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Based on observation and staff interview, it was determined the hospital failed to ensure patient medical records were stored to protect from potential water damage. The hospital census was 127.

Findings include:

Observations were made in the Medical Records Department on 02/03/10 between 11:20 AM and 12:15 PM with Medical Record Staff Z and AA. Observations revealed four large, metal racks of patient medical records (in paper form) stored directly under three sprinkler heads. The metal racks were open in the front. There was no protective cover or other means in place to protect the paper copy patient medical records from water damage/destruction in the event of activation of the sprinkler system.

Interview with Staff Z and AA confirmed on 02/03/10 at 12:15 PM that two years of patient medical records were kept in the Medical Record Department. Staff Z and AA further stated at this time there was no backup (scanned/Xeroxed, etc) copies of the patient records.

Based on observation and staff interview, it was determined the hospital failed to ensure the medication refrigerator (containing prescription medications) was locked and secured on the second floor Intensive Care Unit. The patient census on the second floor intensive care unit was 15.

Findings include:

On 02/01/10 between 1:20 PM and 3:00 PM observations were made with Staff B on the second floor Intensive Care Unit (ICU). A medication refrigerator was seen in the supply room beside the medication area. The medication refrigerator had a locking mechanism. The medication refrigerator was seen to be unlocked and accessible to any staff entering the room. Prescription medications consisting of Dilantin (seizures), Diflucan (antifungal), and Vancomycin (antibiotic) were stored in the unlocked medication refrigerator. On 02/01/10 at 2:00 PM Staff B verified the medication refrigerator was unlocked and contained prescription medications. Staff B further confirmed at this time the medication refrigerator should be locked at all times. Staff B also stated at this time this supply room was not locked and was accessible to all staff.

Based on observation and staff interview, the hospital failed to ensure unusable medications (medications of other patients and non labelled medications) were not available for patient use on the second floor Intensive Care Unit (ICU). The patient census on the ICU was 15.

Findings include:

Observations were made on the second floor Intensive Care Unit (ICU) on 02/02/10 at 8:45 AM. In patient room 267 at 8:45 AM observations revealed medications were stored in an unlocked cabinet in the patient room. Neosynephrine (nasal spray) labeled with the name of the patient who occupied this room on the previous day was stored in this drawer. In addition, Magic mouth wash and a topical antibiotic ointment labeled with the name of another patient were also stored in this drawer. A bottle of Novolog 70/30 insulin that was not labeled or dated when opened was also seen stored in this drawer. Further observations revealed a Nitropatch packet in the drawer. None of these medications were for Patient #33 who currently resided in this room.

Interview with Staff A on 02/02/10 at 8:45 AM revealed medications from previous patients are to be removed from the room upon discharge. Staff A verified these medications should have been removed. Staff A further verified these medications should not be used for any other patient.

Based on observations and staff interviews, the hospital failed to ensure that the life safety from fire requirements were met related to two hour fire separation between the main building of the Physicians office center not being maintained, corridors not separated from use areas by walls constructed with at least a one half hour fire resistance rating in one waiting area, and the electrical fixture in the medical gas storage. The total facility census was 127 patients.

Findings include;

Building 1 of 3

The facility failed to maintain at least a two hour fire separation between the main hospital building and the Physicians Office Center. See K14.

The facility failed to ensure that corridors were separated from use areas by walls constructed with at least a one-half hour fire resistance rating in one waiting area in nuclear medicine. See K17.

The facility failed to ensure that the electrical fixture in the medical gas storage area was located at least five feet above the floor. See K76.

Buildings 2 and 3 - no deficiencies

Based on observations and staff interviews, the hospital failed to ensure that the life safety from fire requirements were met related to two hour fire separation between the main building in the Physicians office center not being maintained, corridors not separated from use areas by walls constructed with at least a one half hour fire resistance rating in one waiting area, and the electrical fixture in the medical gas storage. The total facility census was 127 patients.

Findings include;

Building 1 of 3

The facility failed to maintain at least a two hour fire separation between the main hospital building and the Physicians Office Center. See K14.

The facility failed to ensure that corridors were separated from use areas by walls constructed with at least a one-half hour fire resistance rating in one waiting area in nuclear medicine. See K17.

The facility failed to ensure that the electrical fixture in the medical gas storage area was located at least five feet above the floor. See K76.

Buildings 2 and 3 - no deficiencies

Based on medical record review, direct observation and staff interview, the hospital failed to ensure infection control policies were followed in regards to following established precautions to prevent to spread of infectious disease for Patient #8, #33 and #35. The hospital further failed to ensure staff followed established infection control policies in regards to the use/care of patient equipment for Patient #33. The total hospital census was 127 patients.

Findings include;

On 02/02/10 at 8:15 AM observations were made of a medication administration to Patient #33. Patient #33 resided in the Intensive Care Unit (ICU/Room 267). Staff A was seen to prepare an antibiotic intravenous medication and place the 100 milliliter bag of normal saline solution containing the antibiotic medication additive on the shelf of the computer in the patient's room. The bag of solution (containing the antibiotic additive) was seen to have leaked a large puddle of solution onto the computer shelf. Staff A stated they had not gotten the connection between the antibiotic additive and the port to the saline solution tight. Staff A proceeded to wipe up the solution spill from the computer shelf surface. Staff A then picked up the saline solution bag (with the antibiotic additive) and proceeded to leave the patient's room. Staff A was seen to drop the saline solution bag (with additive) onto the floor in the corridor outside the patient's room. Staff A then picked the intravenous solution bag from the floor and went to the medication preparation room. At approximately 8:45 AM Staff A picked up the same bag of intravenous saline solution, with the antibiotic additive, (that had not sealed tightly and leaked onto a surface and had been dropped onto the floor) and started to return to Patient #33's room. At this time the surveyor asked Staff A if they were going to administer this normal saline solution with the antibiotic additive to Patient #33. Staff A stated yes. The surveyor then asked Staff A if they would not consider the antibiotic solution to be contaminated since it had leaked onto a surface (without a tight seal) and had been dropped onto the floor. Staff A stated "Yes, you're right, I just did not think about it." After the surveyor intervened, Staff A proceeded to discard the contaminated intravenous solution and mix the medication.

Further observations on 02/02/10 between 8:15 AM and 8:55 AM revealed Patient #33 was wearing a BiPAP mask (respiratory assistive breathing device that delivers a flow of air under pressure). Staff A was seen to remove the patient's BiPAP mask to administer oral medications. Observations revealed the BiPAP tubing disconnected from the mask and fell to the floor. The BiPAP tubing was picked up from the floor surface by Staff A and was reconnected to the patient's BiPAP mask. Staff A did not clean or sanitize the BiPAP tubing (that had been in direct floor contact) before reattaching it to the BiPAP mask.

On 02/03/10 at 8:40 AM, Staff R was observed entering Patient #35's room to answer the call light. Patient #35 was observed seated on the side of the bed, eating breakfast from a tray on an over bed table. In response to the call light, Staff R was observed entering the room to answer the light. Staff R was observed carrying an unopened box of gloves under his/her left arm and an open full box of gloves against his/her body, holding it with the left forearm. Staff R was observed carrying these gloves into the room. Staff R was then observed removing items from the patient's tray, and throwing them into an open trash can in the room. The employee then proceeded to leave the room without washing his/her hands. A sign observed on the patient's room door identified Patient #35 as under contact precautions. After exiting the room, the surveyor stopped Staff R (in the presence of Staff D) and questioned what action the employee should take since entering the room and handling items without using personal protective equipment as indicated on the contact precaution sign on the door. Staff R stated he/she was not aware of the patient being in contact precaution isolation. Staff R stated he/she did not know what he/she should do, and then questioned Staff D. Staff D informed Staff R to re-enter Patient #35's room, leave the two containers of gloves, and then wash his/her hands. Staff R was then observed following Staff D's instructions.

A review was conducted of the Contact Precautions procedures on 01/03/10 at 8:45 AM. This procedure stated the following:
Gloves- Wear gloves when entering room. Change gloves after contact with infective material. Remove gloves before leaving patient's room and practice strict hand hygiene.
Wash hands- Use alcohol hand rub immediately after glove removal. Wash hands with soap and water if visibly soiled or contaminated with body fluid.
Gown- Wear if you provide any patient care or have contact with the patient's environment. Remove gown before leaving the patient's environment.

Staff D verified at that time Staff R did not follow the contact precaution protocol when providing care for Patient #35.

Medical record review conducted for Patient #35 on 02/03/10 revealed the patient was admitted on 01/30/10 with a diagnosis of diabetic foot infection. A wound culture collected on 01/31/10 of the patient's feet revealed the patient does have an infectious bacterial organism of both feet, and was placed in contact precaution isolation due to this organism.



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An observational tour was made of the 4 West unit of the hospital on 02/01/10 at 2:00 PM, with Staff D (Registered Nurse Manager) and Staff E (Registered Nurse Clinical Manager). Staff D verified with the surveyor the patients on the unit with isolation precautions.
Patient #8 was identified in isolation precautions with C Diff (Clostridium Difficile). The isolation prevention sign was posted on the entry door to the patient's room. This sign indicated donning of gloves and gown prior to entry. A visitor, the patient's husband, was in the room with the patient and was not wearing a gown or gloves. There was no intervention by Staff D and Staff E to inform the patient's visitor of the need to wear the protective equipment.
Patient #7 was identified in isolation precautions with VRE (Vancomycin Resistant Enterococci). The isolation prevention sign was posted on the entry door to the patient's room. The sign indicated donning of gloves and gown prior to entry. A staff member was observed in the patient's room wearing a white laboratory coat and no gown or gloves.

A tour of the Dialysis Unit was made with Staff D (Registered Nurse Manager) on 02/02/10 at 10:00 AM. There were 3 plastic jugs labeled as bicarbonate that were not dated when opened. The jars were stored upright on the dialysis machines. The jugs contained visible white creamy fluid in the bottom.
The staff was unable to verify when the jugs were opened or cleaned after use. Interview with Staff Y (Regional Dialysis Manager) on 02/02/10 at 2:15 PM revealed the bicarbonate jugs when opened are to be used within 24 hours of opening. In addition, the jars are to be rinsed with bleach water and stored inverted.


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