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Based on interview and record review during a survey, the Medical Staff Bylaws and Medical Staff Rules and Regulations are not consistent with Federal and State laws and regulations.
Findings:
During interview on 12/6/12 at 10:00 am, the Medical Director confirmed the Medical Staff Bylaws and Rules and Regulations fail to include the following requirement:
A post-anesthesia evaluation by a practitioner qualified to administer anesthesia within 48 hours after surgery. [See 482.52(b)(3)]. The Bylaws include the medical record requirements for surgical patients without reference to the post-anesthesia evaluation.

Based on record review and interview, in 7 of 28 records reviewed the hospital failed to ensure patient consent forms were dated/timed in accordance with this regulation and hospital policy. Additionally, 2 of these medical records lacked dates/times on restraint orders.

Findings:

-5 out of 28 medical records were reviewed on 12/4-12/5/2012 for date and time of patient's signature and witness to the consent. 2 of these 5 (Patients #1, #2) lacked dates and times signed on general and surgical consent forms.

5 medical records reviewed on 12/4-12/5/2012 for the use of patient restraints revealed that one record (patient #6) did not have the documented time when the restraint was ordered and one record (patient #7) did not have the date or time the physician signed a telephone order.







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Based on observation and interview, the hospital did not ensure the physical plant was maintained in a manner to ensure the safety and well being of patients.

Findings are:

During the tour with the Facilities Director the following items were noted :

a) It was noted on 12/3/12 at 11:00 that the walls in the bathroom of room 420 and the 4A clean utility room were not in a smooth and easily cleanable condition.
b) It was noted on 12/4/12 at 11:30 am that the wall above the new instrument washers in Central Processing needed patching and painting.
c) It was noted on 12/5/12 at 10:45 am during a tour of the OR suite that the walls underneath the hopper and behind the door in the soiled utility room were not in a smooth and easily cleanable condition.
d) It was noted during the tour of the OR suite on 12/5/12 at 10:30 am that the floors in both the male and female locker room bathrooms were moldy underneath the soap dispensers.

All of the above findings were confirmed with the Facilities Director at the time of observation.

Based on observation and interview, the hospital failed to adequately maintain the water distribution system.

Findings are:

During the tour with the Facilities Director the following items were noted:

a) During a tour of the PACU with the Facilities Director on 12/5/12 at 1:30pm, it was noted that the water supply to the handwash sink in the soiled utility room had been disconnected.
b) During a tour of the obstetrical unit with the Facilities Director on 12/3/12 at 3:30pm, it was noted that the sink trap in the soiled utility room was leaking onto the floor.

All of the above findings were confirmed with the Facilities Director at the time of observation.

Based on observation and interview, the facility failed to maintain acceptable airflow and ventilation in the appropriate rooms.

Findings are:

a) During a tour of the endoscopy suite with the Facilities Director on 12/4/12 at 10:40am, it was noted that the return air grate in Procedure Room B was broken and dusty. No air movement was detected through this grate. Also, a cart with stereo equipment was stored directly in front of this air grate.
b) During a tour of the obstetrical suite with the Facilities Director on 12/3/12 at 4:00pm it was noted the patient bathroom in Room 205 did not have operable exhaust ventilation. Additionally, both the supply and return air ducts in this patient room were coated with dust. Upon further inquiry, the Facilities Director determined the motor connected to the exhaust ventilation for the entire obstetrical unit suite was not working.
c) During the tour of 4M on 12/3/12 at 10:30am it was noted that the soiled utility ("hopper") room did not have exhaust ventilation.

All of the above was confirmed with the Facilities Director.

Based on record review and interview the hospital failed to evaluate infection control data and report the analysis to the infection control committee. Additionally, based on observation, facility staff did not follow all Centers for Disease Control and Prevention (CDC) recommended safe injection practices.

Findings are:

-Review of the infection control committee meeting minutes for 2012 indicate that a continuous collection of data is maintained for ventilator associated pneumonias, blood stream infections, septicemias, and multi drug resistant infections. However, data is not analyzed to produce reports to the infection control committee that are both unit specific and organism specific. Additionally, National Healthcare Safety Network (NHSN) data is not reported to the infection control committee, so that the committee can design, implement, and evaluate preventative strategies. This impedes opportunities to improve patient care. This finding was confirmed on interview with the infection control preventionist on 12/4/2012.

-While observing care in operating room #3 during the morning of 12/5/2012 an Anesthesiologist was observed opening a medication vial without cleansing the top of the vial prior to punching the septum with a syringe and withdrawing the medication. The medication was then administered to the patient.

Both the CDC and APIC (Association for Professionals in Infection Control and Epidemiology) recommend that the access diaphragm of vials (including single use vials) be cleaned with an antiseptic prior to puncturing them with a needle.

Based on observation, record review and interview, 5 of 5 surgical records reviewed did not have an anesthesia post-op evaluation by the anesthesiologist prior to the patient being discharged. This is a repeat deficiency from the 2008 Medicare recertifcation.

Findings are:

-4 surgical in-patient charts were reviewed (patients # 1, 2, 3, and 4) and did not have a post-op anesthesia evaluation 48 hours prior to discharge.

-1 same day surgical patient's record (patient #5) was reviewed and the patient was observed in the post anesthesia care unit (PACU). The patient underwent a cataract extraction under monitored anesthesia care. She was observed being discharged from the post anesthesia care unit at approximately at 1:00 PM. Patient #5 did not have a post-op evaluation by an anesthesiologist prior to discharge.

-These findings were confirmed with the Vice President for Patient Services, Chief of Anesthesia, and the Director of Surgical Services at approximately 5:00 PM on 12/5/2012.