HospitalInspections.org

Based on observations as referenced in the Life Safety report of survey completed May 23, 2019, the hospital failed to have an effective governing body ensuring a safe environment for patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~ cross refer 482.41 Physical Environment - Condition Tag A0700

Based on policy and procedure review, observations during tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure that potentially hazardous foods were served and maintained at safe temperatures and stored in a safe and sanitary manner.

The findings include:

1. Review of the Food and Nutrition Services "Daily Documentation and Verification" policy revised October 2015 revealed "Purpose: To define responsibilities for the completion and monitoring of documents related to daily functions within the food service area. Policy: The following document has been developed for tracking and monitoring information important to the operation of the department. The positions responsible for completion of the documents are listed as well as the position responsible for monitoring completion. Monthly and Quarterly summaries are completed by the Manager and Coordinator." Review of the referenced document revealed "3. Temperature and Taste Control of Patients Food" with a "frequency of completion" listed as three times a day. Review revealed the person responsible for completion as the Supervisor of patient food services with the Manager listed as responsible for monitoring. Review of an attached "Trayline Temperature Log" revealed a place to record the date and blank areas for Breakfast, Lunch and Supper that included the food item and temperature. The form included information regarding "Temperature Standards ... Hot holding food temperature should be at least 140 degrees."

Observation during tour of the dietary department on 05/22/2019 at 1125 revealed a staff member placing hot foods onto plates from a hot food line for delivery to patients. Observation revealed the tray line included stew beef, spaghetti sauce, chicken and green beans. Interview with the staff member during the tour reveled she did not have any documentation of the hot food temperatures that were checked prior to serving the food. The staff member stated she had not kept a log of food temperatures for several months now and that she had made her supervisor aware that she didn't have a place to log food temperatures.

Telephone interview on 05/22/2019 at 1245 with the Production Chef supervisor reveled every cook has a thermometer and stated "All hot foods are temped when put on the line, but no log was kept. I don't know how long it has not been done. I was not aware that it was not being done." Interview revealed a log of food temperatures should be recorded that included food temperatures for breakfast, lunch and supper.

Interview on 05/22/2019 at 1200 with the Dietary Department Director revealed the food temperature logs should be done with each meal preparation and he was not aware they were not being done. The Director stated "It is my responsibility to see that the food temp logs were done and monitored."

2. Review of a Food and Nutrition Services "Housekeeping and Sanitation" policy revised November 2015 revealed "... K) Automatic ice maker/dispensers are provided in the cafeteria. Gloves and ice scoops are used on cafeteria and patient serving lines. Further review of the policy revealed no mention of where to store the ice scoop.

Observation during tour of the dietary department on 05/22/2019 at 1030 revealed an automatic ice machine with the lid closed. Observation revealed a staff member preparing glasses of ice for patient trays. Observation of the side of the ice machine revealed an empty holder for the ice scoop. Observation revealed the ice scoop was located laying inside the ice machine on top of the ice with the handle touching the ice.

Interview during tour on 05/22/2019 at 1030 with the Dietary Department Director reveled the ice scoop should be stored in the holder on the side of the automatic ice dispenser. Interview confirmed the finding. Interview revealed the dietary staff failed to follow hospital policy and procedure.

3. Review of a Food and Nutrition Services "Food Storage" policy revised July 2016 revealed "1) DRY STORAGE
... Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit. Post a sign so that items will not be used. ..."

Observation during tour in the dry storage area of the dietary department on 05/22/2019 at 1020 revealed
two dented (damaged) cans of peaches stored on the same shelf as undamaged canned food items.

Interview during tour on 05/22/2019 at 1020 with the Dietary Department Director reveled dented cans are not supposed to be stored on the same shelves as undamaged canned foods. Interview revealed damaged cans are separated, removed and stored on the "dented can shelf" and are to be returned to the supplier for credit. Interview revealed the dietary staff failed to follow hospital policy and procedure.

4. Review of a Food and Nutrition Services "Food Storage" policy revised July 2016 revealed "... FROZEN STORAGE ... Store frozen items in their original packaging with original labels if possible; bags of product should be resealed with the twist tie or put into a zip-lock type storage bag. Items can be stored in NSF (National Sanitation Foundation) approved containers that have tight fitting lids. Label both the bin and the lid if used. ..."

Observation during tour in the walk in freezer area of the dietary department on 05/22/2019 at 1040 revealed a box of frozen cauliflower that was opened to air with half of the contents remaining in the opened container. Observation revealed no label or date opened was recorded on the box.

Interview during tour on 05/22/2019 at 1040 with the Dietary Department Director reveled the item should have been discarded and should not have been placed back in the freezer without a label and date when opened. The staff member stated the vegetable should have been closed and not left open to air exposure.

Based on observations as referenced in the Life Safety report of survey completed May 23, 2019, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702.

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0709.

Based on observations as referenced in the Life Safety Report of Survey completed May 23, 2019 the hospital staff failed to assure the safety of patients, staff, and visitors by failing to ensure the essential electrical system was maintained to provide emergency power and lighting to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 0408: Hospice

1. The facility inspection of the generator annunciator was non-compliant the specific items include:

The remote generator annunciator is located at the nurse's station and its indicators shall be readily observed by operating personnel at a regular work station. The safety indications and shutdowns do not give all the indicators required, including low fuel main tank (h), and battery charger ac failure (n).

Ref: 2012 NFPA 101 Sections 19.2.9.1; 7.9.2.4
2012 NFPA 99 Sections 6.4.1.1.17

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0916

Building 0808: Red Brick Building - Four Story Acute Care Bed Tower Attached to Main Bldg 1

The facility inspection of emergency lighting was non-compliant the specific items include:

The facility does not have emergency lighting in exit egress stairwell leading from the old OR department on the second floor of the building.

Ref: 2012 NFPA 101 Sections 19.2.9.1; 7.9.1.1

This deficiency affected one required egress in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0916

Based on observations as referenced in the Life Safety Report of Survey completed May 23, 2019, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association ensuring that the life safety from fire requirements are met.

The findings include:

Building 0108: DNT Building

1. The facility inspection of exit directional signage was non-compliant the specific items include:
The facility does not have complete exit directional signage from the second floor Cath lab leading from the staff exit to the egress corridor.

Ref: 2012 NFPA 101 Sections 19.2.10.1; 7.10.1; 7.10.2; 7.10.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

2. The facility did not have proper protection of rooms containing storage was non-compliant the specific items include:

The I.T. storage room 1005.1 is greater than 50 square feet and is located on the main corridor of the first floor does not have a door closing device installed. . Combustible Storage Rooms/Spaces
(over 50 square feet)

Ref: 2012 NFPA 101 Section 19.3.2.1; 8.7.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

3. The facility inspection and testing of supervisory signals to the fire alarm control panel was non-compliant the specific items include:

The facility supervised tamper valve was tested in the south stairwell, during this test the supervisory alert was audible and visual at the fire alarm control panel. The audible signal was silenced and did not return as required.

The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2012 NFPA 72 Section 14.1.1; 10.11.5.5

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0352

4. The facility inspection of smoke barrier wall areas separating suites was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier wall at the first floor imaging suite above the ceiling near room D1110.

Ref: 2012 NFPA 101 Sections 19.3.7.1; 8.5.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

Building 0208: East Building

The facility inspection of special locking system was non-compliant the specific items include:

1. The special locking system at the second and first floors secured units did not have an additional emergency release switch at a regularly manned station serving the locked unit.

Ref: 2012 NFPA 101 Sections 19.3.4.; 9.6.1.5; 7.2.1.6

a. The facility number 2 seclusion electromagnet was not able to be unlocked with the key override switch attached to the door when tested.

NOTE: The door electromagnet did release with activation of the fire alarm system utilizing smoke detection.

Ref: 2012 NFPA 101 Sections 19.2.2.2.5.2.; 19.2.2.2.6

b. The special locking system at the first floor did not release with activation of the fire alarm system utilizing smoke detection. The door (special locking) did release with Override switch and loss of normal power NOTE: The magnet was disassembled and deenergized at that time.

Ref: 2012 NFPA 101 Sections 19.3.4.; 9.6.1.5; 7.2.1.6 (c)

This deficiencies affected three smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0222

2. The facility inspection of exit directional signage was non-compliant the specific items include:

a. The exit directional signage near room 3502 did not have all the letter in the word "EXIT" as required.

b. The exit directional sign at the connector was not obvious as directional chevrons showing exiting from the space different from what is available to staff and patients.

Ref: 2012 NFPA 101 Sections 19.2.10.1; 7.10.1; 7.10.2; 7.10.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

3. The facility inspection of sprinkler coverage was non-compliant the specific items include:

The facility is utilizing speical locking systesms and is requried to be fully protected by an automatic sprinkler system and/or smoke detection system.

The third floor stairwell "West" is not protected by automatic sprinkler covverage or smoke detection as requried.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.1; 9.7.5

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0351

4. The facility inspection of smoke barrier wall areas separating suites was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

a. first floor above the ceiling near room E12303
b. second floor above the ceiling near room E2216.

Ref: 2012 NFPA 101 Sections 19.3.7.1; 8.5.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

5. The facility inspection and maintenance of receptacles near water sources in the facility was non-compliant the specific items include:

The facility ground-fault circuit interrupters installed within six feet the medical sink area on the third floor did not work properly when tested.

Ref: 2012 NFPA 101 Sections 19.5.1
NFPA 99 Section 6.3.2.2.8.1

This deficiency affected one smoke compartment in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0913

Building 0308: Bed Tower

1. The facility inspection of floor separation was non-compliant the specific items include:

The facility has unsealed penetrations in the rated floor/ceiling assembly in the sixth floor I.T. closet. These penetrate the rated assembly with PVC piping. The facility was not able to provide a listing for the required fire stop involving the PVC piping penetrating the floor/ ceiling assembly.

Ref: 2012 NFPA 101 Sections 19.1.6.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0161

2. The facility inspection of exit egress paths was non-compliant the specific items include:

a. The South Stairwell "B" required exit has a light fixture protruding greater than 4 inches into the egress path less than six feet eight inches above the finished floor.

b. The facility has housekeeping room doors that protrude greater than 4 inches into the egress corridor when opened at fully at 180 degrees and do not have door closing devices installed to keep the doors in the closed position after being opened at the following locations.

(a) 748
(b) 648
(c) 548
(d) 448

Ref: 2012 NFPA 101 Sections 19.2.1; 7.1.10.1; 7.1.5
Ref: 2012 NFPA 101 Sections 19.2.1; 7.1.10.1

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211

3. The facility inspection and maintenance of suite separation was non-compliant the specific items include:

The corridor door BS645597 at on the third-floor elevator lobby did not latch properly when tested.

Ref: NFPA 101 Sections 19.2.5.7.1.2 (1); 19.3.6.3.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0255

4. The facility inspection of vertical shafts was non-compliant the specific items include:

The facility has a vertical laundry chute on fourth-floor South in room 445 with one hour fire door that did not close and latch properly when tested.

Ref: 2012 NFPA 101 Sections 19.3.1.1

Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6

This deficiency affected one smoke compartment in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0311

5. The facility inspection of sprinkler heads was non-compliant the specific items include:

The facility has debris on quick response sprinkler head on the second-floor South mechanical room behind the pharmacy near the exhaust fan. Sprinklers shall have no signs of leakage, shall be free of corrosion, foreign materials paint, dust and physical damages and shall be installed in the correct orientation.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.5; 9.7.1.1*
2011 NFPA 25 Section 5.2.1.1; 5.2.1.1.2,

This deficiency affected one smoke compartment in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0353

6. The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

a. First floor above the ceiling in the egress corridor near room T109

b. Second floor above the ceiling in the egress corridor at the EVS room T222

c. Third floor above the ceiling in the egress corridor at the elevator lobby East wall

d. Sixth floor above the ceiling in the egress corridor at the back side of the South wall near room 645 on the corridor side of the wall.

Ref: 2012 NFPA 101 Sections 19.3.7.1; 8.5.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

7. The facility inspection of HVAC ductwork penetrating rated barrier walls was non-compliant the specific items include:

The facility has a flex ductwork grater than six inches in diamater in the elevator lobby on the seventh-floor near elevator number five that is not equipped with a fire damper as required.

Ref: 2012 NFPA 101 Sections 19.5.2.1; 9.2.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0521

Building 0408: Hospice

1. The facility inspection of the oxygen storage in the facility was non-compliant the specific items include:

a. The facility has "E" type oxygen cylinders in storage that are not 5 feet away from combustible materials in that space as required.

b. The facility oxygen storage did not have proper signage that denotes the separation full from empty oxygen cylinders as required.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section, 11.3.2.3 (1) 11.6.5.2

This deficiency affected the only oxygen storage room in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

Building 0508: Wound Care Building

1. The facility has debris on quick response sprinkler head in the egress corridor across from the full oxygen storage room. Sprinklers shall have no signs of leakage, shall be free of corrosion, foreign materials paint, dust and physical damages and shall be installed in the correct orientation.

2. The facility has combustible items stored closer than 18 inches to the quick response sprinkler heads in the attic space.

3. The facility light fixture in the attic space is too close to the quick response sprinkler head.

Ref: 2012 NFPA 101 Sections 21.3.5.1; 9.7.5; 9.7.1.1*
2011 NFPA 25 Section 5.2.1.1; 5.2.1.1.2,
2011 NFPA 25 Section 8.6.5.2.1.1
2011 NFPA 25 Section 8.5.5.2.1

This deficiency affected two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0353

Building 0808: Red Brick Building - Four Story Acute Care Bed Tower Attached to Main Bldg 1

1. The following rooms are equipped with thumb latch devices along with other latching hardware resulting in more than one motion of the hand to exit the room with both devices engaged on the doors at the following locations:

a. third floor room B305
b. first floor dining room leading from the small dining room to the egress corridor near the tray return area.

Releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified. Doors shall be arraigned to be opened readily from the egress side whenever the building is occupied.

Ref: 2012 NFPA 101 Sections 19.2.1; 7.2.1.5.1; 7.2.1.5.10.3; 7.2.1.5.10.6.

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0211

2. The facility inspection of special locking system was non-compliant the specific items include:

The special locking system at the third floor behavioral health unit did not have an additional emergency release switch at a regularly manned station serving the locked unit.

Ref: 2012 NFPA 101 Sections 19.3.4.; 9.6.1.5; 7.2.1.6

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0222

3. The facility inspection and maintenance of suite separation was non-compliant the specific items include:

The corridor doors at C378 that open from the Suite onto the required exit egress corridor did not latch properly when tested.

Ref: NFPA 101 Sections 19.2.5.7.1.2 (1); 19.3.6.3.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0255

4. The facility inspection of exit directional signage was non-compliant the specific items include:

The exit directional signage leading from the small dining room to the main egress corridor on the first floor near the tray disposal area was not illuminated during the survey.

Ref: 2012 NFPA 101 Sections 19.2.10.1; 7.10.1; 7.10.2; 7.10.5

This deficiency affected one smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0293

5. The facility did not have proper protection of hazardous room was non-compliant the specific items include:

a. The first floor mechanical/ electrical room in the dietary department on the first floor is not covered by automatic sprinklers. The room is protected by two-hour construction. The door separating the rated protected room has louvers installed. This door rating cannot be maintained with louvers installed.

b. The facility dry storage room in the dietary department was wedged open. Doors with door closing devices installed shall have no impediment to the door closing.

This deficiency affected one smoke compartment in the facility.

Ref: 2000 NFPA 101 Section 19.3.2.1;19.3.2.1.5 (7); 8.7.1.3
Ref: 2000 NFPA 101 Section 19.3.6.3.5 (1)

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0321

6. The facility inspection of smoke barrier wall areas separating suites was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

a. Second floor above the ceiling in the egress corridor near room B260.

b. Third floor above the ceiling in the egress corridor near room A308A

Ref: 2012 NFPA 101 Sections 19.3.7.1; 8.5.1

This deficiency affected two smoke compartments in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0372

7. The facility inspection of the oxygen storage in the facility was non-compliant the specific items include:

The facility has "H" type oxygen cylinders that unsupported in the old OR unit number 2 on the second floor of the building.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section, 11.6.2.3 (11)

This deficiency affected the one oxygen storage room in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0923

Based on policy and procedure review, manufacturer guidelines, facility logs, observation and staff interview, the facility staff failed to demonstrate proper infection control practice in the maintenance and strength testing of the solution (Acecide- C) used for high level disinfection in 1 of 1 OLYMPUS endoscope reprocessor.

The findings include:

1. Review of the policy "Endoscope Cleaning Protocol" last revised 11/18 does not address maintenance and testing of the Acecide-C Solution used for high level disinfection.

Review of Acecide-C Solution instructions for use revealed, " ....This solution may be used and reused for up to 5 days..."

Review of Acecide-C Testing Record revealed "Date of change of Acecide-C" documented on 4/27/19, 5/2/19, 5/9/19 and 5/16/19 ( 7 days between solution changes).

Interview during tour on 5/22/2019 at 1030 revealed Sterile Processing Tech #1 (SPT #1) stated the Acecide-C solution is changed every 7 days. Interview revealed she was told 7 days during her training and orientation process.

Interview with the Operating Room Manager on 05/23/19 at 1515 revealed new staff receive training on the use and maintenance of the endoscope reprocessor upon hire and must successfully complete demonstrated competency.

2. Review of Acecide-C Solution test strips instructions for use revealed, "Directions for Use: 1. Take 1 test strip from the canister and immediately replace the cap...2. Dip the entire reaction zone of the ACECIDE Test Strip in ACECIDE-C Use - Solution for 3 seconds then retrieve the test strip. 3. Remove excess solution: Blot excess...remove excess solution within 3 seconds. 4. Evaluate: Evaluate the reaction zone 7 seconds after removing excess solution..."

Observation on 05/22/2019 at 1030 of strength testing revealed SPT #1 removing ACECIDE- C solution from the reprocessor and placing in a clear 1 ounce cup. SPT #1 then placed the test strip in the cup and let it remain submerged for approximately 30 seconds. Demonstration revealed the evaluation of the test strip was completed while submerged in the solution.

Interview during tour on 5/22/2019 at 1030 revealed Sterile Processing Tech #1 (SPT #1) stated the Acecide-C testing strip was to be evaluated after 30 seconds while the test strip remains in the solution. Interview revealed this technique was how she was trained during her orientation process.

Interview with the Operating Room Manager on 05/23/19 at 1515 revealed new staff receive training on the use and maintenance of the endoscope reprocessor upon hire and must successfully complete demonstrated competency.

Based on Medical Staff Rules and Regulations review, medical record review and staff interview, the hospital failed to ensure an updated history and physical was completed within 24 hours after admission and prior to surgery for 2 of 7 sampled surgical patients (#23 and #6).

The findings include:

Review of the Medical Staff Bylaws and Rules updated 11/26/2018 revealed,".... b. A Preoperative History and Physical Examination of Updated History and Physical Examination must be entered in the medical record prior to the surgery or procedure. An updated patient examination must be documented on the chart within 24 hours of surgery..."

1. Open medical record review for Patient #23 revealed a 68 year-old male admitted on 05/20/2019 for an "ultrasound-guided left common femoral artery; abdominal aortogram with bilateral runoff; and selective right leg angiogram with arterectomy/angioplasty right posterior tibial artery/popliteal artery with 3 mm (millimeter) x (by) 100 mm ultraverse balloon and 4 mm x 100 mm drug-eluting balloon" (surgical procedure to improve blood flow). Record review revealed the surgery started at 0808 and ended at 1005. Record review revealed physician's documentation of a history and physical examination that was documented on 05/13/2019 (7 days before the patient's admission and surgery). Record review revealed no documentation of an updated history and physical within 24 hours after admission and prior to surgery.

Interview on 05/23/2019 at 1510 with a surgical administrative staff member revealed an updated history and physical must be completed within 24 hours of admission and prior to surgery. Interview confirmed there was no documented evidence of an updated history and physical within 24 hours of admission and prior to the patient's surgery.




35304

2. Closed medical record review for Patient #6 revealed a 61 year old male admitted on 03/15/2019 for a "cyctoscopy". Record review revealed the procedure was performed on 03/19/2019. Record review revealed physician's documentation of a history and physical examination that was performed on 03/15/2019 (4 days prior to the patient's procedure). Record review revealed no documentation of an updated history and physical with in 24 hours prior to the patient's surgery.

Interview on 05/23/2019 at 1510 with a surgical administrative staff member revealed an updated history and physical must be completed within 24 hours of admission and prior to surgery. Interview confirmed there was no documented evidence of an updated history and physical within 24 hours of admission and prior to the patient's surgery.