HospitalInspections.org

Based on MR review, review of facility P&P, and 3 of 3 staff interviews (EE, SS, VV), the hospital failed to follow Medicare guidelines to provide discharge appeal information to its Medicare population in 3 of 4 MR reviewed (Pt.s #4, 7, 18). Failure to provide Medicare patients with information about their right to appeal their discharge affects all Medicare recipients receiving care in this facility.

Findings include:

CMS directs facilities to give information regarding the right to appeal discharge to Medicare recipients within 48 hours of admission and 48 hours of discharge. For short stay patients only one notice is required if it has been within 48 hours of receiving the first notice.

The facility's procedure, provided to Surveyor on 7/25/2012 at 11:12 a.m. by RN EE, is titled, "Important Message from Medicare regarding Hospital Discharge Appeal Rights." There is no effective/revision date on the procedure. The procedure reiterates CMS's expectations regarding when patients should receive the notice. The facility's Case Management department is responsible for ensuring patients receive the follow-up notice prior to discharge and, per the procedure, "The 'Additional Information' section of the IM [Important Message] will be used to document the delivery. Patient or representative to sign and date this section."

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. # 4 was admitted on 2/6/2012 and discharged on 2/10/2012. A Medicare discharge appeal notice was signed by Pt. #4 on 2/6/2012, however there is no evidence this information was given again within 48 hours of discharge. RN EE confirmed these findings.

A MR review was completed on Pt. #7's closed inpatient record on 7/25/2012 at 1:30 p.m. in the presence of RN VV. Pt. #7 was admitted on 4/3/2012 and discharged on 4/6/2012. A Medicare discharge appeal notice was signed by Pt. #7 on 4/3/2012, however there is no evidence this information was given again within 48 hours of discharge. Health Care Informatiics VV confirmed these findings.


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A MR review was completed on Pt. #18's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN SS who confirmed the finding. Pt. #18 was admitted on 3/3/2012 and discharged on 3/7/2012. A Medicare discharge appeal notice was signed by Pt. #18 on 3/3/2012, however there is no evidence this information was given again within 48 hours of discharge. Health Care Informatics SS confirmed these findings.

Based on 4 of 4 staff interviews (KKK, B, CC, FF), and observation, the hospital failed to ensure that it's contracted services are reviewed and evaluated for quality. This deficiency had the potential to affect patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per interview, with Board of Director member and Chief Medical Officer (KKK) on 7/24/12 at 2:30 PM, it was revealed that contracted services just recently became a part of the QI program. A specific scorecard has been developed to evaluate the contracted services used by the facility.

Per interview, with Accreditation Specialist (B), on 7/25/12 at 8:35 AM, it was revealed that contracted services were not a part of the QI program.

Per interview, with AS (B) on 7/25/12 at 2:55 PM, the Dietary, and Laundry departments are not a part of the QI program. Per (B), "there is a gap, they were missed."

On 7/24/12 beginning at 8:50 a.m. an interview and tour of the laundry area was accompanied by Supervisor of Linen Courier Services CC. During the tour and interview, CC stated that the Linen Management Committee meets quarterly, but do not report to quality assurance. Per CC the laundry department is a contract service and nothing is reported beyond this department.

On 7/24/2012, 8:34 a.m. - 9:06 a.m., surveyor interviewed Director of Nutrition Services and Dietetics-FF (DNSD-FF); and asked what quality assurance and performance indicators does the dietary department have that is integrated with the other departments in the facility? DNSD-FF stated she is not asked to report into other departments. Dietary does its own collecting of data such as patient satisfaction, room service audits and phone courtesy audits, but that information is not "funneled" in with other departments and into the hospital-wide QI program.

Based on 5 of 5 observations, review of facility patient rights, and 3 of 3 staff interviews (V, W, X), the hospital failed to ensure that patients on the behavioral health unit are ensured a safe physical environment. This deficiency affects all patients with psychiatric disorders being treated in the behavioral health unit.

Findings include:
Review of "Patient Rights and Responsibilities" P&P, last revision date 2/11, on 7/25/12 in the AM, directs the following: "Patient Rights: As a patient, I or my legally authorized representative, have the right to: Receive considerate, respectful care in a clean, safe and private place free of neglect, harassment and abuse."

On 7-24-2012 at 9:05 AM a tour of the inpatient behavioral health unit (IBHU) was completed with Nursing Administrator V, Director of IBHU W and RN X who validated the following observations: Shower room #645 was noted to have peeling paint on the ceiling of the shower stall which could be ingested by patients, cracked ceramic tile on threshold of shower exposing sharp edges, and cracked and sharp tile exposed on the north wall next to shower stall which could be used to inflict self-harm.

Tub room #646 had peeling paint around the shower stall, and sitting on the edge of the tub was a circle piece of thin rubber which could be ingested by patients. Director of IBHU W, explained staff must be using the rubber to clog the drain so the tub holds water. It was also noted that a housekeeping cart located in a hallway with a cabinet containing chemicals was unlocked and easily accessed by IBHU patients who could ingest the chemicals to inflict self-harm.

Based on 15 of 31 MR reviewed (#1-34), three of three staff interviews (VV, Q, EE), and policy and procedure reviews, the hospital failed to maintain a proper medical record service. This deficiency had the potential to affect all patients treated in the facility.

Findings include:

1. Hospital failed to ensure all MR entries are complete (see A450)
2. Hospital failed to ensure all orders are dated, signed, and authentiated (see A454, A457)
3. Hospital failed to ensure consultative reports are complete (see A464)
4. Hospital failed to ensure all consents are documented (see A466)
5. Hospital failed to ensure all discharge records are complete (see A469)

The cumulative affect of these deficiencies has the potential to affect all current and past patients in this hospital.

Based on 15 of 31 MR reviewed (10, 12, 13, 21, 22, 23, 24, 25, 26, 31, 34, 1, 2, 4, 7), and 3 of 3 staff interviews (VV, Q, EE), the hospital failed to ensure that all entries into the MR are dated, timed, authenticated and complete. These deficiencies had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:


05409

Per MR review of Pt. #10 assisted by HIC (Health Care Informatics) VV, beginning at 2:45 p.m. on 7/24/12, the following was noted: A nursing requisition order form for pharmacy was written by nursing staff at " 1700 " (5:00 p.m.) for Sodium Chloride and Heparin, but the date is not completed. An order was written by a physician on 5/4/12 at 6:10 p.m. and under information as to when it was sent to pharmacy a time is documented, but not a date. These findings were confirmed by VV during the record review.

Per MR review of Pt. #12 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: General pre-operative orders is a 6 page document requiring a physician to initial each of the first 5 pages. There are no physician initials on pages #1, #2, #3, #4, or #5. General Surgical Post-operative Admission Orders is an 11 page document which was signed by nursing 3/1/12, but the required physician initial on each of 10 sheets was not initialed on sheets #1, #2, #3, #4, #5, #6, #7, #8, #9, or #10. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #13 assisted by HIC VV beginning at 3:15 p.m. on 7/24/12, the following was noted: The 8 page document for Adult Admission orders requires a physician to initial each of the first 7 pages. Nursing signed the form on 2/6/12, but pages #1, #2, #3, #4, #5, #6, and #7 lack physician initials. HIC VV confirmed these findings during the record review.

Per MR review of the medical record of Pt. #21 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: the inpatient pneumococcal and influenza protocol sheet signed by nursing on 4-1-12 lacks a time when signed. A form entitled Discharge orders Universal are authenticated by nursing on 4/2/12, but not initialed by the physician on any of the 7 pages requiring a physician initial. Admission Adult Orders is an 8 page document requiring physician initials on the first 7 pages. Page 7 of the document signed by nursing on 4/1/12 lacks a physician initial. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The universal Discharge Orders are an 8 page document which requires the physician to initial the first 7 pages of the document. The document lacks physician initials for page #1. This was confirmed by VV during the record review.


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Pt #23's MR review on 7/24/12 at 9:05 AM revealed there is no documented MD notification time for Pt 24's ER (emergency room) visit on 5/5/12. The Summary of Care is not dated and timed when signed. The Sexual Assault Record is not dated and timed by the RN. There is no signature, date and time on the discharge instructions confirming the patient's guardian received and understands them. This is confirmed in interview with RN Q on 7/24/12 at 9:15 AM.

Pt #24's MR review on 7/24/12 at 8:45 AM revealed there is no documented MD notification time for Pt 24's ER visit on 5/5/12. The Summary of Care is not signed, dated and timed by Pt #24. There is no signature, date and time, on the discharge instructions confirming the patient received and understands them. This is confirmed in interview with RN Q on 7/24/12 at 9:05 AM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed the Delivery Record for the 4/26/12 admission is not dated and timed when signed by staff. The Progress Notes OB Delivery sheet is not dated and timed by person completing the form. The pathologist's report dated 4/27/12 is not authenticated by the pathologist with a date and time. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is no circumcision procedure note that was done on 5/3/12. This is confirmed in interview with RN Q on 7/14/12 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed the discharge instruction sheet is not timed when signed by the Pt on 2/7/12. The Progress Notes OB Delivery sheet is not dated and timed when completed by staff. The Delivery Record sheet is not signed, dated or timed by staff. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #34's MR review on 7/24/12 at 2:15 PM revealed there is no date and time when the newborn initial physical is completed. The circumcision procedure note is not timed. There is no time when the MD reviewed the history and physical and when the procedure time out was done for the circumcision on 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 2:15 PM.


26711

A MR review was completed on Pt. #1 closed same day surgical record on 7/24/2012 at 3:00 p.m. Pt. #1 had a colonoscopy on 3/1/2012. The H&P does not include a time the physician signed it. There is no time indicated for when the procedure started.
These findings were confirmed by RN EE at the time of the record review.

A MR review was conducted on Pt. #2 closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. The discharge instructions do not include a date or time the patient signed them and are not signed by a hospital representative. Pt. #2 MR had numerous progress notes that did not include the time the notes were written by the physician. A final operation report was not signed by the physician. These findings were confirmed by RN EE during the MR review.

A MR review was completed on Pt. #4 closed MR on 7/25/2012 at 10:00 a.m. Pt. #4's discharge summary was dictated by a physician assistant and not counter signed by the MD. According to Administrator EEE, in an interview on 7/25/2012 at 10:40 a.m., it is an expectation in this facility that physician assistant's work is counter signed by the MD. These findings were confirmed by RN EE at the time of the record review.

A MR review was completed on Pt. #7 closed surgical record on 7/25/2012 at 1:30 p.m. Pt. #7 was discharged on 4/6/2012. The final H&P contains a blank line.
This finding was confirmed by Health Care Informatics VV at the time of the record review.

Based on 11 of 31 MR reviewed (#10, 12, 13, 21, 22, 25, 26, 33, 18, 9, 2) and 4 of 4 staff interviews (VV, Q, SS, EE), the hospital failed to ensure that medical staff date, time and authenticate all orders entered into the MR. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:


05409

Per MR review of Pt. #10 assisted by HIC (Health Care Informatics) VV beginning at 2:45 p.m. on 7/24/12, the following was noted: The form entitled Medication Reconciliation Report for Admission (7 page report) is signed/authenticated by the MD, but not dated and timed on the 7 pages. HIC VV confirmed this during the record review.

Per MR review of Pt. #12 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: The post anesthesia care unit adjunct order form is signed and dated 3/1/12 by the physician, but the form lacks the time the physician signed. HIC VV confirmed this finding during the record review.

Per MR review of Pt. #13 assisted by HIC VV beginning at 3:15 p.m. on 7/24/12, the following was noted: The 8 page Adult admission orders signed by nursing on 2/6/12 requires a full physician signature with date and time signed. The 8th page of this document lacks the time the physician signed these orders. A physician order was written on 2/6/12 at 3:00 p.m. and the next physician order written on 2/6/12 lacks the time it was written and signed. The medication Reconciliation Report for Admission contains 6 pages of orders that were faxed to the physician on 2/6/12. The physician signed and dated the orders, but did not document the time the orders were signed. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #21 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: Verbal orders signed by nursing for 4/1/12 at 5:47 p.m. were faxed to the physician who signed the orders. The MD did not date or time the orders when signed. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The physician wrote orders on 4/6/12 and 4/5/12 without documenting the times the orders were signed. The reconciliation Report for Admission is a 6 page document containing medication orders which were faxed to the physician. The physician signed and dated the first 5 pages and did not document the times these pages were signed. This was confirmed by VV during the record review.


18816

Pt #25's MR review on 7/24/12 at 9:20 AM revealed there are orders written on 4/26/12 and 4/30/12 that are not signed, dated, or timed by the staff writing the orders. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there are admission orders that are not dated when written. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #33's MR review on 7/24/12 at 2:30 PM revealed there is an order written on 2/5/12 that not timed when written by the MD. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.


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Pt #18's MR review was completed with RN SS on 7/25/12 at 10:00 AM revealed there is an order written on 3/7/12 that was not signed, timed, or dated by the MD. This is confirmed with RN SS.

Pt #9's MR review was completed with RN SS on 7/25/12 at 8:00 AM revealed there is an order written that was signed by the MD but did not contain the date or time. This is confirmed with RN SS.


26711

A MR review was conducted on Pt. #2 closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. Pt. #2 had numerous physician orders that did not include the time the physician wrote the orders from several physicians. There were several preprinted order sets comprised of several pages each that were to be initialed on every page and signed on either the first or last of these pages that were missing initials and signatures, dates and/or times. These findings were confirmed by RN EE during the MR review.

Based on 6 of 31 MR reviewed (#2, 1, 8, 26, 31, 33), review of medical staff rules and regulations and facility P&P, and 2 of 2 staff interviews (EE, Q), the hospital failed to ensure that MD telephone and verbal orders are authenticated to include a time and date to ensure accuracy of the orders within 48 hours per medical staff rules and regulations. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
The facility's policy titled, "Patient Care Orders," dated 8/09, was reviewed on 7/24/2012 at 2:30 p.m. The policy states in part on page 1, #5, "Verbal orders must be kept to a minimum and are most appropriate for emergency situations only." In this same policy on page 4, Authentication/Validation of Orders, B. states, "All verbal/telephone orders must signed/e-signed within 48 hours with date and time."

Review of medical staff rules and regulations (dated December 2011) on 7/25/12 in the AM directs the following: Orders: Orders dictated to a RN or authorized person will be signed by the medical staff within 48 hours.

A MR review was conducted on Pt. #2's closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. Pt. #2 had 23 verbal orders during the hospital stay that were not properly authenticated by the physician (missing dates, times and/or signatures). RN EE confirmed these findings at the time of discovery.

A MR review was completed on Pt. #1's closed same day surgery record. On 4/2/2012 there is a verbal order for medication that has not been signed by a physician. RN EE confirmed these findings at the time of discovery.


18816

Pt #8's MR review on 7/24/12 at 1:50 AM revealed there is a verbal order written on 3/2/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is a verbal order written 4/30/12 that is not authenticated by the MD with a date. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there is a verbal order written on 2/5/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review 7/24/12 at 2:30 PM revealed there is a verbal order written on 2/7/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.

Based on 1 of 31 MR reviewed (#2) and 1 of 1 staff interview (EE), the hospital failed to ensure that consultative reports are completed and entered into the MR. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
A MR review was conducted on Pt. #2's closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. A transfer to an Intensive Care (IC) was ordered due to the need to intubate and place Pt. #2 on the ventilator because of respiratory problems during a surgical procedure. There is no consult report from an IC physician found in Pt. #2 MR. RN EE confirmed these findings during the MR review.

Based on 17 of 29 MR reviewed requiring a consent (12, 14, 16, 19, 22, 8, 23, 24, 25, 26, 31, 33, 34, 1, 4, 6, 35), P&P review and review of the consent for treatment forms, and 3 of 3 staff interviews (VV, Q, EE), the hospital failed to ensure that a patient/representative consent is obtained prior to a procedure, and that consents signed by the patient/representative and witness include the date and time they were signed. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.


Findings include:
Review of the Consent P&P (last revision date 1/10) on 7/25/12 in the AM, directs the following: "Policy: The consent should be documented in dictation or physician notes, and in appropriate instances such as surgery or invasive procedures, on written, signed consent form." A review of the consent form revealed that it requires a time and a date the consent was signed by the patient/representative/witness.


05409

Per review of Pt. #12 MR assisted by HIC (Health Care Informatics) VV beginning at 9:22 a.m. on 7/25/12, the following was noted: The procedure consent form signed by Pt. #12 lacks the time signed. The consent for treatment form signed by Pt. #12 and a witness lacks the times #12 and the witness signed the form. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #14 assisted by HIC VV beginning at 9:55 a.m. on 7/25/12, the following was noted: The consent for treatment form was signed and dated but lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #16 assisted by HIC VV beginning at 8:59 a.m. on 7/25/12, the following was noted: A general consent for treatment was signed by #16's son on 2/3/12, but the form lacks the time signed. Another general consent for treatment was signed by Pt. #16 on 2/11/12, but lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #19 assisted by HIC VV beginning at 7:40 a.m. on 7/25/12, the following was noted: the consent for general treatment form was signed and dated by Pt. #19, but the form lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The General consent for treatment form was signed by Pt. #22, but lacks the date and time #22 signed. This was confirmed by VV during the record review.


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Pt #8's MR review on 7/24/12 at 1:50 PM revealed there is no consent for treatment, and no informed consent for cesarean section performed on 3/1/12. This is confirmed in interview with RN Q on 7/24/12/ at 1:50 PM.

Pt #23's MR review on 7/24/12 at 9:05 AM revealed there is no time on the consent for a sexual assault examination on 5/5/12. This is confirmed in interview with RN Q on 7/24/12 at 9:15 AM.

Pt #24's MR review on 7/24/12 at 8:45 AM revealed there is no time on the consent for a sexual assault examination, nor on the consent for treatment on 5/5/12. This is confirmed in interview with RN Q on 7/24/12 at 9:05 AM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed there is no signed informed consent for the epidural that was attempted to be placed during labor. The consent for treatment is not timed when signed on admission on 4/26/12. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is no consent for treatment upon admission on 4/27/12, and there is no signed informed consent for circumcision. This is confirmed in interview with RN Q on 7/2/412 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there there is no signed informed consent for the epidural Pt #31 received during labor on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review on 7/24/1/2 at 2:30 PM revealed there is no consent for treatment upon admission on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 2:20 PM.

Pt #34's MR review on 7/24/12 at 2:15 AM revealed there is no consent for treatment upon admission on 3/1/12, and there is no signed informed consent for circumcision. This is confirmed in interview with RN Q on 7/2/412 at 2:15 PM.


26711

A MR review was completed on Pt. #1's closed same day surgery record on 7/24/2012 at 3:00 p.m. in the presence of RN EE. Pt. #1's general consent for care does not include a time the patient signed it. RN EE confirmed these findings.

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. # 4's general consent for care does not include a time or date the patient signed it. RN EE confirmed these findings.

A MR review was completed on Pt. 6's closed same day surgery record on 7/25/2012 at 1:05 p.m. in the presence of Health Care Informatics (HCI) VV. Pt. #6's general consent for care does not include a time the patient signed it. HCI VV confirmed these findings.

A MR review was completed on Pt. #35's closed emergency department record on 7/25/2012 at 1:37 p.m. in the presence of HCI VV. Pt. # 35's general consent for care does not include a time the patient signed it. HCI VV confirmed these findings.

Based on 5 of 31 MR reviewed (8, 25, 26, 31, 33), review of medical staff rules and regulations, and 1 of 1 staff interviews (Q), the hospital failed to ensure that MR are complete within 30 days of discharge. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Review of medical staff rules and regulations on 7/25/12 in the AM revealed that: "Records: 12. Privileges to admit patients and conduct consultations will be automatically suspended if the practitioner fails to complete a patient's medical record within fifteen (15) days after the MR is available to the practitioner."

Pt #8's MR review on 7/24/12 at 1:50 PM revealed there is a verbal order written on 3/2/12 that are not authenticated by the MD, over 30 days from discharge date of 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed the Discharge Summary dictated on 4/29/12 is authenticated on 6/3/12 greater than 30 days from discharge date 5/1/12. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed the MR is incomplete beyond 30 days with no circumcision procedure note. There is a verbal order written on 4/30/12 that is not authenticated with a date, unable to confirm date order was signed. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there is a verbal order written on 2/5/12 that is not authenticated by the MD, over 30 days from discharge date of 2/7/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review on 7/24/12 at 2:30 PM revealed there is a verbal order written on 2/7/12 that is not authenticated by the MD, over 30 days from discharge date of 2/7/12. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.

Based on P&P review, 3 of 3 staff interview (I, H, A), and nationally recognized standards of practice from the Center for Disease Control (CDC), this facility failed to follow safe injection practices with multiple dose vials in the Operating Room (OR) setting. Failure to follow safe injection practices has the potential to affect all patients in the facility

Findings include:
According to the CDC Safe Injection Practices 2007, "Safe Injection Practices to Prevent Transmission of Infections to Patients," states, "Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations."

In an interview with MD I on 7/23/2012 at 1:35 p.m., MD I stated that Lidocaine, a medication used to numb tissue prior to invasive procedures with needles and scalpels, is a multiple dose vial used for multiple patients in the OR, and it is drawn into syringes in a patient care area (the OR). This facility has 10 ORs. Administrator H was present and verified this interview.

The facility policy titled, "Multi-dose Vial Expiration Policy," dated 2/11, was reviewed on 7/24/2012 at 11:08 a.m. The policy states in #7, "The following medications will continue to be supplied in multi-dose vials however these items are relatively inexpensive so staff are encouraged to treat these items as single use products and discard any remaining amount after initial opening: Lidocaine 1%, 10 ml [milliliter], Lidocaine 1% with Epinephrine 20 ml, Lidocaine 2% with Epinephrine 20 ml."

The findings of this policy were discussed and verified with Administrator A on 7/25/2012 at 11:00 a.m.

Based on 18 of 19 emergency crash carts observed, P&P review, and 10 of 10 staff interviews (UU, Y, S, R, D, C, H, K, N, TT) the hospital failed to ensure that all medications and biologicals including those in emergency crash carts are secured from unauthorized access. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per review, of hospital P&P " drug distribution " on 7/25/12 in the AM (last revision date 11/17/02) directs the following: " 3. Storage and control monitoring of medications includes review of the following: Medication carts and medication storage areas are secured by being under constant supervision, are located in areas restricted to authorized personnel only, or are located in an area where patients/visitors are not allowed without supervision of health care personnel. "

The medication carts observed during the survey contained break away locks and were stored in unlocked areas where staff were not present or could not observe the medication cart to ensure security. As a result, the lack of security of all drugs/IV solutions on the crash carts allows for removal, tampering, destruction or personal use by unauthorized personnel, patients and visitors.

Per observation, while touring the ICU with Pt. Care Director (UU) and Nursing Director (Y) on 7/25/12 at 9:00 AM, it was noted that the ICU had two adult and one pediatric emergency crash carts which contained medications and IV solutions. 2 of 3 crash carts were not secured from unauthorized assess. The pediatric crash cart was in an unlocked storage room on a blind corner of a hallway. An adult crash cart was located in a hallway alcove which was not in direct view by ICU staff. Both carts had breakaway devices allowing for unauthorized access. The observations were confirmed by (UU) and (Y) during the tour.

Per observation, while touring the ED with ED Director (S) and Nursing Administrator (R) on 7/24/12 at 9:00 AM, it was noted that 6 of 6 emergency crash carts which contained medications and IV solutions were not secured from unauthorized access. An adult and pediatric crash cart in room #1, adult carts in rooms #2, 3, adult cart in the CAT (computerized axial tomography) scan room, and one between rooms 11 and 12 all had breakaway devices allowing for unauthorized access. Per interview with (UU), patients, family and other visitors could access the emergency crash carts resulting in the removal, tampering, destruction or use of the medications/IV solutions on the carts.


05409

At 8:40 a.m. on 7/24/12 it was noted that a crash cart located in the sub-nursing station on the 7 7th floor of the medical surgical unit, which is not occupied by nursing staff but in an alcove not visible on all 2 of 4 sides, had an easy break away lock on the cart. This crash cart is not in constant view of staff. Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.

At 8:43 a.m. on 7/24/12 tour of the 9 9th floor medical surgical unit revealed that a Pediatric and an Adult crash cart were both located in an unlocked clean utility room and both had easy break away locks. This clean utility room and the 2 crash carts are not under constant view of staff. Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.

At 8:46 a.m. on 7/24/12 tour of the 3rd floor medical surgical unit revealed that a crash cart was stored in an unlocked clean utility room with an easy break away lock. This cart is not in constant view of staff . Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.


18816

Per tour of the 5th floor Birthing Center with RN Mgr D and Administrator C on 7/23/12 between 1:00 PM and 2:45 PM the following was observed:

There are unsecured medications stored in the ante room off the labor/delivery/recovery (LDR) room 1. The medications are in a box with breakaway tags, and the cupboards and doors from the corridor and LDR rooms do not lock.

The crash cart in the Birthing Center operating room (OR) has a medication box on top with breakaway locks. The crash cart is not in constant view of staff, and the OR is unsecured. The above is confirmed in interview with RN Mgr D and Administrator C on 7/23/12 at approximately 2:45 PM.


26711

Emergency carts with medications and intravenous solutions and carts/drawers with needles and syringes were observed to be unsecured from unauthorized personnel (housekeeping staff would have after hour access without being supervised by authorized personnel) in the following areas:

--On 7/24/2012 at 7:35 a.m. in the Cancer Care Center
--On 7/24/2012 at 8:20 a.m. in the Day Surgery area
--On 7/24/2012 at 10:35 a.m. in the Endoscopy Suite

These findings were confirmed by Administrator H at the time of discovery.

On 7-23-2012 at 2:55 PM a tour of the Special Procedures Unit (SPU) was completed with Nursing Administrator K, Administration L and Director of the CCL, N. A crash cart with seal number 729617 was observed across from the nurses ' station. Director of the CCL, N explained the crash cart is not under direct supervision after the SPU closes.

On 7-24-2012 at 1:00 PM a tour of the 4th floor sleep lab was completed with Supervisor TT and Nursing Administrator K. A crash cart with breakaway seal #729609 was observed in the pass through area between the sleep lab and the CV unit.

Based on observations, 4 of 4 staff interviews (OO, FF, NN, LL) and record reviews, the facility does not prepare and serve food under sanitary conditions. This has the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
HAIR RESTRAINTS
The 2009 FDA Food Code states that " FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

On 7/24/2012, during 7:42 a.m. - 11:45 a.m., it was observed that the following foodservice employees in the kitchen without proper hair restraints: Director of Nutrition Services and Dietetics FF (facial hair), Food Service Volunteer GG (bangs), Ingredient Control staff HH (facial hair), Cook JJ (facial hair), Cook KK (facial hair), Cook LL (facial hair), Chef MM (facial hair), and Food Production Supervisor OO (facial hair).

On 7/24/2012, 1:40 p.m., review of Policy #: NSD 60, revised date 2/2012, " Uniform & Personal Appearance Policy, " determines it does not reflect current standard of practice based on section " Procedure: " A. 3. " A mustache is permitted, provided it is well trimmed, above the top lip, and not over the corners of the mouth. "

FOOD STORED AND PREPARED IN A SAFE MANNER
According to the 2009 Federal Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, (Time/Temperature Control for Safety Food), Date Marking. " (A) ... READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded when held at a temperature of 5oC (41oF) or less for a maximum of 7 days. "

On 7/24/2012, 7:49 a.m. - 8:07 a.m., surveyor, accompanied by Food Production Supervisor OO (FPS-OO) made the following observations of food items without any type of identification:
· Freezer # 004: bag of chicken tenders, bag of chicken wings, bag of popcorn chicken, half a bag of pizza sausage, and half a bag of frozen grilled cheese sandwiches.
· Cooler #016: container of grated cheese, half a container of cubed chicken.
· Cooler #14: 14 turkey sandwiches and three trays of desserts.
· Cooler #13: Bakery rack of cookies.

Staff FPS-OO acknowledged surveyor observations of food items without any type of identification to be true.

On 7/24/2012, 2:22 p.m., review of facility ' s policy " Food Labeling, Dating, and Expiration Policy, " revised date, 9/9/10, states " All foods purchased, prepared, or stored in the Nutrition Services and Dietetics Department must be labeled and dated. "

COVERING RECEPTACLES
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled;

On 7/24/2012, surveyor observed the following garbage receptacles without lids and were currently not in use: 10:43a.m. - receptacle next to food line, 11:12 a.m. - receptacle next to griddle. All observations of receptacles without lids were all verified by Director of Nutrition Services and Dietetics-FF, Clinical Dietetics Supervisor-NN, and Food Production Supervisor-OO.

HAND HYGIENE
According to the 2009 Federal Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. Hands are to be washed during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and before donning gloves for working with food.

On 7/24/2012, 11:15 a.m., surveyor observations of Cook PP wearing the same pair of disposable gloves for multiple tasks are as follows: opening and closing microwave; picking up a heated piece of roast beef out of container and placing onto plate; grabbing a garnish of kale and orange slice and placing onto plate next to roast beef; removed gloves and did not wash hands. These observations were verified by Director of Nutrition Services and Dietetics-FF and Clinical Dietetics Supervisor-NN.

On 7/24/2012, 11:26 a.m., surveyor observed Cook LL at griddle, remove disposable gloves, then put on another pair of disposable gloves without washing hands. Surveyor asked Cook LL if he washed his hands, which he stated " no. "

CROSS-CONTAMINATION
According to the 2009 FDA Food Code, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination.

On 7/24/2012, 7:38 a.m., surveyor observed a bakery rack with homemade breadsticks next to the hand washing sink exposed to any splash from individuals washing their hands. Clinical Dietetics Supervisor NN agreed it shouldn ' t ' be there and promptly removed the rack from the area.

On 7/24/2012, 8:10 a.m., surveyor observed stacks of clean pots and pans stored on a narrow shelf connected to hand washing sink. There was also a container of corn and another 6 inch quarter pan that had been prepared with a food release spray. Clinical Dietetics Supervisor NN and Food Production Supervisor OO promptly removed the items and agreed the pots and pans should not be stored on that shelf.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:
Building Ce -"Tower-Main Building"- "Existing Healthcare Occupancy" used.
K11: Unreliable separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K15: Interior finishes without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls and doors were not smoke tight w/ ratings.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Egress width was obstructed.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper identification.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A
K71: Rubbish and linens chutes properly maintained
K75: Proper storage and handling of rubbish and soiled materials.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous items.
K140: Medical gas alarm panels located in unoccupied areas.
K147: Electrical system not to NFPA 70 minimum standards.

Findings include:
Building Cm - "CAMS Building"- "New Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K14: Interior finishes of corridors and egress did not have minimum class rating.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K27: Proper labels on doors for a smoke compartment were not present.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K71: Rubbish and linens chutes properly maintained
K77: Medical Gas system zone valves not compliant.
K108: Emergency Generator Alarms are not compliant.
K147: Electrical system not to NFPA 70 minimum standards

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The hospital failed to ensure that patient supplies are secure from unauthorized access and that the building is maintained to ensure the safety and well-being of patients and staff. See Tag A-701

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on 6 of 6 observations, P&P review, and 6 of 6 staff interviews (R, S, H, V, W, X), the hospital failed to ensure that patient supplies are secure from unauthorized access and that the building is maintained to ensure the safety and well-being of patients and staff. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per observation, while touring the ED with RN (R) and (S) on 7/24/12 at 9:00 AM, it was noted that a large clean patient supply room was not secured from unauthorized access. The room is located at the end of a hall-way and just inside the ambulance garage. Examples of supplies found in the room were: oxygen canisters, syringes, needles, instruments, lab supplies etc. Per RN (R) and (S), visitors, patients and unauthorized staff could enter the patient supply room and remove, tamper with, destroy or use the supplies.


26711

A tour of the Surgery area, which included the Post Anesthesia Care Unit (PACU), Decontamination room, and operating rooms (OR) was conducted on 7/23/2012 accompanied by Administrator (Admin) H who verified all of the following findings at the time of discovery:

PACU (2:40 p.m.):
--Clean Utility room-walls had areas of gouges and paint missing, there was a missing ceiling tile above a water dispensing unit. Behind the water dispensing unit there was a build up of paint chips/flakes and debris.

Decontamination room (2:55 p.m.):
--The tile floor had gouges and missing pieces of tile making it a non-smooth surface and difficult to clean effectively.

ORs (3:00 p.m.):
--OR 4 had chips in the laminate of the desk top by the Medical Doctor (MD) dictation area creating a non-smooth surface.
--OR 5 had chips in the laminate of the desk top by the MD dictation area creating a non-smooth surface.
--OR 7 had chips in the laminate of the desk top by the MD dictation area creating a non-smooth surface.
--The surgery storage room door had gouges and chips in the laminate exposing porous wood underneath.

A tour of Cancer Center was conducted on 7/24/2012 accompanied by Admin H who verified the following finding at the time of discovery (7:35 a.m.): numerous gouges in the walls throughout the patient care area.

On 7-24-2012 at 9:05 AM a tour of the inpatient behavioral health unit (IBHU) was completed with Nursing Administrator V, Director of IBHU W and RN X who validated the following observations: Shower room #645 was noted to have peeling paint on the ceiling of the shower stall which could be ingested by patients, cracked ceramic tile on threshold of shower exposing sharp edges, and cracked and sharp tile exposed on the north wall next to shower stall which could be used to inflict self-harm by.

Tub room #646 had peeling paint around the shower stall, and sitting on the edge of the tub was a circle piece of thin rubber which could be ingested by patients. Director of IBHU W, explained staff must be using the rubber to clog the drain so the tub holds water. It was also noted that a housekeeping cart located in a hallway with a cabinet containing chemicals was unlocked and easily accessed by IBHU patients who could ingest the chemicals to inflict self-harm.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:
Building Ce -"Tower-Main Building"- "Existing Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K15: Interior finishs without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls and doors were not smoke tight w/ ratings.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Egress width was obstructed.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper siganage.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A
K71: Rubbish and linens chutes properly maintained
K75: Proper storage and handling of rubbish and soiled materials.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous items
K140: Medical gas alarm panels located in unoccupied areas.
K147: Electrical system not to NFPA 70 minimum standards

Findings include:
Building Cm -"CAMS Building" - "New Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K14: Interior finishes of corridors and egress did not have minimum class rating.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K27: Proper labels on doors for a smoke compartment were not present.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K71: Rubbish and linens chutes properly maintained
K77: Medical Gas system zone valves not compliant.
K108: Emergency Generator Alarms are not compliant.
K147: Electrical system not to NFPA 70 minimum standards

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.


14105

Based on observation and 3 of 3 staff interviews (XX, YY, DDD), the facility did not provide adequate ventilation due to lack of filtration in accordance with CDC and AIA guidelines. In addition, air flow was from dirty to clean. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection for all patients receiving services at this hospital.

Findings include:
The CDC guidelines can be found in the website


1. On 07/19/2012 at 9:50 am surveyor observed on the basement Air Handler Unit 14 did not have 30% prefilters for hospital spaces. The 2006 Guidelines for Design and Construction of Health Care Facilities requires all hospitals to 30% prefilters. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
2. On 07/23/2012 at 2:50 PM surveyor observed at the service closet 1-67 on the first floor, that the air flow was from the janitors closet to the corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires air flow from clean to dirty. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
3. On 07/23/2012 at 3:25 PM surveyor observed at the corridor next to stair one, that there was no ventilation in the room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have 2 air changes per hour of air flow. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
4. On 07/24/2012 at 9:40 AM, surveyor observed at the angio room that air flow was from clean supply to the angio room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires air flow from clean to dirty. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
5. On 07/24/2012 at 11:43 AM surveyor observed at the mechanical room being uses as as planning room, that there was no ventilation in the room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
6. On 07/24/2012 at 3:50 PM surveyor observed at the corridor next to the clinic one, that there was no ventilation in the corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have 2 air changes per hour of air flow. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).

7. On 7/23/2012 at 7:42 am surveyor #14105 observed that the flow of air from OR #2 was not positive from this room into Corridor 300-3 [Third Level /I-2 occupancy]. 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have positive air flow from clean to dirty. This observed situation was not compliant. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on 25 of 26 observations, P&P review, and 10 of 10 staff interviews (DD, UU, Y, CC, C, D, H, EEE, K, N), the hospital failed to ensure that clean/sterile and dirty supplies are kept separate, that staff follow universal precautions, that intravenous sites are protected from potential contamination, that sterile fields are protected from potential contamination, that staff wear appropriate personal protective equipment, that hospital environment and equipment is kept clean and maintained, and that clean linen is protected from dust and debris. These deficient infection control practices, with the risk for cross-contamination of micro-organisms, had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per CDC Guidelines for preventing transmission of infectious agents in healthcare settings 2007: IV. Standard Precautions: washing/gloving standards are as follows: " IV.A.3.a Before having direct contact with patients. IV.A.3.b After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. IV.A.3.c After contact with a patient's intact skin (e.g; when taking a pulse or blood pressure or lifting a patient). IV.A.3.d If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e After contact with inanimate objects (including medical equipment in the immediate vicinity of the patient. IV.A.3.f After removing gloves.

Occupational Safety and Health Administration Bloodborne Pathogen standards at 29 CFR 1910.1030(d)(3)(ix) requires the following: " Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces. "

Per CDC "Guideline for Hand Hygiene in Health-Care Settings" (MMWR 10/25/02) recommendations for glove use, page 33 #6 states, in pert: "Change gloves if moving from a contaminated body site to a clean body site. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects." ttp:www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Per CDC "Guidelines for Preventing Transmission of Infectious Agents in Healthcare Settings 2007" IV.B.1.a Wear PPE, as described in IV.B.2-4 when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur."

Per observation, while touring the Radiology department with Radiology Director (DD) and Surveyor on 7/24/12 at 2:15 PM, it was noted that a storage room with two filing cabinets, chairs, and bulletin boards also held sterile supplies and packs for pain/spinal injections. there were 6 boxes of sterile radiology injection packs on the floor, needles, chloraprep, gloves and syringes on a table. Per (DD), he is not sure how this room reached a point that it held both clean/sterile and dirty supplies.

Per observation, while touring the ICU with RN (UU) and RN (Y) at 9:00 AM on 7/25/12, it was noted that a janitor closet had clean brown garbage bags laying directly on the floor. In addition, there were personal affects in this dirty room: family pictures and jewelry hanging on a bulletin board. Per RN (UU), personal items should not be kept in this dirty janitor closet and the garbage bags should not be on the floor.

During this same tour, the door to the soiled holding room was propped open allowing for the disruption of the negative air-flow and the potential for cross-contamination. Two doors leading to a clean supply room that also held the medication dispensing system were also propped open allowing for the disruption of positive air-flow and the potential for cross-contamination.


05409

On 2 of 3 medication passes observed by Surveyor, the following was noted:
At 7:46 a.m. on 7/24/12 RN Z came to Pt. Room #930 to administer medication to Pt.
#29. Pt #29 asked RN Z to look at right ankle. RN Z touched Pt. #29's right ankle and then directly touched the scanner on the computer on wheels, contaminating the scanner. RN Z removed the computer on wheels with the contaminated scanner from room #930 without cleansing it. Nurse Administrator Y also observed and confirmed this observation.

At 8:51 a.m. on 7/24/12 RN BB Administered medications to Pt. #30 in #30's 7 7th floor room, then proceeded to assess Pt. #30's feet, lungs, and abdomen with gloved hands. RN BB removed the glove on BB's right hand and without cleansing the right hand, used the right hand to move the mouse on the computer on wheels stand. BB then removed the glove from the left hand and discarded the glove. Without cleansing hands, RN BB donned a new pair of gloves, which BB wore to flush #30's IV (Intravenous port). Nurse Administrator Y also observed and confirmed this observation.

At 8:28 a.m. on 7/24/12, Surveyor, who was accompanied by Nurse Administrator Y, observed Nephrologist AA on the inpatient hemodialysis unit. AA was not wearing a cover coat on the unit when entered both of the pt. hemodialysis stations while occupied during hemodialysis. Per interview with Patient Care Director UU at 10:46 a.m. on 7/24/12, UU confirmed that Nephrologist AA is required to wear a cover coat while pts. are in the unit receiving hemodialysis.

On 2 of 2 days of tour of the Laundry area accompanied by Supervisor of Linen Courier Services CC and Nurse Administrator Y, Surveyor observed the following:

On the initial tour of the Laundry beginning at 8:50 a.m. on 7/24/12, Surveyor noted that the double doors to the Laundry area were open. Upon entering the corridor where linen carts are being filled with clean linen, it was noted that 8 of 10 of the rooms had the room doors open while linen carts of clean linen were stored uncovered.

Beginning at 11:15 a.m. on 7/25/12 Surveyor was accompanied by Nurse Administrator Y and Supervisor CC, to verify that linen is not stored properly in the clean linen area. Staff Y and CC verified these following findings:

8 of 10 rooms in the clean linen area were noted to have open doors and uncovered carts containing clean linen:
Room #Sa 3-27 open door with 2 of 4 clean linen carts uncovered.
Room #Sa 3-21 open door with 10 clean linen carts uncovered.
Room #Sa 3-19 open door with 4 uncovered clean linen carts.
Room #Sa 3-15 open door with 13 uncovered clean linen carts.
Room #Sa 3-07 door open with 2 carts uncovered clean linen.
Room #Sa 3-05 door open with 1 uncovered clean linen cart.
Room #Sa 3-08 door open with 1 uncovered clean linen cart.
Room #Sa 3-18 door open with 7 uncovered clean linen carts.

Per interview with Supervisor CC at 11:25 a.m. on 7/25/12, there is no policy regarding when doors of clean linen rooms are closed, but it is facility practice to ensure that the clean linen room doors are closed at the end of the day and added that the double doors from the laundry area to the sky walk are not closed daily until 8:00 p.m. to 10:00 p.m.


18816

Per tour of the 5th floor nursing center, with RN Mgr D and Administrator C, on 7/23/12 between 1:00 PM and 2:45 PM the following was observed: The (environmental) Service Closet in the NICU (neonatal intensive care unit) has a box on the floor lined with a plastic bag.

The labor/delivery/recovery (LDR) rooms 1, 2, and 3 had unsecured needles and syringes in the fetal monitor cart.

The adjacent ante rooms to the LDR rooms have unsecured medications, needles and syringes.

Antepartum rooms 500 and 502 have syringes and needles unsecured in the fetal monitor cart.

The medication room off the nursing station is not secured and contains needles and syringes.

The clean utility room/medication room has urinalysis cups under the sink allowing for potential contamination.

The above is confirmed in interview with RN Mgr D and Administrator C on 7/23/12 at approximately 2:45 PM.

On 7/24/12 at 8:25 AM surveyor observed RN O complete a medication pass for Pt #32 in room 530. RN O entered the medication room, obtained percocet and ibuprofen from the pyxis and proceeded to go to room 530 with a computer on wheels. RN O entered the room, performed the identification check, administered the medication, left the room and returned to the nursing station. RN O did not wash with soap and water or hand gel during the entire process.


26711

A tour of the Surgery area, which included the Post Anesthesia Care Unit (PACU), corridor behind the operating rooms (OR) was conducted on 7/23/2012 accompanied by Administrator (Admin) H who verified all of the following findings at the time of discovery:

PACU (2:40 p.m.):
--Clean Utility room had an opened can of soda on the shelf. The linen cart was being stored in the clean utility room with a water dispensing machine, uncovered.

OR Corridor (3:00 p.m.):
--In the back OR corridor on the window ledges there were rolling balls of dust.

A tour of the Cancer Care Center was conducted on 7/24/2012 accompanied by Admin H who verified the following finding at the time of discovery (7:35 a.m.):
--There was calcium deposit build up around the drains and water spigots of the water dispensing machine; making the surface porous.
--The storage room did not have a separation of clean and dirty. There was bagged trash on the floor and a open flush hopper in the same room with a medical supply cart that contained syringes for injections and packages of dressings for non-intact skin, as well as clean supplies.

On 7/24/2012 at 7:45 a.m. an observation of a Patient Care Technician (PCT) FFF was made, accompanied by Admin H, in the Day Surgery area. PCT FFF was observed exiting the room of Pt. #28 with blue gloves on. PCT FFF went to a work station and proceeded to clean the glucose meter and case that FFF carried out of the room with these same gloves on. When questioned, RN EEE informed Surveyor and Admin H that RN EEE performed the blood sugar.

On 7/24/2012 at 8:10 a.m. in the Sterile Processing room, the ceiling vents were noted to have a layer of dust on them and the edges were rusty making the cleaning of them difficult. This finding was confirmed by Admin H at the time of discovery.

On 7/24/2012 from 8:54 a.m. through 9:36 a.m. an observation of Pt. #28's abdominal surgery was conducted accompanied by Admin H who observed the procedure as well.
Certified Registered Nurse Anesthetist (CRNA) JJJ was observed placing an arterial line (tube inserted into an artery for closer blood pressure monitoring in patients who require this). At the start of this procedure MD-Anesthesia U asked MD-Surgeon HHH to wait briefly before handling Pt. #28 as the placement of an arterial line requires the patient to be still and the area to remain aseptic (free from contamination). While CRNA JJJ was performing the insertion of the arterial the line in Pt. #28's right wrist, MD HHH began shaving Pt. #28's abdomen with a battery powered razor. This action allowed for the potential entry of hair and microorganisms into the blood stream.

During this same surgical observation MD U was observed to miss two opportunities for hand washing between glove changes.

On 7/24/2012 at 9:45 a.m. accompanied by Admin H, an observation of OR 8, the Cystoscopy (bladder procedure) room, was made. The base of the Cystoscopy machine was noted to have exposed rust along the bottom and a supply cart in the room also had exposed rust on the legs above the casters. Rusty surfaces are porous and cannot be effectively cleaned. Also in this room on the wall was a vinyl covered transfer board. The vinyl was fraying on the edges and flaking off to the floor.

On 7-23-2012 at 2:40 PM a tour of the Cardiac Catheterization Lab (CCL) was completed with Nursing Administrator K, Administration L and Director of the CCL, N. In the supply core two procedure rooms can be accessed, room sf-2-17 had the door open while a patient was undergoing a procedure. On 7-27-2012 at 11:30 AM a review of the Policy & Procedure (P&P) titled, " Infection Control: Traffic Pattern in the OR Suite " states in part, under Traffic R/T OR Room - " Keep doors to the operating room closed except during movement of personnel, patient, or equipment. "

Based on 6 of 6 staff interviews (RR, B, J, H, GGG, Q), policy and procedure reviews and observations, the hospital failed to ensure safe surgical practices. This deficiency had the potential to affect all surgical patients.

Findings include:

1. Hospital failed to ensure all surgical staff assistants are granted surgical privileges (see A945)
2. Hospital failed to perform fire drills for surgery staff and failed to ensure surgical skin preparation liquids are dry prior to surgery (see A951)

The cumulative effect of these failures has the potential for harm for all surgical patients and surgical staff.

Based on 3 of 3 staff interviews (RR, B, J), 1 of 1 first assist files reviewed (QQ), and review of the Medical Staff Rules and Regulations, the hospital failed to ensure that staff assisting Surgeon (LLL) with surgery are credentialed and privileged to do so. This affects all Surgeon (LLL) surgical patients.

Findings include:
The Medical Staff Rules and Regulations, dated December 20111 and reviewed on 7/24/2012 in the AM, revealed that surgical staff who are granted surgical privileges and appropriate staff status per the Medical Staff Bylaws and Credentialing Policies do not include surgical technicians who accompany/assist a surgeon and are not hospital employees.

Per interview, with QI Director (RR) on 7/23/12 at 3:30 PM, it was revealed ST (surgical technician) (QQ) assists Plastic Surgeon (LLL) perform surgery and does manipulate tissue. Per (RR), there are no other ST who accompany surgeons into the hospital OR who are not employees of the hospital.

Review of (QQ) personnel file on 7/24/12 revealed that ST (QQ) is not an employee of the hospital and has not gone through the established criteria, qualifications and credentialing process to be granted specific privileges to be performed as a ST accompanying Surgeon (LLL). This was validated in interview with AS (B) on 7/24/12 at 1:00 PM. A "OR Surgical Assistant Competencies" list in her file, dated 2/9/09, indicates ST (QQ) can perform the following: provides retraction of tissue and organs, clamps, cuts and or cauterizes vessels or tissue, placement of ties, suture ligatures and application of chemical hemostatic agents, use of electrocautery, closure of all wound layers, and insertion of drainage tubes.

Per interview, with RN (J) on 7/24/12 at 1:45 PM, ST (QQ) had completed the credentialing and privileging process at one time, but it is not current at this time.

Based on observation of 1 of 1 surgical procedure (Pt. #28), 4 of 9 surgery MR reviewed out of a total of 31 MR reviewed (#8, 31, 26, 34), 4 of 4 staff interviews (H, J, GGG, Q), and P&P review, this facility failed to conduct drills for patients in the Operating Room (OR), validate confirmation that an alcohol based skin preparation (ABSP) was dry prior to draping, and perform a "time-out" to ensure appropriate identification procedures prior to the start of surgery. These deficiencies had the potential to affect all patients who receive surgical procedures in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
In an interview regarding Surgical Services in which Administrator (Admin) H and RN Educator J was present on 7/23/2012 at 1:30 p.m. it was discovered that this facility failed to conduct regular fire drills regarding the potential for patients on fire in the OR.

RN Educator J produced a copy of a fire drill from the OR area which was dated June 15, 2006 and stated this was the last fire drill the facility documented regarding the patient being involved with the fire.

On 7/25/2012 at 2:04 p.m., Patient Safety Officer III confirmed that the OR does not have a procedure for how often fire drills are done in the OR.

On 7/24/2012 from 8:54 a.m. through 9:36 a.m. an observation of Pt. #28's abdominal surgery was conducted accompanied by Admin H.

Circulating RN GGG was observed to cleanse Pt. #28's abdomen with DuraPrep, an ABSP at 9:22 a.m. At 9:25 a.m. MD HHH began applying sterile draping to Pt. #28's abdomen. No member of the surgical team in the room confirmed that the ABSP was dry prior to the MD applying the drapes.

In an interview with RN GGG, during the observation, RN GGG stated, "That isn't part of our process and its one of my pet peeves." RN GGG was referring to the verbal confirmation of the ABSP being dry even though there is an area in the medical record to document that it is. Admin H confirmed this finding at the time of the discovery.

Review of the facility's policy titled, "Pre-Operative Skin Preparation of Surgical Patient Procedure," dated 1/10 was completed on 7/25/2012 at 1:30 p.m. The policy does not address how confirmation that an ABSP is dry prior to draping is addressed or that this should be documented.


18816

Pt #8's MR review by surveyor on 7/24/12 at 1:50 PM revealed the Time Out on the Site/Patient/Verification for Surgery/Procedure sheet is not signed, dated or timed by staff. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #31's MR review by surveyor on 7/24/12 at 11:10 AM revealed there is no documented Time Out for a procedure to manually remove a retained placenta on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #26's MR review by surveyor on 7/24/12 at 10:10 AM revealed there is no documented Time Out for a circumcision done on 5/3/12. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #34's MR review by surveyor on 7/24/12 at 2:15 PM revealed the Time Out for a circumcision is not timed by the staff on 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 2:15 PM.

Based on 5 out of 9 surgery records reviewed out of a total of 31 MR reviewed (Pt. #4, 5, 6, 7, 31), 4 of 4 staff interviews (I, EE, VV, Q) this facility failed to complete a post-anesthesia evaluation to include all of the elements of an adequate post-anesthesia evaluation in a time frame appropriate for recovery from the anesthesia. Failure to complete an appropriate post-anesthesia evaluation has the potential to affect all surgical patients who require this evaluation.

Findings include:
In an interview with MD of Anesthesia I on 7/23/2012 at 1:35 p.m. in the presence of Administrator H, MD I stated that post-anesthesia evaluation is conducted by a member of the anesthesia team (either an MD or CRNA), usually about an hour after the procedure.

The facility form used for Pre/Post Anesthesia Evaluation has a section at the bottom left corner that includes level of consciousness ( a line and check box to indicate if the patient has returned to pre-anesthesia status), cardiopulmonary (a line and a check box to indicate if vital signs are stable [VSS]), a line for follow up care if indicated, and a line for complications (with a check box for none). A space for signature, date, and time are also in this section.

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. #4 had spinal anesthesia for a left total knee replacement. The post-anesthesia evaluation does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by RN EE at the time of the MR review.

A MR review was completed on Pt. # 5's closed same day surgery record on 7/25/2012 at 11:10 a.m. in the presence of RN EE. Pt. #5 is a 7 year old who had a general anesthetic to remove tonsils and adenoids. Anesthesia started at 8:53 a.m. and ended at 10:00 a.m. The post-anesthesia evaluation was conducted at 10:02 a.m., an insufficient time to determine if the patient has sufficiently recovered from anesthesia. The post-anesthesia evaluation also does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by RN EE at the time of the MR review.

A MR review was completed on Pt. #6's closed same day surgery record on 7/25/2012 at 1:05 p.m. in the presence of Health Care Informatics (HCI) specialist VV. Pt. #6 had a general anesthetic for a hysterectomy. The post-anesthesia evaluation does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by HCI VV at the time of the MR review.

A MR review was completed on Pt. #7's closed inpatient record on 7/25/2012 at 1:30 p.m. in the presence of HCI VV. Pt. #7 had general anesthetic for back surgery. Anesthesia started at 10:19 a.m. on 4/3/2012 and ended at 1:16 p.m. The post-anesthesia evaluation was conducted at 1:25 p.m., an insufficient time frame to determine if the patient has sufficiently recovered from anesthesia. The post-anesthesia evaluation also does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration.
These findings were confirmed by HCI VV at the time of the MR review.


18816

Pt #31's MR reviewed by surveyor on 7/24/12 at 11:10 AM revealed there is no post anesthesia note after removal of an epidural catheter that was placed on 2//5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Based on MR review, review of facility P&P, and 3 of 3 staff interviews (EE, SS, VV), the hospital failed to follow Medicare guidelines to provide discharge appeal information to its Medicare population in 3 of 4 MR reviewed (Pt.s #4, 7, 18). Failure to provide Medicare patients with information about their right to appeal their discharge affects all Medicare recipients receiving care in this facility.

Findings include:

CMS directs facilities to give information regarding the right to appeal discharge to Medicare recipients within 48 hours of admission and 48 hours of discharge. For short stay patients only one notice is required if it has been within 48 hours of receiving the first notice.

The facility's procedure, provided to Surveyor on 7/25/2012 at 11:12 a.m. by RN EE, is titled, "Important Message from Medicare regarding Hospital Discharge Appeal Rights." There is no effective/revision date on the procedure. The procedure reiterates CMS's expectations regarding when patients should receive the notice. The facility's Case Management department is responsible for ensuring patients receive the follow-up notice prior to discharge and, per the procedure, "The 'Additional Information' section of the IM [Important Message] will be used to document the delivery. Patient or representative to sign and date this section."

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. # 4 was admitted on 2/6/2012 and discharged on 2/10/2012. A Medicare discharge appeal notice was signed by Pt. #4 on 2/6/2012, however there is no evidence this information was given again within 48 hours of discharge. RN EE confirmed these findings.

A MR review was completed on Pt. #7's closed inpatient record on 7/25/2012 at 1:30 p.m. in the presence of RN VV. Pt. #7 was admitted on 4/3/2012 and discharged on 4/6/2012. A Medicare discharge appeal notice was signed by Pt. #7 on 4/3/2012, however there is no evidence this information was given again within 48 hours of discharge. Health Care Informatiics VV confirmed these findings.


26390

A MR review was completed on Pt. #18's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN SS who confirmed the finding. Pt. #18 was admitted on 3/3/2012 and discharged on 3/7/2012. A Medicare discharge appeal notice was signed by Pt. #18 on 3/3/2012, however there is no evidence this information was given again within 48 hours of discharge. Health Care Informatics SS confirmed these findings.

Based on 4 of 4 staff interviews (KKK, B, CC, FF), and observation, the hospital failed to ensure that it's contracted services are reviewed and evaluated for quality. This deficiency had the potential to affect patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per interview, with Board of Director member and Chief Medical Officer (KKK) on 7/24/12 at 2:30 PM, it was revealed that contracted services just recently became a part of the QI program. A specific scorecard has been developed to evaluate the contracted services used by the facility.

Per interview, with Accreditation Specialist (B), on 7/25/12 at 8:35 AM, it was revealed that contracted services were not a part of the QI program.

Per interview, with AS (B) on 7/25/12 at 2:55 PM, the Dietary, and Laundry departments are not a part of the QI program. Per (B), "there is a gap, they were missed."

On 7/24/12 beginning at 8:50 a.m. an interview and tour of the laundry area was accompanied by Supervisor of Linen Courier Services CC. During the tour and interview, CC stated that the Linen Management Committee meets quarterly, but do not report to quality assurance. Per CC the laundry department is a contract service and nothing is reported beyond this department.

On 7/24/2012, 8:34 a.m. - 9:06 a.m., surveyor interviewed Director of Nutrition Services and Dietetics-FF (DNSD-FF); and asked what quality assurance and performance indicators does the dietary department have that is integrated with the other departments in the facility? DNSD-FF stated she is not asked to report into other departments. Dietary does its own collecting of data such as patient satisfaction, room service audits and phone courtesy audits, but that information is not "funneled" in with other departments and into the hospital-wide QI program.

Based on 5 of 5 observations, review of facility patient rights, and 3 of 3 staff interviews (V, W, X), the hospital failed to ensure that patients on the behavioral health unit are ensured a safe physical environment. This deficiency affects all patients with psychiatric disorders being treated in the behavioral health unit.

Findings include:
Review of "Patient Rights and Responsibilities" P&P, last revision date 2/11, on 7/25/12 in the AM, directs the following: "Patient Rights: As a patient, I or my legally authorized representative, have the right to: Receive considerate, respectful care in a clean, safe and private place free of neglect, harassment and abuse."

On 7-24-2012 at 9:05 AM a tour of the inpatient behavioral health unit (IBHU) was completed with Nursing Administrator V, Director of IBHU W and RN X who validated the following observations: Shower room #645 was noted to have peeling paint on the ceiling of the shower stall which could be ingested by patients, cracked ceramic tile on threshold of shower exposing sharp edges, and cracked and sharp tile exposed on the north wall next to shower stall which could be used to inflict self-harm.

Tub room #646 had peeling paint around the shower stall, and sitting on the edge of the tub was a circle piece of thin rubber which could be ingested by patients. Director of IBHU W, explained staff must be using the rubber to clog the drain so the tub holds water. It was also noted that a housekeeping cart located in a hallway with a cabinet containing chemicals was unlocked and easily accessed by IBHU patients who could ingest the chemicals to inflict self-harm.

Based on 15 of 31 MR reviewed (#1-34), three of three staff interviews (VV, Q, EE), and policy and procedure reviews, the hospital failed to maintain a proper medical record service. This deficiency had the potential to affect all patients treated in the facility.

Findings include:

1. Hospital failed to ensure all MR entries are complete (see A450)
2. Hospital failed to ensure all orders are dated, signed, and authentiated (see A454, A457)
3. Hospital failed to ensure consultative reports are complete (see A464)
4. Hospital failed to ensure all consents are documented (see A466)
5. Hospital failed to ensure all discharge records are complete (see A469)

The cumulative affect of these deficiencies has the potential to affect all current and past patients in this hospital.

Based on 15 of 31 MR reviewed (10, 12, 13, 21, 22, 23, 24, 25, 26, 31, 34, 1, 2, 4, 7), and 3 of 3 staff interviews (VV, Q, EE), the hospital failed to ensure that all entries into the MR are dated, timed, authenticated and complete. These deficiencies had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:


05409

Per MR review of Pt. #10 assisted by HIC (Health Care Informatics) VV, beginning at 2:45 p.m. on 7/24/12, the following was noted: A nursing requisition order form for pharmacy was written by nursing staff at " 1700 " (5:00 p.m.) for Sodium Chloride and Heparin, but the date is not completed. An order was written by a physician on 5/4/12 at 6:10 p.m. and under information as to when it was sent to pharmacy a time is documented, but not a date. These findings were confirmed by VV during the record review.

Per MR review of Pt. #12 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: General pre-operative orders is a 6 page document requiring a physician to initial each of the first 5 pages. There are no physician initials on pages #1, #2, #3, #4, or #5. General Surgical Post-operative Admission Orders is an 11 page document which was signed by nursing 3/1/12, but the required physician initial on each of 10 sheets was not initialed on sheets #1, #2, #3, #4, #5, #6, #7, #8, #9, or #10. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #13 assisted by HIC VV beginning at 3:15 p.m. on 7/24/12, the following was noted: The 8 page document for Adult Admission orders requires a physician to initial each of the first 7 pages. Nursing signed the form on 2/6/12, but pages #1, #2, #3, #4, #5, #6, and #7 lack physician initials. HIC VV confirmed these findings during the record review.

Per MR review of the medical record of Pt. #21 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: the inpatient pneumococcal and influenza protocol sheet signed by nursing on 4-1-12 lacks a time when signed. A form entitled Discharge orders Universal are authenticated by nursing on 4/2/12, but not initialed by the physician on any of the 7 pages requiring a physician initial. Admission Adult Orders is an 8 page document requiring physician initials on the first 7 pages. Page 7 of the document signed by nursing on 4/1/12 lacks a physician initial. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The universal Discharge Orders are an 8 page document which requires the physician to initial the first 7 pages of the document. The document lacks physician initials for page #1. This was confirmed by VV during the record review.


18816

Pt #23's MR review on 7/24/12 at 9:05 AM revealed there is no documented MD notification time for Pt 24's ER (emergency room) visit on 5/5/12. The Summary of Care is not dated and timed when signed. The Sexual Assault Record is not dated and timed by the RN. There is no signature, date and time on the discharge instructions confirming the patient's guardian received and understands them. This is confirmed in interview with RN Q on 7/24/12 at 9:15 AM.

Pt #24's MR review on 7/24/12 at 8:45 AM revealed there is no documented MD notification time for Pt 24's ER visit on 5/5/12. The Summary of Care is not signed, dated and timed by Pt #24. There is no signature, date and time, on the discharge instructions confirming the patient received and understands them. This is confirmed in interview with RN Q on 7/24/12 at 9:05 AM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed the Delivery Record for the 4/26/12 admission is not dated and timed when signed by staff. The Progress Notes OB Delivery sheet is not dated and timed by person completing the form. The pathologist's report dated 4/27/12 is not authenticated by the pathologist with a date and time. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is no circumcision procedure note that was done on 5/3/12. This is confirmed in interview with RN Q on 7/14/12 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed the discharge instruction sheet is not timed when signed by the Pt on 2/7/12. The Progress Notes OB Delivery sheet is not dated and timed when completed by staff. The Delivery Record sheet is not signed, dated or timed by staff. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #34's MR review on 7/24/12 at 2:15 PM revealed there is no date and time when the newborn initial physical is completed. The circumcision procedure note is not timed. There is no time when the MD reviewed the history and physical and when the procedure time out was done for the circumcision on 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 2:15 PM.


26711

A MR review was completed on Pt. #1 closed same day surgical record on 7/24/2012 at 3:00 p.m. Pt. #1 had a colonoscopy on 3/1/2012. The H&P does not include a time the physician signed it. There is no time indicated for when the procedure started.
These findings were confirmed by RN EE at the time of the record review.

A MR review was conducted on Pt. #2 closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. The discharge instructions do not include a date or time the patient signed them and are not signed by a hospital representative. Pt. #2 MR had numerous progress notes that did not include the time the notes were written by the physician. A final operation report was not signed by the physician. These findings were confirmed by RN EE during the MR review.

A MR review was completed on Pt. #4 closed MR on 7/25/2012 at 10:00 a.m. Pt. #4's discharge summary was dictated by a physician assistant and not counter signed by the MD. According to Administrator EEE, in an interview on 7/25/2012 at 10:40 a.m., it is an expectation in this facility that physician assistant's work is counter signed by the MD. These findings were confirmed by RN EE at the time of the record review.

A MR review was completed on Pt. #7 closed surgical record on 7/25/2012 at 1:30 p.m. Pt. #7 was discharged on 4/6/2012. The final H&P contains a blank line.
This finding was confirmed by Health Care Informatics VV at the time of the record review.

Based on 11 of 31 MR reviewed (#10, 12, 13, 21, 22, 25, 26, 33, 18, 9, 2) and 4 of 4 staff interviews (VV, Q, SS, EE), the hospital failed to ensure that medical staff date, time and authenticate all orders entered into the MR. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:


05409

Per MR review of Pt. #10 assisted by HIC (Health Care Informatics) VV beginning at 2:45 p.m. on 7/24/12, the following was noted: The form entitled Medication Reconciliation Report for Admission (7 page report) is signed/authenticated by the MD, but not dated and timed on the 7 pages. HIC VV confirmed this during the record review.

Per MR review of Pt. #12 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: The post anesthesia care unit adjunct order form is signed and dated 3/1/12 by the physician, but the form lacks the time the physician signed. HIC VV confirmed this finding during the record review.

Per MR review of Pt. #13 assisted by HIC VV beginning at 3:15 p.m. on 7/24/12, the following was noted: The 8 page Adult admission orders signed by nursing on 2/6/12 requires a full physician signature with date and time signed. The 8th page of this document lacks the time the physician signed these orders. A physician order was written on 2/6/12 at 3:00 p.m. and the next physician order written on 2/6/12 lacks the time it was written and signed. The medication Reconciliation Report for Admission contains 6 pages of orders that were faxed to the physician on 2/6/12. The physician signed and dated the orders, but did not document the time the orders were signed. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #21 assisted by HIC VV beginning at 9:22 a.m. on 7/25/12, the following was noted: Verbal orders signed by nursing for 4/1/12 at 5:47 p.m. were faxed to the physician who signed the orders. The MD did not date or time the orders when signed. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The physician wrote orders on 4/6/12 and 4/5/12 without documenting the times the orders were signed. The reconciliation Report for Admission is a 6 page document containing medication orders which were faxed to the physician. The physician signed and dated the first 5 pages and did not document the times these pages were signed. This was confirmed by VV during the record review.


18816

Pt #25's MR review on 7/24/12 at 9:20 AM revealed there are orders written on 4/26/12 and 4/30/12 that are not signed, dated, or timed by the staff writing the orders. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there are admission orders that are not dated when written. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #33's MR review on 7/24/12 at 2:30 PM revealed there is an order written on 2/5/12 that not timed when written by the MD. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.


26390

Pt #18's MR review was completed with RN SS on 7/25/12 at 10:00 AM revealed there is an order written on 3/7/12 that was not signed, timed, or dated by the MD. This is confirmed with RN SS.

Pt #9's MR review was completed with RN SS on 7/25/12 at 8:00 AM revealed there is an order written that was signed by the MD but did not contain the date or time. This is confirmed with RN SS.


26711

A MR review was conducted on Pt. #2 closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. Pt. #2 had numerous physician orders that did not include the time the physician wrote the orders from several physicians. There were several preprinted order sets comprised of several pages each that were to be initialed on every page and signed on either the first or last of these pages that were missing initials and signatures, dates and/or times. These findings were confirmed by RN EE during the MR review.

Based on 6 of 31 MR reviewed (#2, 1, 8, 26, 31, 33), review of medical staff rules and regulations and facility P&P, and 2 of 2 staff interviews (EE, Q), the hospital failed to ensure that MD telephone and verbal orders are authenticated to include a time and date to ensure accuracy of the orders within 48 hours per medical staff rules and regulations. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
The facility's policy titled, "Patient Care Orders," dated 8/09, was reviewed on 7/24/2012 at 2:30 p.m. The policy states in part on page 1, #5, "Verbal orders must be kept to a minimum and are most appropriate for emergency situations only." In this same policy on page 4, Authentication/Validation of Orders, B. states, "All verbal/telephone orders must signed/e-signed within 48 hours with date and time."

Review of medical staff rules and regulations (dated December 2011) on 7/25/12 in the AM directs the following: Orders: Orders dictated to a RN or authorized person will be signed by the medical staff within 48 hours.

A MR review was conducted on Pt. #2's closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. Pt. #2 had 23 verbal orders during the hospital stay that were not properly authenticated by the physician (missing dates, times and/or signatures). RN EE confirmed these findings at the time of discovery.

A MR review was completed on Pt. #1's closed same day surgery record. On 4/2/2012 there is a verbal order for medication that has not been signed by a physician. RN EE confirmed these findings at the time of discovery.


18816

Pt #8's MR review on 7/24/12 at 1:50 AM revealed there is a verbal order written on 3/2/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is a verbal order written 4/30/12 that is not authenticated by the MD with a date. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there is a verbal order written on 2/5/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review 7/24/12 at 2:30 PM revealed there is a verbal order written on 2/7/12 that is not authenticated by the MD. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.

Based on 1 of 31 MR reviewed (#2) and 1 of 1 staff interview (EE), the hospital failed to ensure that consultative reports are completed and entered into the MR. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
A MR review was conducted on Pt. #2's closed surgical chart on 7/25/2012 at 7:50 a.m. accompanied by RN EE. Pt. #2 was admitted 2/4/2012 and discharged 2/10/2012. A transfer to an Intensive Care (IC) was ordered due to the need to intubate and place Pt. #2 on the ventilator because of respiratory problems during a surgical procedure. There is no consult report from an IC physician found in Pt. #2 MR. RN EE confirmed these findings during the MR review.

Based on 17 of 29 MR reviewed requiring a consent (12, 14, 16, 19, 22, 8, 23, 24, 25, 26, 31, 33, 34, 1, 4, 6, 35), P&P review and review of the consent for treatment forms, and 3 of 3 staff interviews (VV, Q, EE), the hospital failed to ensure that a patient/representative consent is obtained prior to a procedure, and that consents signed by the patient/representative and witness include the date and time they were signed. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.


Findings include:
Review of the Consent P&P (last revision date 1/10) on 7/25/12 in the AM, directs the following: "Policy: The consent should be documented in dictation or physician notes, and in appropriate instances such as surgery or invasive procedures, on written, signed consent form." A review of the consent form revealed that it requires a time and a date the consent was signed by the patient/representative/witness.


05409

Per review of Pt. #12 MR assisted by HIC (Health Care Informatics) VV beginning at 9:22 a.m. on 7/25/12, the following was noted: The procedure consent form signed by Pt. #12 lacks the time signed. The consent for treatment form signed by Pt. #12 and a witness lacks the times #12 and the witness signed the form. HIC VV confirmed these findings during the record review.

Per MR review of Pt. #14 assisted by HIC VV beginning at 9:55 a.m. on 7/25/12, the following was noted: The consent for treatment form was signed and dated but lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #16 assisted by HIC VV beginning at 8:59 a.m. on 7/25/12, the following was noted: A general consent for treatment was signed by #16's son on 2/3/12, but the form lacks the time signed. Another general consent for treatment was signed by Pt. #16 on 2/11/12, but lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #19 assisted by HIC VV beginning at 7:40 a.m. on 7/25/12, the following was noted: the consent for general treatment form was signed and dated by Pt. #19, but the form lacks the time signed. This was confirmed by VV during the record review.

Per MR review of Pt. #22 assisted by HIC VV beginning at 10:30 a.m. on 7/25/12, the following was noted: The General consent for treatment form was signed by Pt. #22, but lacks the date and time #22 signed. This was confirmed by VV during the record review.


18816

Pt #8's MR review on 7/24/12 at 1:50 PM revealed there is no consent for treatment, and no informed consent for cesarean section performed on 3/1/12. This is confirmed in interview with RN Q on 7/24/12/ at 1:50 PM.

Pt #23's MR review on 7/24/12 at 9:05 AM revealed there is no time on the consent for a sexual assault examination on 5/5/12. This is confirmed in interview with RN Q on 7/24/12 at 9:15 AM.

Pt #24's MR review on 7/24/12 at 8:45 AM revealed there is no time on the consent for a sexual assault examination, nor on the consent for treatment on 5/5/12. This is confirmed in interview with RN Q on 7/24/12 at 9:05 AM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed there is no signed informed consent for the epidural that was attempted to be placed during labor. The consent for treatment is not timed when signed on admission on 4/26/12. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed there is no consent for treatment upon admission on 4/27/12, and there is no signed informed consent for circumcision. This is confirmed in interview with RN Q on 7/2/412 at 10:10 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there there is no signed informed consent for the epidural Pt #31 received during labor on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review on 7/24/1/2 at 2:30 PM revealed there is no consent for treatment upon admission on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 2:20 PM.

Pt #34's MR review on 7/24/12 at 2:15 AM revealed there is no consent for treatment upon admission on 3/1/12, and there is no signed informed consent for circumcision. This is confirmed in interview with RN Q on 7/2/412 at 2:15 PM.


26711

A MR review was completed on Pt. #1's closed same day surgery record on 7/24/2012 at 3:00 p.m. in the presence of RN EE. Pt. #1's general consent for care does not include a time the patient signed it. RN EE confirmed these findings.

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. # 4's general consent for care does not include a time or date the patient signed it. RN EE confirmed these findings.

A MR review was completed on Pt. 6's closed same day surgery record on 7/25/2012 at 1:05 p.m. in the presence of Health Care Informatics (HCI) VV. Pt. #6's general consent for care does not include a time the patient signed it. HCI VV confirmed these findings.

A MR review was completed on Pt. #35's closed emergency department record on 7/25/2012 at 1:37 p.m. in the presence of HCI VV. Pt. # 35's general consent for care does not include a time the patient signed it. HCI VV confirmed these findings.

Based on 5 of 31 MR reviewed (8, 25, 26, 31, 33), review of medical staff rules and regulations, and 1 of 1 staff interviews (Q), the hospital failed to ensure that MR are complete within 30 days of discharge. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Review of medical staff rules and regulations on 7/25/12 in the AM revealed that: "Records: 12. Privileges to admit patients and conduct consultations will be automatically suspended if the practitioner fails to complete a patient's medical record within fifteen (15) days after the MR is available to the practitioner."

Pt #8's MR review on 7/24/12 at 1:50 PM revealed there is a verbal order written on 3/2/12 that are not authenticated by the MD, over 30 days from discharge date of 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #25's MR review on 7/24/12 at 9:20 AM revealed the Discharge Summary dictated on 4/29/12 is authenticated on 6/3/12 greater than 30 days from discharge date 5/1/12. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #26's MR review on 7/24/12 at 10:10 AM revealed the MR is incomplete beyond 30 days with no circumcision procedure note. There is a verbal order written on 4/30/12 that is not authenticated with a date, unable to confirm date order was signed. This is confirmed in interview with RN Q on 7/24/12 at 9:20 AM.

Pt #31's MR review on 7/24/12 at 11:10 AM revealed there is a verbal order written on 2/5/12 that is not authenticated by the MD, over 30 days from discharge date of 2/7/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #33's MR review on 7/24/12 at 2:30 PM revealed there is a verbal order written on 2/7/12 that is not authenticated by the MD, over 30 days from discharge date of 2/7/12. This is confirmed in interview with RN Q on 7/24/12 at 2:30 PM.

Based on P&P review, 3 of 3 staff interview (I, H, A), and nationally recognized standards of practice from the Center for Disease Control (CDC), this facility failed to follow safe injection practices with multiple dose vials in the Operating Room (OR) setting. Failure to follow safe injection practices has the potential to affect all patients in the facility

Findings include:
According to the CDC Safe Injection Practices 2007, "Safe Injection Practices to Prevent Transmission of Infections to Patients," states, "Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations."

In an interview with MD I on 7/23/2012 at 1:35 p.m., MD I stated that Lidocaine, a medication used to numb tissue prior to invasive procedures with needles and scalpels, is a multiple dose vial used for multiple patients in the OR, and it is drawn into syringes in a patient care area (the OR). This facility has 10 ORs. Administrator H was present and verified this interview.

The facility policy titled, "Multi-dose Vial Expiration Policy," dated 2/11, was reviewed on 7/24/2012 at 11:08 a.m. The policy states in #7, "The following medications will continue to be supplied in multi-dose vials however these items are relatively inexpensive so staff are encouraged to treat these items as single use products and discard any remaining amount after initial opening: Lidocaine 1%, 10 ml [milliliter], Lidocaine 1% with Epinephrine 20 ml, Lidocaine 2% with Epinephrine 20 ml."

The findings of this policy were discussed and verified with Administrator A on 7/25/2012 at 11:00 a.m.

Based on 18 of 19 emergency crash carts observed, P&P review, and 10 of 10 staff interviews (UU, Y, S, R, D, C, H, K, N, TT) the hospital failed to ensure that all medications and biologicals including those in emergency crash carts are secured from unauthorized access. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per review, of hospital P&P " drug distribution " on 7/25/12 in the AM (last revision date 11/17/02) directs the following: " 3. Storage and control monitoring of medications includes review of the following: Medication carts and medication storage areas are secured by being under constant supervision, are located in areas restricted to authorized personnel only, or are located in an area where patients/visitors are not allowed without supervision of health care personnel. "

The medication carts observed during the survey contained break away locks and were stored in unlocked areas where staff were not present or could not observe the medication cart to ensure security. As a result, the lack of security of all drugs/IV solutions on the crash carts allows for removal, tampering, destruction or personal use by unauthorized personnel, patients and visitors.

Per observation, while touring the ICU with Pt. Care Director (UU) and Nursing Director (Y) on 7/25/12 at 9:00 AM, it was noted that the ICU had two adult and one pediatric emergency crash carts which contained medications and IV solutions. 2 of 3 crash carts were not secured from unauthorized assess. The pediatric crash cart was in an unlocked storage room on a blind corner of a hallway. An adult crash cart was located in a hallway alcove which was not in direct view by ICU staff. Both carts had breakaway devices allowing for unauthorized access. The observations were confirmed by (UU) and (Y) during the tour.

Per observation, while touring the ED with ED Director (S) and Nursing Administrator (R) on 7/24/12 at 9:00 AM, it was noted that 6 of 6 emergency crash carts which contained medications and IV solutions were not secured from unauthorized access. An adult and pediatric crash cart in room #1, adult carts in rooms #2, 3, adult cart in the CAT (computerized axial tomography) scan room, and one between rooms 11 and 12 all had breakaway devices allowing for unauthorized access. Per interview with (UU), patients, family and other visitors could access the emergency crash carts resulting in the removal, tampering, destruction or use of the medications/IV solutions on the carts.


05409

At 8:40 a.m. on 7/24/12 it was noted that a crash cart located in the sub-nursing station on the 7 7th floor of the medical surgical unit, which is not occupied by nursing staff but in an alcove not visible on all 2 of 4 sides, had an easy break away lock on the cart. This crash cart is not in constant view of staff. Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.

At 8:43 a.m. on 7/24/12 tour of the 9 9th floor medical surgical unit revealed that a Pediatric and an Adult crash cart were both located in an unlocked clean utility room and both had easy break away locks. This clean utility room and the 2 crash carts are not under constant view of staff. Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.

At 8:46 a.m. on 7/24/12 tour of the 3rd floor medical surgical unit revealed that a crash cart was stored in an unlocked clean utility room with an easy break away lock. This cart is not in constant view of staff . Nursing Administrator Y, who accompanied Surveyor on this tour verified these findings.


18816

Per tour of the 5th floor Birthing Center with RN Mgr D and Administrator C on 7/23/12 between 1:00 PM and 2:45 PM the following was observed:

There are unsecured medications stored in the ante room off the labor/delivery/recovery (LDR) room 1. The medications are in a box with breakaway tags, and the cupboards and doors from the corridor and LDR rooms do not lock.

The crash cart in the Birthing Center operating room (OR) has a medication box on top with breakaway locks. The crash cart is not in constant view of staff, and the OR is unsecured. The above is confirmed in interview with RN Mgr D and Administrator C on 7/23/12 at approximately 2:45 PM.


26711

Emergency carts with medications and intravenous solutions and carts/drawers with needles and syringes were observed to be unsecured from unauthorized personnel (housekeeping staff would have after hour access without being supervised by authorized personnel) in the following areas:

--On 7/24/2012 at 7:35 a.m. in the Cancer Care Center
--On 7/24/2012 at 8:20 a.m. in the Day Surgery area
--On 7/24/2012 at 10:35 a.m. in the Endoscopy Suite

These findings were confirmed by Administrator H at the time of discovery.

On 7-23-2012 at 2:55 PM a tour of the Special Procedures Unit (SPU) was completed with Nursing Administrator K, Administration L and Director of the CCL, N. A crash cart with seal number 729617 was observed across from the nurses ' station. Director of the CCL, N explained the crash cart is not under direct supervision after the SPU closes.

On 7-24-2012 at 1:00 PM a tour of the 4th floor sleep lab was completed with Supervisor TT and Nursing Administrator K. A crash cart with breakaway seal #729609 was observed in the pass through area between the sleep lab and the CV unit.

Based on observations, 4 of 4 staff interviews (OO, FF, NN, LL) and record reviews, the facility does not prepare and serve food under sanitary conditions. This has the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
HAIR RESTRAINTS
The 2009 FDA Food Code states that " FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

On 7/24/2012, during 7:42 a.m. - 11:45 a.m., it was observed that the following foodservice employees in the kitchen without proper hair restraints: Director of Nutrition Services and Dietetics FF (facial hair), Food Service Volunteer GG (bangs), Ingredient Control staff HH (facial hair), Cook JJ (facial hair), Cook KK (facial hair), Cook LL (facial hair), Chef MM (facial hair), and Food Production Supervisor OO (facial hair).

On 7/24/2012, 1:40 p.m., review of Policy #: NSD 60, revised date 2/2012, " Uniform & Personal Appearance Policy, " determines it does not reflect current standard of practice based on section " Procedure: " A. 3. " A mustache is permitted, provided it is well trimmed, above the top lip, and not over the corners of the mouth. "

FOOD STORED AND PREPARED IN A SAFE MANNER
According to the 2009 Federal Food Code, 3-501.17 Ready-to-Eat, Potentially Hazardous Food, (Time/Temperature Control for Safety Food), Date Marking. " (A) ... READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold or discarded when held at a temperature of 5oC (41oF) or less for a maximum of 7 days. "

On 7/24/2012, 7:49 a.m. - 8:07 a.m., surveyor, accompanied by Food Production Supervisor OO (FPS-OO) made the following observations of food items without any type of identification:
· Freezer # 004: bag of chicken tenders, bag of chicken wings, bag of popcorn chicken, half a bag of pizza sausage, and half a bag of frozen grilled cheese sandwiches.
· Cooler #016: container of grated cheese, half a container of cubed chicken.
· Cooler #14: 14 turkey sandwiches and three trays of desserts.
· Cooler #13: Bakery rack of cookies.

Staff FPS-OO acknowledged surveyor observations of food items without any type of identification to be true.

On 7/24/2012, 2:22 p.m., review of facility ' s policy " Food Labeling, Dating, and Expiration Policy, " revised date, 9/9/10, states " All foods purchased, prepared, or stored in the Nutrition Services and Dietetics Department must be labeled and dated. "

COVERING RECEPTACLES
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled;

On 7/24/2012, surveyor observed the following garbage receptacles without lids and were currently not in use: 10:43a.m. - receptacle next to food line, 11:12 a.m. - receptacle next to griddle. All observations of receptacles without lids were all verified by Director of Nutrition Services and Dietetics-FF, Clinical Dietetics Supervisor-NN, and Food Production Supervisor-OO.

HAND HYGIENE
According to the 2009 Federal Food Code, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. Hands are to be washed during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks and before donning gloves for working with food.

On 7/24/2012, 11:15 a.m., surveyor observations of Cook PP wearing the same pair of disposable gloves for multiple tasks are as follows: opening and closing microwave; picking up a heated piece of roast beef out of container and placing onto plate; grabbing a garnish of kale and orange slice and placing onto plate next to roast beef; removed gloves and did not wash hands. These observations were verified by Director of Nutrition Services and Dietetics-FF and Clinical Dietetics Supervisor-NN.

On 7/24/2012, 11:26 a.m., surveyor observed Cook LL at griddle, remove disposable gloves, then put on another pair of disposable gloves without washing hands. Surveyor asked Cook LL if he washed his hands, which he stated " no. "

CROSS-CONTAMINATION
According to the 2009 FDA Food Code, food items and equipment must be properly stored to prevent transmission of foodborne pathogens or contamination.

On 7/24/2012, 7:38 a.m., surveyor observed a bakery rack with homemade breadsticks next to the hand washing sink exposed to any splash from individuals washing their hands. Clinical Dietetics Supervisor NN agreed it shouldn ' t ' be there and promptly removed the rack from the area.

On 7/24/2012, 8:10 a.m., surveyor observed stacks of clean pots and pans stored on a narrow shelf connected to hand washing sink. There was also a container of corn and another 6 inch quarter pan that had been prepared with a food release spray. Clinical Dietetics Supervisor NN and Food Production Supervisor OO promptly removed the items and agreed the pots and pans should not be stored on that shelf.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:
Building Ce -"Tower-Main Building"- "Existing Healthcare Occupancy" used.
K11: Unreliable separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K15: Interior finishes without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls and doors were not smoke tight w/ ratings.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Egress width was obstructed.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper identification.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A
K71: Rubbish and linens chutes properly maintained
K75: Proper storage and handling of rubbish and soiled materials.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous items.
K140: Medical gas alarm panels located in unoccupied areas.
K147: Electrical system not to NFPA 70 minimum standards.

Findings include:
Building Cm - "CAMS Building"- "New Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K14: Interior finishes of corridors and egress did not have minimum class rating.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K27: Proper labels on doors for a smoke compartment were not present.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K71: Rubbish and linens chutes properly maintained
K77: Medical Gas system zone valves not compliant.
K108: Emergency Generator Alarms are not compliant.
K147: Electrical system not to NFPA 70 minimum standards

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.

The hospital failed to ensure that patient supplies are secure from unauthorized access and that the building is maintained to ensure the safety and well-being of patients and staff. See Tag A-701

The cumulative effect of these deficiencies has the potential to affect the safety of all patients receiving services at the hospital.

Based on 6 of 6 observations, P&P review, and 6 of 6 staff interviews (R, S, H, V, W, X), the hospital failed to ensure that patient supplies are secure from unauthorized access and that the building is maintained to ensure the safety and well-being of patients and staff. This deficiency had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per observation, while touring the ED with RN (R) and (S) on 7/24/12 at 9:00 AM, it was noted that a large clean patient supply room was not secured from unauthorized access. The room is located at the end of a hall-way and just inside the ambulance garage. Examples of supplies found in the room were: oxygen canisters, syringes, needles, instruments, lab supplies etc. Per RN (R) and (S), visitors, patients and unauthorized staff could enter the patient supply room and remove, tamper with, destroy or use the supplies.


26711

A tour of the Surgery area, which included the Post Anesthesia Care Unit (PACU), Decontamination room, and operating rooms (OR) was conducted on 7/23/2012 accompanied by Administrator (Admin) H who verified all of the following findings at the time of discovery:

PACU (2:40 p.m.):
--Clean Utility room-walls had areas of gouges and paint missing, there was a missing ceiling tile above a water dispensing unit. Behind the water dispensing unit there was a build up of paint chips/flakes and debris.

Decontamination room (2:55 p.m.):
--The tile floor had gouges and missing pieces of tile making it a non-smooth surface and difficult to clean effectively.

ORs (3:00 p.m.):
--OR 4 had chips in the laminate of the desk top by the Medical Doctor (MD) dictation area creating a non-smooth surface.
--OR 5 had chips in the laminate of the desk top by the MD dictation area creating a non-smooth surface.
--OR 7 had chips in the laminate of the desk top by the MD dictation area creating a non-smooth surface.
--The surgery storage room door had gouges and chips in the laminate exposing porous wood underneath.

A tour of Cancer Center was conducted on 7/24/2012 accompanied by Admin H who verified the following finding at the time of discovery (7:35 a.m.): numerous gouges in the walls throughout the patient care area.

On 7-24-2012 at 9:05 AM a tour of the inpatient behavioral health unit (IBHU) was completed with Nursing Administrator V, Director of IBHU W and RN X who validated the following observations: Shower room #645 was noted to have peeling paint on the ceiling of the shower stall which could be ingested by patients, cracked ceramic tile on threshold of shower exposing sharp edges, and cracked and sharp tile exposed on the north wall next to shower stall which could be used to inflict self-harm by.

Tub room #646 had peeling paint around the shower stall, and sitting on the edge of the tub was a circle piece of thin rubber which could be ingested by patients. Director of IBHU W, explained staff must be using the rubber to clog the drain so the tub holds water. It was also noted that a housekeeping cart located in a hallway with a cabinet containing chemicals was unlocked and easily accessed by IBHU patients who could ingest the chemicals to inflict self-harm.

Based on tour and observation, staff interview, and record review, this hospital failed to maintain a safe and secure building. This deficiency has the potential to affect all patients, staff and visitors.

Findings include:
Building Ce -"Tower-Main Building"- "Existing Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K12: Class of Construction did not meet non-combustible standards of a Type II(protected)
K15: Interior finishs without flame spread ratings.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K21: Rating doors on hold-open without automatic closing capabilities via a local interconnected smoke detector.
K22: Access to exits without readily visible signs.
K25: Smoke Compartment walls and doors were not smoke tight w/ ratings.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K33: Exit enclosure is open to an unoccupied space.
K38: Access to exits was not accessible due to a dead-end.
K39: Egress width was obstructed.
K42: Suite configuration not at code minimums.
K43: Delayed egress door locking devices without proper siganage.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The HVAC system did not meet the minimum standards on NFPA 90A
K71: Rubbish and linens chutes properly maintained
K75: Proper storage and handling of rubbish and soiled materials.
K103: Interior partitions were constructed of combustible materials.
K130: Miscellaneous items
K140: Medical gas alarm panels located in unoccupied areas.
K147: Electrical system not to NFPA 70 minimum standards

Findings include:
Building Cm -"CAMS Building" - "New Healthcare Occupancy" used.
K11: Separation from a non-healthcare occupancy
K14: Interior finishes of corridors and egress did not have minimum class rating.
K17: Smoke tight corridor not maintained.
K18: Positive latching and smoke tight openings into the corridor.
K20: Vertical shafts were not constructed to the proper hourly rating.
K25: Smoke Compartment walls and doors were not smoke tight w/ratings.
K27: Proper labels on doors for a smoke compartment were not present.
K29: Reliable enclosure of hazardous areas was lacking at locations through out the building.
K51: Fire alarm strobes were not installed in all common areas.
K52: Fire alarm repairs could not be substantiated of being completed.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K71: Rubbish and linens chutes properly maintained
K77: Medical Gas system zone valves not compliant.
K108: Emergency Generator Alarms are not compliant.
K147: Electrical system not to NFPA 70 minimum standards

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate building found later in this report.


14105

Based on observation and 3 of 3 staff interviews (XX, YY, DDD), the facility did not provide adequate ventilation due to lack of filtration in accordance with CDC and AIA guidelines. In addition, air flow was from dirty to clean. This deficient practice had a potential of contaminating air in clean spaces with undesirable contaminants, and causing possible infection for all patients receiving services at this hospital.

Findings include:
The CDC guidelines can be found in the website


1. On 07/19/2012 at 9:50 am surveyor observed on the basement Air Handler Unit 14 did not have 30% prefilters for hospital spaces. The 2006 Guidelines for Design and Construction of Health Care Facilities requires all hospitals to 30% prefilters. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
2. On 07/23/2012 at 2:50 PM surveyor observed at the service closet 1-67 on the first floor, that the air flow was from the janitors closet to the corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires air flow from clean to dirty. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
3. On 07/23/2012 at 3:25 PM surveyor observed at the corridor next to stair one, that there was no ventilation in the room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have 2 air changes per hour of air flow. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
4. On 07/24/2012 at 9:40 AM, surveyor observed at the angio room that air flow was from clean supply to the angio room. The 2006 Guidelines for Design and Construction of Health Care Facilities requires air flow from clean to dirty. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
5. On 07/24/2012 at 11:43 AM surveyor observed at the mechanical room being uses as as planning room, that there was no ventilation in the room. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).
6. On 07/24/2012 at 3:50 PM surveyor observed at the corridor next to the clinic one, that there was no ventilation in the corridor. The 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have 2 air changes per hour of air flow. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff XX (Protector System Specialist), staff YY (Administrator Support Services) and staff DDD (Construction Specialist).

7. On 7/23/2012 at 7:42 am surveyor #14105 observed that the flow of air from OR #2 was not positive from this room into Corridor 300-3 [Third Level /I-2 occupancy]. 2006 Guidelines for Design and Construction of Health Care Facilities requires health care corridor to have positive air flow from clean to dirty. This observed situation was not compliant. The condition was confirmed at the time of discovery by a concurrent observation and interview with Staff WW (CAO), ZZ (Construction Supervisor), AAA (Electrician), and BBB (Safety Coordinator).

Based on 25 of 26 observations, P&P review, and 10 of 10 staff interviews (DD, UU, Y, CC, C, D, H, EEE, K, N), the hospital failed to ensure that clean/sterile and dirty supplies are kept separate, that staff follow universal precautions, that intravenous sites are protected from potential contamination, that sterile fields are protected from potential contamination, that staff wear appropriate personal protective equipment, that hospital environment and equipment is kept clean and maintained, and that clean linen is protected from dust and debris. These deficient infection control practices, with the risk for cross-contamination of micro-organisms, had the potential to affect all patients treated in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
Per CDC Guidelines for preventing transmission of infectious agents in healthcare settings 2007: IV. Standard Precautions: washing/gloving standards are as follows: " IV.A.3.a Before having direct contact with patients. IV.A.3.b After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. IV.A.3.c After contact with a patient's intact skin (e.g; when taking a pulse or blood pressure or lifting a patient). IV.A.3.d If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e After contact with inanimate objects (including medical equipment in the immediate vicinity of the patient. IV.A.3.f After removing gloves.

Occupational Safety and Health Administration Bloodborne Pathogen standards at 29 CFR 1910.1030(d)(3)(ix) requires the following: " Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces. "

Per CDC "Guideline for Hand Hygiene in Health-Care Settings" (MMWR 10/25/02) recommendations for glove use, page 33 #6 states, in pert: "Change gloves if moving from a contaminated body site to a clean body site. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects." ttp:www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Per CDC "Guidelines for Preventing Transmission of Infectious Agents in Healthcare Settings 2007" IV.B.1.a Wear PPE, as described in IV.B.2-4 when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur."

Per observation, while touring the Radiology department with Radiology Director (DD) and Surveyor on 7/24/12 at 2:15 PM, it was noted that a storage room with two filing cabinets, chairs, and bulletin boards also held sterile supplies and packs for pain/spinal injections. there were 6 boxes of sterile radiology injection packs on the floor, needles, chloraprep, gloves and syringes on a table. Per (DD), he is not sure how this room reached a point that it held both clean/sterile and dirty supplies.

Per observation, while touring the ICU with RN (UU) and RN (Y) at 9:00 AM on 7/25/12, it was noted that a janitor closet had clean brown garbage bags laying directly on the floor. In addition, there were personal affects in this dirty room: family pictures and jewelry hanging on a bulletin board. Per RN (UU), personal items should not be kept in this dirty janitor closet and the garbage bags should not be on the floor.

During this same tour, the door to the soiled holding room was propped open allowing for the disruption of the negative air-flow and the potential for cross-contamination. Two doors leading to a clean supply room that also held the medication dispensing system were also propped open allowing for the disruption of positive air-flow and the potential for cross-contamination.


05409

On 2 of 3 medication passes observed by Surveyor, the following was noted:
At 7:46 a.m. on 7/24/12 RN Z came to Pt. Room #930 to administer medication to Pt.
#29. Pt #29 asked RN Z to look at right ankle. RN Z touched Pt. #29's right ankle and then directly touched the scanner on the computer on wheels, contaminating the scanner. RN Z removed the computer on wheels with the contaminated scanner from room #930 without cleansing it. Nurse Administrator Y also observed and confirmed this observation.

At 8:51 a.m. on 7/24/12 RN BB Administered medications to Pt. #30 in #30's 7 7th floor room, then proceeded to assess Pt. #30's feet, lungs, and abdomen with gloved hands. RN BB removed the glove on BB's right hand and without cleansing the right hand, used the right hand to move the mouse on the computer on wheels stand. BB then removed the glove from the left hand and discarded the glove. Without cleansing hands, RN BB donned a new pair of gloves, which BB wore to flush #30's IV (Intravenous port). Nurse Administrator Y also observed and confirmed this observation.

At 8:28 a.m. on 7/24/12, Surveyor, who was accompanied by Nurse Administrator Y, observed Nephrologist AA on the inpatient hemodialysis unit. AA was not wearing a cover coat on the unit when entered both of the pt. hemodialysis stations while occupied during hemodialysis. Per interview with Patient Care Director UU at 10:46 a.m. on 7/24/12, UU confirmed that Nephrologist AA is required to wear a cover coat while pts. are in the unit receiving hemodialysis.

On 2 of 2 days of tour of the Laundry area accompanied by Supervisor of Linen Courier Services CC and Nurse Administrator Y, Surveyor observed the following:

On the initial tour of the Laundry beginning at 8:50 a.m. on 7/24/12, Surveyor noted that the double doors to the Laundry area were open. Upon entering the corridor where linen carts are being filled with clean linen, it was noted that 8 of 10 of the rooms had the room doors open while linen carts of clean linen were stored uncovered.

Beginning at 11:15 a.m. on 7/25/12 Surveyor was accompanied by Nurse Administrator Y and Supervisor CC, to verify that linen is not stored properly in the clean linen area. Staff Y and CC verified these following findings:

8 of 10 rooms in the clean linen area were noted to have open doors and uncovered carts containing clean linen:
Room #Sa 3-27 open door with 2 of 4 clean linen carts uncovered.
Room #Sa 3-21 open door with 10 clean linen carts uncovered.
Room #Sa 3-19 open door with 4 uncovered clean linen carts.
Room #Sa 3-15 open door with 13 uncovered clean linen carts.
Room #Sa 3-07 door open with 2 carts uncovered clean linen.
Room #Sa 3-05 door open with 1 uncovered clean linen cart.
Room #Sa 3-08 door open with 1 uncovered clean linen cart.
Room #Sa 3-18 door open with 7 uncovered clean linen carts.

Per interview with Supervisor CC at 11:25 a.m. on 7/25/12, there is no policy regarding when doors of clean linen rooms are closed, but it is facility practice to ensure that the clean linen room doors are closed at the end of the day and added that the double doors from the laundry area to the sky walk are not closed daily until 8:00 p.m. to 10:00 p.m.


18816

Per tour of the 5th floor nursing center, with RN Mgr D and Administrator C, on 7/23/12 between 1:00 PM and 2:45 PM the following was observed: The (environmental) Service Closet in the NICU (neonatal intensive care unit) has a box on the floor lined with a plastic bag.

The labor/delivery/recovery (LDR) rooms 1, 2, and 3 had unsecured needles and syringes in the fetal monitor cart.

The adjacent ante rooms to the LDR rooms have unsecured medications, needles and syringes.

Antepartum rooms 500 and 502 have syringes and needles unsecured in the fetal monitor cart.

The medication room off the nursing station is not secured and contains needles and syringes.

The clean utility room/medication room has urinalysis cups under the sink allowing for potential contamination.

The above is confirmed in interview with RN Mgr D and Administrator C on 7/23/12 at approximately 2:45 PM.

On 7/24/12 at 8:25 AM surveyor observed RN O complete a medication pass for Pt #32 in room 530. RN O entered the medication room, obtained percocet

Based on 6 of 6 staff interviews (RR, B, J, H, GGG, Q), policy and procedure reviews and observations, the hospital failed to ensure safe surgical practices. This deficiency had the potential to affect all surgical patients.

Findings include:

1. Hospital failed to ensure all surgical staff assistants are granted surgical privileges (see A945)
2. Hospital failed to perform fire drills for surgery staff and failed to ensure surgical skin preparation liquids are dry prior to surgery (see A951)

The cumulative effect of these failures has the potential for harm for all surgical patients and surgical staff.

Based on 3 of 3 staff interviews (RR, B, J), 1 of 1 first assist files reviewed (QQ), and review of the Medical Staff Rules and Regulations, the hospital failed to ensure that staff assisting Surgeon (LLL) with surgery are credentialed and privileged to do so. This affects all Surgeon (LLL) surgical patients.

Findings include:
The Medical Staff Rules and Regulations, dated December 20111 and reviewed on 7/24/2012 in the AM, revealed that surgical staff who are granted surgical privileges and appropriate staff status per the Medical Staff Bylaws and Credentialing Policies do not include surgical technicians who accompany/assist a surgeon and are not hospital employees.

Per interview, with QI Director (RR) on 7/23/12 at 3:30 PM, it was revealed ST (surgical technician) (QQ) assists Plastic Surgeon (LLL) perform surgery and does manipulate tissue. Per (RR), there are no other ST who accompany surgeons into the hospital OR who are not employees of the hospital.

Review of (QQ) personnel file on 7/24/12 revealed that ST (QQ) is not an employee of the hospital and has not gone through the established criteria, qualifications and credentialing process to be granted specific privileges to be performed as a ST accompanying Surgeon (LLL). This was validated in interview with AS (B) on 7/24/12 at 1:00 PM. A "OR Surgical Assistant Competencies" list in her file, dated 2/9/09, indicates ST (QQ) can perform the following: provides retraction of tissue and organs, clamps, cuts and or cauterizes vessels or tissue, placement of ties, suture ligatures and application of chemical hemostatic agents, use of electrocautery, closure of all wound layers, and insertion of drainage tubes.

Per interview, with RN (J) on 7/24/12 at 1:45 PM, ST (QQ) had completed the credentialing and privileging process at one time, but it is not current at this time.

Based on observation of 1 of 1 surgical procedure (Pt. #28), 4 of 9 surgery MR reviewed out of a total of 31 MR reviewed (#8, 31, 26, 34), 4 of 4 staff interviews (H, J, GGG, Q), and P&P review, this facility failed to conduct drills for patients in the Operating Room (OR), validate confirmation that an alcohol based skin preparation (ABSP) was dry prior to draping, and perform a "time-out" to ensure appropriate identification procedures prior to the start of surgery. These deficiencies had the potential to affect all patients who receive surgical procedures in the facility during the survey between 7/18/12 and 7/25/12.

Findings include:
In an interview regarding Surgical Services in which Administrator (Admin) H and RN Educator J was present on 7/23/2012 at 1:30 p.m. it was discovered that this facility failed to conduct regular fire drills regarding the potential for patients on fire in the OR.

RN Educator J produced a copy of a fire drill from the OR area which was dated June 15, 2006 and stated this was the last fire drill the facility documented regarding the patient being involved with the fire.

On 7/25/2012 at 2:04 p.m., Patient Safety Officer III confirmed that the OR does not have a procedure for how often fire drills are done in the OR.

On 7/24/2012 from 8:54 a.m. through 9:36 a.m. an observation of Pt. #28's abdominal surgery was conducted accompanied by Admin H.

Circulating RN GGG was observed to cleanse Pt. #28's abdomen with DuraPrep, an ABSP at 9:22 a.m. At 9:25 a.m. MD HHH began applying sterile draping to Pt. #28's abdomen. No member of the surgical team in the room confirmed that the ABSP was dry prior to the MD applying the drapes.

In an interview with RN GGG, during the observation, RN GGG stated, "That isn't part of our process and its one of my pet peeves." RN GGG was referring to the verbal confirmation of the ABSP being dry even though there is an area in the medical record to document that it is. Admin H confirmed this finding at the time of the discovery.

Review of the facility's policy titled, "Pre-Operative Skin Preparation of Surgical Patient Procedure," dated 1/10 was completed on 7/25/2012 at 1:30 p.m. The policy does not address how confirmation that an ABSP is dry prior to draping is addressed or that this should be documented.


18816

Pt #8's MR review by surveyor on 7/24/12 at 1:50 PM revealed the Time Out on the Site/Patient/Verification for Surgery/Procedure sheet is not signed, dated or timed by staff. This is confirmed in interview with RN Q on 7/24/12 at 1:50 PM.

Pt #31's MR review by surveyor on 7/24/12 at 11:10 AM revealed there is no documented Time Out for a procedure to manually remove a retained placenta on 2/5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.

Pt #26's MR review by surveyor on 7/24/12 at 10:10 AM revealed there is no documented Time Out for a circumcision done on 5/3/12. This is confirmed in interview with RN Q on 7/24/12 at 10:10 AM.

Pt #34's MR review by surveyor on 7/24/12 at 2:15 PM revealed the Time Out for a circumcision is not timed by the staff on 3/4/12. This is confirmed in interview with RN Q on 7/24/12 at 2:15 PM.

Based on 5 out of 9 surgery records reviewed out of a total of 31 MR reviewed (Pt. #4, 5, 6, 7, 31), 4 of 4 staff interviews (I, EE, VV, Q) this facility failed to complete a post-anesthesia evaluation to include all of the elements of an adequate post-anesthesia evaluation in a time frame appropriate for recovery from the anesthesia. Failure to complete an appropriate post-anesthesia evaluation has the potential to affect all surgical patients who require this evaluation.

Findings include:
In an interview with MD of Anesthesia I on 7/23/2012 at 1:35 p.m. in the presence of Administrator H, MD I stated that post-anesthesia evaluation is conducted by a member of the anesthesia team (either an MD or CRNA), usually about an hour after the procedure.

The facility form used for Pre/Post Anesthesia Evaluation has a section at the bottom left corner that includes level of consciousness ( a line and check box to indicate if the patient has returned to pre-anesthesia status), cardiopulmonary (a line and a check box to indicate if vital signs are stable [VSS]), a line for follow up care if indicated, and a line for complications (with a check box for none). A space for signature, date, and time are also in this section.

A MR review was completed on Pt. #4's closed inpatient record on 7/25/2012 at 10:00 a.m. in the presence of RN EE. Pt. #4 had spinal anesthesia for a left total knee replacement. The post-anesthesia evaluation does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by RN EE at the time of the MR review.

A MR review was completed on Pt. # 5's closed same day surgery record on 7/25/2012 at 11:10 a.m. in the presence of RN EE. Pt. #5 is a 7 year old who had a general anesthetic to remove tonsils and adenoids. Anesthesia started at 8:53 a.m. and ended at 10:00 a.m. The post-anesthesia evaluation was conducted at 10:02 a.m., an insufficient time to determine if the patient has sufficiently recovered from anesthesia. The post-anesthesia evaluation also does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by RN EE at the time of the MR review.

A MR review was completed on Pt. #6's closed same day surgery record on 7/25/2012 at 1:05 p.m. in the presence of Health Care Informatics (HCI) specialist VV. Pt. #6 had a general anesthetic for a hysterectomy. The post-anesthesia evaluation does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration. These findings were confirmed by HCI VV at the time of the MR review.

A MR review was completed on Pt. #7's closed inpatient record on 7/25/2012 at 1:30 p.m. in the presence of HCI VV. Pt. #7 had general anesthetic for back surgery. Anesthesia started at 10:19 a.m. on 4/3/2012 and ended at 1:16 p.m. The post-anesthesia evaluation was conducted at 1:25 p.m., an insufficient time frame to determine if the patient has sufficiently recovered from anesthesia. The post-anesthesia evaluation also does not include respiratory function, including respiratory rate, airway patency, and oxygen saturation, cardiovascular function, including pulse rate and blood pressure, temperature, pain, nausea and vomiting, and post-operative hydration.
These findings were confirmed by HCI VV at the time of the MR review.


18816

Pt #31's MR reviewed by surveyor on 7/24/12 at 11:10 AM revealed there is no post anesthesia note after removal of an epidural catheter that was placed on 2//5/12. This is confirmed in interview with RN Q on 7/24/12 at 11:10 AM.