergency department patients by evaluating both patient acuity and resources."

3. On November 5, 2014, five (5) Emergency Services records were reviewed with the Nurse Director of Emergency Service. One (1) Emergency Services record did not contain documentation that a patient had been triaged. RECORD M was missing the documentation that triage had been performed. This finding was confirmed at 0925, on November 5, 2014, by the Nurse Director of Emergency Services.

Based on interview with the Director of Plant Operation and tour of the CAH on November 4-5, 2014, it was determined that the CAH is not constructed, arranged and maintained to ensure access to and safety of patients, and provide adequate space for the provision of services.

The findings include:

1. The Laboratory Department had nine (9) soiled phlebotomy trays that are taken to patient areas throughout the hospital. In addition, there was no system for routine cleaning of the trays.

2. The kitchen entry area had soiled, ill-fitting ceiling tiles and walls that were gouged, with chipped paint.

3. The Laundry Room and Operating Room (OR) had door frames that were gouged, with chipped paint, not easily sanitized.

4. The doors on the Medical Surgical Unit were gouged with worn varnish surfaces, not easily sanitized.

5. The OR had flooring that was separating from the wall, two scrub sinks with torn vinyl surfaces and rusted feet. In addition, the ceiling tiles in OR 1&2 were discolored, with what appeared to be rusted areas on the metal ceiling grids in OR 1.

6. The above findings were confirmed with the Director of Plant Operations on November 4 & 5, 2014.

Based on document review and interviews with key personnel on November 4-5, 2014, it was determined that the Chief Executive Officer failed to ensure that all facility policies were followed.

The findings Include:

1. The Employee Performance Evaluation policy states "...Periodic evaluations are to be completed within no later than 1 year of the last evaluation."

2. A review of twelve (12) personnel files was conducted. Two (2) employee files contained periodic evaluations that exceeded the required time frame (Employee File A&B).

3. Employee A was last evaluated during "September 2013".

4. Employee B was last evaluated during "May 2013".

5. These findings were confirmed with the Human Resources Manager on November 4, 2014, at 1400. She stated that she had requested that the managers complete the evaluations in a timely manner on "multiple occasions." Additionally, she reported that she had requested that the documents contain the actual date of the evaluation.

6. The Stephen Memorial Hospital "Code Cart, Checking and Restocking" policy specifies that "Once a day the integrity of the locked system, portable O2 tank and portable monitor/defibrillator are to be checked. This will be documented on the checklist located in each cart".

7. A tour was conducted on November 5, 2014 indicated that three (3) of six (6) crash carts failed to have daily documentation of code cart checks. Two code carts on the Medical Surgical Unit and one Code cart on the Endoscopy Unit failed to document the safety checks on the following dates:
A. Medical- Surgical Pediatric Code Cart: 10/2, 10/10, 10/28, 10/31, 9/22, 8/29, 7/17 & 7/2/2014.
B. Medical Surgical Adult Code Cart: 10/22, 10/11, 10/10, 9/28, 8/14, 8/15 & 7/2/2014.
C. Endoscopy Code Cart: 10/22, 10/15, 9/24, 8/11, 6/23, 6/24, 6/30 & 5/28/2014.

8. These findings were confirmed with the Director of Pharmacy on November 5, 2014 at approximately 1530.

Based on review of medical records and interviews with key personnel on November 4, 2014, it was determined that the facility failed to ensure that each medical record was complete and accurately documented.

Findings include:

The Stephens Memorial Hospital Patient Rights policy states, "8. Consent to Care and Treatment. To the degree possible, patients shall be provided by their physician with a clear explanation of their medical condition, the proposed technical procedures ...Those responsible for authorizing and performing procedures/treatments shall be made known to the patient."

1. On November 4, 2014, five (5) surgical records were reviewed with the Lead Surgical Services Registered Nurse. One (1) surgical record did not contain a properly executed informed consent


The Stephens Memorial Hospital Medical Record Department Informed Consent policy states, "A. Written, signed, informed, surgical and anesthesia consent must be obtained and documented in the medical record prior to the operative procedure ...A properly executed consent form contains at least the following: Date and time consent is obtained and signature of professional person witnessing the consent..".

2. RECORD D was missing the date and time that the consent was signed and the professional witness signature. This finding was confirmed at 1140, on November 4, 2014, by the Lead Surgical Services Registered Nurse.

The Stephens Memorial Hospital Medical Records Department Statement states, "Mission: To provide a complete, timely, accurate, and readily accessible unit record including in-patient, ambulatory surgery, observation and Emergency Services reports for each patient treated in the hospital and to protect the patient's rights to confidentiality at all times. Goals: Medical Records personnel are responsible for: Assuring the completion of each patient's medical record and for the filing and maintenance of that record."

The Stephens Memorial Hospital Emergency Services Triage policy states, "Procedure: 1. All patients presenting to Emergency Services will be triaged by: a. A Registered Nurse with documented training in triage. 2. Triage is performed utilizing the Emergency Services Index (ESI) five level triage algorithms that categorize emergency department patients by evaluating both patient acuity and resources."

3. On November 5, 2014, five (5) Emergency Services records were reviewed with the Nurse Director of Emergency Service. One (1) Emergency Services record did not contain documentation that a patient had been triaged. RECORD M was missing the documentation that triage had been performed. This finding was confirmed at 0925, on November 5, 2014, by the Nurse Director of Emergency Services.