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A. Based on review of the Hospital's Medical Staff Bylaws, Rules and Regulations, documentation from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Bylaws, Rules and Regulations reviewed on 9/20/11 at approximately 10:30 AM required, "...H. The patient chart will be considered delinquent should it lack required dictations or signature after 30 days."

2. Documentation presented by the Director of Medical Records on 9/20/11 at 10:30 AM entitled, "Incomplete Records List By Days Outstanding", indicated that as of survey date 9/20/11, there were 24 medical records incomplete (delinquent) greater than 30 days post discharge.

3. The above finding was confirmed with the Director of Medical Records during an interview on 9/20/11 at approximately 10:45 AM.

A. Based on review of Hospital policy, observation, and staff interview, it was determined that for 1 of 1 pharmacy, the Hospital failed to ensure outdated medications were not available for patient use.

Findings include:

1. The Hospital policy entitled, "Monthly Pharmacy Dating Check", was reviewed on 9/20/11 at approximately 9:00 AM and included, "...On the first of each month a list will be prepared...of drugs expiring through the first day of the month. Technicians will use this list to remove those drugs from stock..."

2. During the tour of the Hospital's pharmacy, conducted on 9/20/11 between 11:00 AM and 11:30 AM, the following outdated medications were found:
- 25 vials (5 milliliters) of Heparin 100 units/ml with an expiration date of 8/11
-100 tablets of Doxepin 10 milligram (mg) with an expiration date of 8/11.

3. The above findings were confirmed during interview with the Director of Pharmacy on 9/20/11 at approximately 11:30 AM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 1 Dietary department the Hospital failed to ensure all food products were properly stored and not outdated.

Findings include:

1. The Hospital policy titled, "Food Service Department Infection Control Guidelines" required that, "The Food Service Director is responsible for meeting standards set forth in the Illinois Department of Public Health (IDPH) Food Service Sanitation Code regarding ...handling and storage of food; cleaning and sanitizing ... equipment, utensils...
Refrigerated Storage Procedure: ... 6. Do not over-crowd or stack food. Space food on shelves so there is good air circulation permitting rapid chilling... 11. Cover all prepared food with foil, plastic wrap... or tightly fitted lids... 14. All food in the freezer should be labeled and dated... 15. Refrigerators must be cleaned daily. Mop floor , wipe up spills, etc..."

2. On 9/20/11 between 11:00 A.M. and 12:10 P.M. a tour of the kitchen was conducted. The following were observed:

- The "reach-in" refrigerator contained 2 plastic bags with employees' food.
- The "walk-in" refrigerator, contained boxes of food stacked up to the refrigerator's ceiling.
- The "jello refrigerator" contained 4 uncovered trays of outdated gelatin dated 9/15/11.
- The "old" walk-in freezer floor was littered with food debris and dirt build-up. The condenser was partially covered by boxes and there was ice condensation throughout the ceiling. Food items taken out of the original packaging were not unlabeled and undated.
- The dry storage area, contained a large opened an undated plastic bag of snack mix. Bulk foods (barley, 15- bean mix, navy beans, brown rice) stored in plastic bins were unlabeled and undated.
- In the food preparation area drawers, clean and soiled items were stored together such as opened sleeves of disposable Styrofoam cups, coffee filters, an unlabeled/undated opened bag of whole coffee beans, an opened plastic bottle of food machine oil, and soiled equipment parts.

3. The above findings were confirmed with the Director of Dietary during an interview on 9/20/11 at approximately 12:10 PM.

B. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 1 (E#8) dietary employee observed, the Hospital failed to ensure the employee was knowledgeable in manual dish washing procedures (sanitization testing and documentation on sanitizer log.

1. The Hospital policy titled, "Food Service Department Infection Control Guidelines" required that, "The Food Service Director is responsible for meeting standards set forth in the Illinois Department of Public Health (IDPH) Food Service Sanitation Code regarding ...handling and storage of food; cleaning and sanitizing ... equipment, utensils...
Refrigerated Storage Procedure ... "Sanitize-Rinse...If sanitizer method is used the sanitizing solution must be at least 200 ppm. Each time water is changed sanitizer must be checked using test strips. Verification of this must be noted on the sanitizer log posted above the 3 compartment sink."

2. On 9/20/11 at approximately 11:15 A.M. during the tour of the kitchen, the dish washing machine was not functioning and the dishes were being washed by hand. At approximately, 11:50 A.M., E #8 (Dish room Staff) was observed filling up the 3-compartment sink with water. The staff was requested by the surveyor to test the water with the test strip to see if the water was adequately sanitized. The result was less than 200 ppm (parts per million), an acceptable level, indicating adequate water sanitization. E #8 was unable to explain the appropriate amount of sanitizer that should be put in the water to obtain adequate water sanitization. E#8 also did not demonstrate that he was familiar with the proper method of testing the sanitizing level. E #8 was then coached by E #9 (Food Service Director) to keep adding the sanitizing agent and on how to use the test strip.

3. The above findings were confirmed with E#9,(Food service Director) during an interview on 9/20/11 at approximately 12:10 P.M. E #9 stated that the dish machine had been out of order since 9/10/11 and they were waiting for parts. E #9 also explained that the 3-compartment sink was not used on a daily basis but is now being used to wash the meal trays and kitchenware and there was no log kept for testing the water sanitization until 9/20/11.

A complaint survey was conducted on 06/22/11 (Complaint # 111258). Based upon the deficiencies cited at that time, the surveyor recommended that the COP, Physical Environment, A700 be found to be NOT MET. The complaint survey has been closed and any uncorrected deficiencies have been transferred to the Survey of 09/21/11.

Any uncorrected findings have been transferred to K130 under the surveyor of 9/21/11

Based on random observation during the survey walk-through, staff interview and document review during the Life Safety portion of a Full Survey Due to a complaint conducted on September 19 - 21, 2001, the surveyors find that the facility failed to provide and maintain a safe and sanitary environment for patients and staff. The surveyor recommends that the COP, Physical Environment, A700 remains NOT MET.

A complaint survey was conducted on 06/22/11 (Complaint # 111258). Based upon the deficiencies cited at that time, the surveyor recommended that the Standard, Life Safety from Fire , A710 be found to be NOT MET. The complaint survey has been closed and any uncorrected K tag deficiencies have been transferred to the Survey of 09/21/11.

Based on random observation during the survey walk-through, staff interview and document review during the Life Safety portion of a Full Survey Due to a complaint conducted on September 19 - 21, 2011, the surveyors find that the facility does not comply with NFPA 101 - 2000, the Life Safety Code. The surveyors recommend that the Standard, Life Safety from Fire , A710 remains NOT MET.

See K-tag deficiencies cited on the survey of 09/21/11

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 1 Surgery Department, the Hospital failed to ensure outdated supplies were not available for patient use.

Finding include:

1. The Hospital policy titled, "Rotating Stock on the Nursing Units" was reviewed on 9/22/11 at 10:00 PM. The policy included, "2. As supplies are rotated, expiration dates shall be checked and outdated supplies returned to the storeroom or discarded ...".

2. At approximately 7:00 AM during a tour of Operating Room 2, the following outdated items were found:
a. 1 packet of 2.0 PDSII (name brand) containing 1 dozen pieces of suture, dated 7/11
b. 1 packet of 0 PDS II containing 1 dozen pieces of suture, dated 7/11

3. At approximately 7:15 AM, during a tour of the Cast Room the following outdated items were found:
a. 1 of 1 packet of Reston self-adhering foam fad, containing 8 pieces of pad, dated 2/11
b. 1 of 1 Delta-Lite Conformables (casting supplies), dated 8/11
c. 1 of 1 Scotch Cast 3 inch Casting Tape, dated 5/11

4. The above findings were confirmed with the Director of Surgical Services on 9/20/11 at approximately 7:50 AM, during an interview.

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 1 Anesthesiologist (E #2) observed, the Hospital failed to ensure staff clean the stopper of multidose vials prior to inserting the needle into the vial per policy.

Findings include:

1. The Hospital policy titled, "Medications Packaged in Vials/Pharmacy" was reviewed on 9/20/11 at approximately 10:00 AM. The policy required, "...To ensure that single and multidose vials are used in a way that minimizes the risk of infection and ensures the potency of the drug. Staff should...follow proper technique... b.) Clean the stopper with 70% alcohol swab before inserting needle or interlink vial access device...."

2. During observational tour of OR-1 on 9/20/11 at approximately 7:18 AM, E #2 was observed drawing medication from 3 multidose vials. E #2 did not cleanse the stopper before inserting the needle into the vials.

3. The above finding was confirmed with the Director of Nursing during an interview on 9/20/11 at approximately 7:40 AM

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 5 of 7 (E#1-3, 6,and 7) surgical team members, the Hospital failed to ensure adherence to the dress code for the surgery department.

Findings include:

1. The Hospital policy titled, "Traffic Patterns and Infection Prevention In The Perioperative Practice Setting," required that "d). All facial head/hair will be covered while in the semi restricted/ restricted area of the surgical suite." "...f). Masks are to be worn at all times in the operating room in the presence of open sterile supplies ..." "...Masks are not to hang down loosely..."

2. On 9/20/11 between 6:46 A.M. and 7:45 A.M. in Operating Room #1, the following were observed:
- At 7:07 A.M., E #2 (Anesthesiologist), walked in the room in the presence of open sterile supplies, holding her mask, then held it over her nose and mouth before securing it in place.

- At 7:15 A.M., E #3 (Unit Secretary), walked in the room in the presence of open sterile supplies, holding her untied mask over her nose and mouth.

- At approximately 7:15 AM, E#7 was observed in the semi-restricted area with approximately 2 inches of hair on the back of head exposed below the surgical cap.

- At approximately 7:20 AM, E #1 was observed in the semi-restricted area with approximately 2 inches hair of both sideburns, and back of head exposed below the surgical cap.

- At 7:22 A.M., E #6 (Scrub Nurse), walked in the room in the presence of open sterile supplies, with her mask not tied securely on one end. E #6 then began arranging the sterile instruments.

3. The above findings were confirmed with the Director of Nursing and the Director of Surgery during an interview, on 9/20/11 at approximately 7:50 A.M.