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Based on a review of facility documentation, Personnel Files (PF), and employee interviews (EMP), it was determined that Warren General Hospital failed to ensure that personnel met applicable standards required by State law for six of 20 Personnel Files (PF5, PF8, PF11, PF13, PF16, and PF19).

Findings include:

A review on March 8, 2017, of Policy 103.55, "Personnel Evaluations," approved June 26, 2002, reviewed annually, revealed, "All employees ... will have ... work performance evaluated annually, and in accordance with State and Federal regulations. Annually, for the purpose of this policy, is ... defined as one year plus or minus one quarter year. ... ."

1. Review, between 8:30 AM and 11:30 AM on March 7, 2017, of PF5, PF8, PF11, PF13, PF16, and PF19, did not reveal documentation of completed annual Personnel Evaluations.

At approximately 1:15 PM on March 7, 2017, EMP17 confirmed the above findings.

2. On March 8, 2017, EMP17 advised that PF11 had not been administered to the employee due to an extended medical leave. EMP17 was uanble to provide a reason why the other Performance Evaluations were not completed and/or administered to the employees identified.

Based on facility documentation review, facility tour, and employee interviews (EMP), it was determined that Warren General hospital failed to ensure that patients have the right to receive care in a safe setting.

Findings include:

Review, on March 9, 2017, of Policy Procedure # 3016, Crash Carts (Adult and Pediatric) effective date 01/07/2017, revealed, "Policy: Emergency drugs and supplies ... shall be available on each patient care unit or service area: ... Cardiology Dept. (1) ... and Pediatrics (1). Purpose: To assure that ... appropriate drugs, supplies, and monitoring equipment ... available and ready for use. ... Procedure: Crash Carts will be maintained in designated Patient Care Areas and checked on the exterior on a daily basis and internally on a monthly basis. 1. Crash carts will be checked daily on the exterior for the following: a) Intact red lock ... i. Red lock has the same number as listed in the Log Book checklist; b. Intact red lock on Broselow Bag (... Pediatric Dept. ...) i. Red lock has same number as listed in the Log Book checklist; c. Cardiac arrest board ... m. Log Book will be maintained and kept on top of each crash cart located in the defined hospital units. Each log book will contain the following: i. daily checklist (external) of both crash cart and Broselow Bag; 1. Initials of person checking cart; a. full signature on page 2 of the Daily Crash Cart Checklist (see Appendix A); 2. Date cart was checked; 3. Cart lock number; ii. monthly checklist (internally); ... ."

1. A tour of the Cardiac Rehab area was conducted from 12:45 PM to 1:15 PM on March 8, 2017. Observation of the Daily Crash Cart Check Log did not reveal documentation of the checks being conducted from March 2 through March 8, 2017.

When asked, at the time of observation, who was responsible for monitoring the crash cart, EMP12 stated, "[EMP52]." EMP12 stated that EMP52 had left for the day.

When asked, at approximately 9:00 AM on March 9, 2017, how frequently Crash Cart Checks are to be done, EMP52 stated, "... exterior once a day and interior once a month ..." When asked why there was not documentation of checks being conducted March 2-8, 2017, EMP52 stated, "Sometimes I'm just so busy."

2. During a tour of the Pediatrics Unit on March 8, 2017, from 1:00 PM to 1:15 PM, a review of the crash cart Log indicated the cart was only being checked once a week.

At the time of observation, EMP21 verified that per the facility policy, the crash cart should be checked daily regardless of whether or not there are Pediatric patients present on the Unit.

Also at the time of observation, EMP21 confirmed the facility was not in compliance with their policy to check the crash cart, as the Log indicated the cart was only being checked once a week.

Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that Warren General Hospital failed to obtain a Physician Order for restraints in two of five records in which restraints were being utilized. (MR1 and MR4).

Findings include:

Review of Restraints, Medical, on March 6, 2017, at approximately 11:40 AM, revealed, "Medical Restraints. Policy: All patients have the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, others... Physical Restraints found in acute care include: side rails, vest, limb holders, safety belts that cannot easily be released by the patient, Geri Chair with tray up, and boxing glove style mitts. For the purpose of ordering a restraint or seclusion, the order must be obtained by a physician ... the maximum duration of the order is 24 hours. If the need for restraint exists after the expiration of the order, a Physician must re-order the restraint ... ."

Review, at approximately 5:00 PM on March 9, 2017, of Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations, updated March 27, 2015, revealed, "... F. Medical Records. Form and Content of Record ... The medical record for inpatient, surgical, emergency, and outpatient therapeutic services must contain the following information: ... documentation of patient's response to the medications or services provided; ... I. Orders and Notes ... Inpatient Orders. Medication or treatment shall be administered to inpatients only upon written and signed orders ... of a practitioner acting within the scope of his or her license. All orders shall be signed, dated, and timed by the ordering practitioner ... ."

1. During tour of the In-Patient Medical Surgical Acute Care Unit on March 6, 2017, at approximately 11:30 AM, the patient (MR1) was observed with all four side rails placed in the up position.

2. Review of MR1, on March 6, 2017, at approximately 11:50 AM revealed that there was no physician order for all the side rails to be up.

3. On March 6, at approximately 11:50 AM EMP27 confirmed that siderails were considered a restraint and confirmed that there was no order for four side rails for the patient (MR1).

4. Review of MR4, on March 6, 2017, at approximately 1:00 PM, revealed documentation indicating that a right upper extremity restraint was applied from 7:30 PM on January 29, 2017, through January 30, 2017, at 2:00 PM. There was no physician order for the right upper extremity restraint for the patient (MR4).

5. On March 6, 2017, at approximately 2:00 PM, EMP18 confirmed that there was no order for the restraint documented for MR4.

Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that Warren General Hospital staff failed to document three doses of Propofol administered for one of one sedation medical records reviewed (MR2).

Findings Include:

Review of policy Medication Administration, revised June 18, 2011, revealed, "... Policy: Medications will be administered only upon the order of licensed independent practitioners, who are members of the medical staff, and are authorized members of the house staff who have been granted clinical privileges to write such orders and under the guidelines of their respective scopes of practice. Administration of medications will be by physicians, registered nurses, licensed practical/vocational nurses, respiratory therapists, physical therapist and/or their respective supervised students...Medication Administration Record (MAR) will be compared with the Pyxis prior to any medication...The individual administering a medication will be aware of the following information concerning each medication before administration:... Appropriate timing of medication administration Normal dosage and maximum safe dosage ... Each dose of medication administered is to be properly recorded in the patient's medical record. ... ."

Review, at approximately 5:00 PM on March 9, 2017, of Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations, updated March 27, 2015, revealed, "... F. Medical Records. Form and Content of Record ... The medical record for inpatient, surgical, emergency, and outpatient therapeutic services must contain the following information: ... documentation of patient's response to the medications or services provided; ... I. Orders and Notes ... Inpatient Orders. Medication or treatment shall be administered to inpatients only upon written and signed orders...of a practitioner acting within the scope of his or her license. All orders shall be signed, dated, and timed by the ordering practitioner ... ."

1. Review of MR2 on March 7, 2017, at approximately 1:45 PM, revealed documentation that the patient received 5mcg of Propofol on February 10, 2017, at 8:00 PM, 10mcg of Propofol on February 10, 2017, at 8:45 PM, and 15mcg of Propofol on February 10, 2017, at 9:15 PM. These medications were not documented in the Medication Administration Record (MAR).

2. During an interview on March 7, 2017, at approximately 1:55 PM, EMP7 confirmed that the medications listed above for MR2 were not documented on the MAR and further indicated, "Yes, the Propofol doses should be on the MAR."

Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that Warren General Hospital failed to document the need for medication to be administered for one of one medical records reviewed for sedation medication administration (MR2).

Findings Include:

Review of policy, Subject: Standards of Practice, General Nursing, revised, July 28, 2016, revealed, "... Policy: It is the policy of the Nursing Services Department of Warren General Hospital to utilize the American Nurses Association's NURSING: Scope and Standards of Practice, 2nd Edition based on the nursing process ... Standard 1:The registered nurse collects comprehensive data pertinent to the healthcare consumer's health and/or the situation ... Standard 5: Implementation. The registered nurse implements the identified plan ... Documents relevant data in a retrievable format. The registered nurse implements the identified plan. Standard. 5. A. Coordination of Care The registered nurse coordinates care delivery ... Documents the coordination of care ... ."

1. On March 6, 2017, at approximately 1:00 PM, review of a physician order for MR2, indicated, "... Start Date ... February 10, 2017, 18:10 ... Continuous: 5 to 50 mcg/kg/min (03. 30mg/kg/kg/hr.) (microgram/kilogram/minute) Text: For Protocol Reference: Propofol Diprovan Protocol for Continuous I.V. (Intravenous) Infusion ... Adult Dose Initial: 50mcg/kg/min (03. mg/kg/hr) IV over 5 minutes. Increase initial rate in increments 5-10 mcg/kg/min (0.3 to 0.6 mg/kg/hr) every 5-10 minutes to desired level of sedation. Continuous: 5-50 mcg/kg/min (0.3 to 30mg/kg/hr) ... ."

2. Review of MR2, on March 6, 2017, at approximately 1:00 PM, revealed that the patient received Propofol twice on February 11, once on February 12, and twice on February 13, 14, and 15, 2017. There was no documentation that the patient was agitated or restless to warrant the continued use of the Propofol.

3. On March 6, 2017, between 1:45 PM and 2:00 PM, EMP7 confirmed the above findings. EMP7 confirmed that the need for the Propofol was not documented for MR2, and EMP7 confirmed that the physician order did not provide the definition or a scale for the "desired level" of sedation.

Based on a review of facility documentation, facility tour, and employee interviews (EMP), it was determined that Warren General Hospital failed to ensure that drugs were kept in a secure area.

Findings include:

Review, at approximately 4:40 PM on March 9, 2017, of a document titled, Operational Standard: Floor Supplies revealed, "... Responsibility ... Food and Nutrition Services Department ... 2. The Food Service employee will place all perishable items ... in the refrigerator in the floor kitchen. ... Expired, out-of-date, opened or uncovered, unlabeled and improperly stored items will be discarded. ... ."

Review, at approximately 4:45 PM on March 9, 2017, of a document titled, Medication Management Storage. Inspection and Inventory, revised December 2016, revealed, "... Procedure: ... Refrigerated Medications: ... Food is not permitted to be stored in medication refrigerators. ... ."

Review, at approximately 4:50 PM on March 9, 2017, of manufacturer information for Anectine-Succinylcholine chloride injection, revised April 2012, revealed, "... Clinical Pharmacology. Succinylcholine is a depolarizing skeletal muscle relaxant. ... Warnings: Succinylcholine should be used only by those skilled in the management of artificial respiration and only when facilities are instantly available for tracheal intubation and for providing adequate ventilation of the patient, including the administration of oxygen under positive pressure and the elimination of carbon dioxide. The clinician must be prepared to assist or control respiration. ... ."

1. A tour of the RehabWorks Department was conducted between 12:45 PM and 1:15 PM on March 8, 2017. Observation of the Cardiac Rehab Area revealed a refrigerator containing nourishments. Further observation revealed a vial of Succinylcholine Chloride Injection 200mg/10 mL, Lot: 7602555, EXP: 05/2017. The refrigerator was not equipped with a lock, and was unattended by staff.

When asked, at the time of observation, who was responsible for the area, EMP12 stated that EMP52 was responsible, and had left the building for the day.

2. At approximately 8:58 AM on March 9, 2017, EMP52 was asked why the Succinylcholine was being stored in the nourishment refrigerator in the Cardiac Rehab area refrigerator. EMP52 stated that they did not know how the medication came to be in the refrigerator, nor why the medication was in the refrigerator. EMP52 further stated that they had not known the medication was in the refrigerator. EMP52 confirmed that the refrigerator is stocked by the Dietary Department.

3. At approximately 9:03 AM on March 9, 2017, when asked how/why the medication would have been in the nourishment refrigerator in the Cardiac Rehab area, EMP54, EMP55, and EMP22 denied knowledge of how or why the medication would have been in the nourishment refrigerator in the Cardiac Rehab area. A request was made for the facility to track the lot number through the distributor to determine if the vial had been part of the facility's inventory.

4. When asked, at approximately 9:30 AM on March 9, 2017, what the process is for stocking the nourishment refrigerators in the individual departments, EMP50 stated, "We have PAR levels. ... We do it once a week." When asked what the expectation would be if a Dietary staff member found a medication in a nourishment refrigerator during rounds, EMP50 stated, "They might report it to me ... or we may discard it." A request was made to speak with the staff member that would have conducted the most recent check of the nourishment refrigerator in question.

5. At approximately 9:45 AM on March 9, 2017, EMP53 was identified as being the Dietary staff member to have conducted the most recent check of the Cardiac Rehab nourishment refrigerator. When asked when the last check was conducted of the identified refrigerator, EMP53 stated that they had conducted checks on the refrigerator Tuesday, February 28, 2017, and Tuesday, March 7, 2017. When asked if they had noticed any medications in the refrigerator at the time of the checks, EMP53 stated, "I saw a little bottle." When asked if they reported the medication to their Supervisor or staff in the area of the refrigerator, EMP53 stated, "No, because I saw it the Tuesday before. ... I just thought it was Insulin. ... I was in a hurry."

6. At approximately 9:50 AM on March 9, 2017, EMP50 confirmed that it would be the expectation that if, upon checks, Dietary staff note medications in a nourishment refrigerator, they would report the inappropriate storage to EMP50.

7. During a tour of the Cancer Center on March 9, 2017, at approximately 9:15 AM revealed two multi-dose vials of Xylocaine, unsecured, in an open Treatment Room.

During an interview, at the time of the tour, EMP20 confirmed the two unsecured medication vials.

Based on a review of facility documentation, observation and employee interviews (EMP), it was determined that Warren General Hospital failed to discard outdated, mislabeled or unusable medications in the Cancer Care Unit and on the Psychiatric Unit of the hospital.

Findings include:

Review of a facility document at approximately 4:45 PM on March 9, 2017, titled, Medication Management Storage. Inspection and Inventory, revised December 2016, revealed, "... Procedure: Inventories/Expiration Dates: ... All opened multi dose vials will be dated 30 days from the date opened, which will indicate the day it can no longer be used ... ."

Review, at approximately 10:15 AM on March 10, 2017, of a document titled, ... Inspection and Inventory (3206), revised June 2014, revealed, "... PROCEDURE: Inventories/Expiration Dates: ... All opened vials will be dated ... ."

Review of manufacturer guidelines on March 10, 2017, at approximately 9:00 AM, revealed, "Maximum Storage Conditions for Insulin Vials ... Lantus ... Refrigerated 36-46 degrees ... Open 28 days ... ."

Review of manufacturer guidelines of the influenza multi-dose vaccine vial revealed, "... Once the stopper of the multidose vial has been pierced, the vial must be discarded within 28 days ... ."

1. Tour of the Cancer Center, on March 9, 2017, at approximately 9:15 AM, revealed one opened multi-dose vial of Xylocaine located in a Treatment Room. There was no open date or use-by-date on the bottle.

2. On March 9, 2017, at approximately 9:15 AM, EMP20 confirmed that the bottle did not have an open date or use-by-date.

3. During a tour of the Psychiatric Unit Medication Room, on March 9, 2017, at approximately 9:30 AM, three opened multi-dose vials [sterile water, Lantus Insulin, and Influenza vaccine] were observed without a use-by or open date.

4. On March 9, 2017, at approximately 9:30 AM, EMP19 confirmed that the sterile water, Lantus Insulin, and Influenza vaccine multi-dose vials were opened and did not contain a use-by or open date.

Based on a review of facility documentation, facility observation, and employee interviews (EMP), it was determined that Warren General Hospital failed to ensure that the physical plant and overall hospital environment was maintained in such a manner that the safety and well being of patients were assured (A-0701); and failed to ensure that the alcohol-based hand sanitizer dispensers were installed in a manner that minimized leaks and spills that could lead to falls and were maintained in accordance with dispenser manufacturer guidelines (A-0716); and failed to ensure that facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality (A-0724).

Findings include:


A-0701

Review, at approximately 10:00 AM on March 10, 2017, of Policy 1000, Building Services Department Mission, reviewed July 2014, revealed, "... Policy: It is the mission of the Building Services Department to provide a safe and comfortable environment for patients, staff and visitors. Procedures: This mission is accomplished through all the various activities of the Department. These include repairs, preventative maintenance programs, floor inspections, etc. ... ."

Review, at approximately 10:05 AM on March 10, 2017, of Policy 8090.00, Environmental Services Policies & Procedures Completed, effective October 4, 2016, revealed, "... 001 ... Principal: A clean, safe environment shall be provided and maintained within the hospital for all Patients, Employees and Visitors ... 002 Importance of Sanitation. Since all of the Environmental Department employees are working in an environment where the possibility of the spread of infection exists, the role of overall sanitation must be stressed. ... ."

1. A tour of the Emergency Care Center (ECC) was conducted between 11:45 AM and 12:37 PM on March 8, 2017. Entering the ECC from the Waiting Area, there were noted to be seven cracked floor tiles prior to entering the Treatment Area.

2. [ECC] Observation of the Family Consult Room revealed cove baseboard molding separating from the wall exposing the drywall underneath.

3. [ECC] Observation of the Patient Restroom across from the Family Consult Room revealed a gray/black substance built up around the base of the back of the toilet, which extended away from the toilet approximately three inches.

4. [ECC] Observation of the Staff Lounge Area revealed an area of exposed drywall in the staff restroom, on the wall, between the handwashing sink and toilet. Further observation of this area revealed approximately six cracked floor tiles.

5. [ECC] Observation outside of Room 2 revealed five cracked floor tiles.

6. [ECC] Observation of Room 3 revealed a cupboard located below the handwashing sink that had broken laminate at the bottom corner, exposing the particulate wood underneath. Further observation of this room revealed an area behind the soiled linen hamper, approximately ½ inch wide x approximately twelve inches long of exposed drywall.

7. [ECC] Observation of the area leading to the Ambulance entrance, at the back, left corner of the Department, revealed a total of 17 cracked floor tiles.

8. [ECC] Observation of the Stock Replenishment Area for ambulance personnel revealed approximately six cracked floor tiles.

9. [ECC] Observation of the ECC Manager's office revealed two ceiling tiles contained brown-colored stains.

10. [ECC] Observation of the ECC Nursing Station revealed pieces of laminate broken off near the floor, exposing particulate wood underneath.

11. [ECC] Observation of the Trauma Room revealed exposed drywall under the window of the imaging control alcove.

12. [ECC] Observation of Room 6 revealed a brown-colored stain on one of the ceiling tiles.

13. [ECC] Observation outside of the Clean Utility Room revealed approximately five cracked floor tiles outside the Room, and four cracked floor tiles inside the Room.

14. [ECC] Observation of the Soiled Utility Room revealed a ceiling tile with an approximately one inch gap between the ceiling tile and the drop-ceiling crossbar. Additional observation revealed multiple areas of exposed drywall.

15. [ECC] Observation of the Nursing Station, across from Room 8 revealed cove baseboard molding separating from the wall exposing the drywall underneath.

16. [ECC] Observation of Room 8 revealed accumulated dust on the top of a ceiling-mounted examination light.

17. [ECC] Observation of the area adjacent the door to the X-ray Department revealed approximately 15 cracked floor tiles.

18. [ECC] Observation of the linen storage area revealed an approximate one inch gap in one ceiling tile.

19. [ECC] Observation of the Dictation Room revealed an approximate one inch diameter hole in one ceiling tile.

20. [ECC] EMP14, present during the tour, confirmed the above findings at the times of observation.

21. [ECC] During additional tour, at approximately 11:05 AM on March 9, 2017, EMP8 confirmed the above findings.

22. An interview was conducted with EMP34 and EMP51 between 10:00 AM and 10:25 AM on March 9, 2017. When asked if either EMP34 or EMP51 were aware of cracks in the floors in the ECC, both denied knowledge.

23. A tour of the RehabWorks Department was conducted between 12:45 PM and 1:15 PM on March 8, 2017.

24. [RehabWorks] Observation of the Treatment Area revealed a cupboard, below a handwashing sink that had broken laminate at the bottom corner, exposing the particulate wood underneath.

25. [RehabWorks] Observation of an area for walker storage revealed a ceiling tile with an approximely one inch gap. Observation further identified a brown-colored stain on one ceiling tile.

26. [RehabWorks] Observation of the area outside of the Pediatric Speech Therapy Room revealed an air return with accumulated dust.

27. [RehabWorks] EMP12 confirmed the above findings at the time of observation.

28. A tour of the Walk-In Clinic was conducted on March 8, 2017, at approximately 1:00 PM. The tour revealed two electrical panels in the corridor of the clinic were left open. Panel One, was not equipped with a lock on the door; and Panel Two was equipped with a lock, which was not secured. Further inspection of Panel Two revealed, two missing breakers, creating potential for injury.

EMP12 confirmed the above findings at the time of observation.

At approximately 3:15 PM on March 8, 2017, EMP4 was informed of the findings and need to correct prior to surveyor departure for the day.

At approximately 3:45 PM on March 8, 2017, EMP4 confirmed that Panel Two had been secured, and the facility had made provisions to monitor Panel One until Clinic closure at 8:00 PM. EMP4 further stated that by morning, Panel One would have a lock installed.

At approximately 9:00 AM, on March 9, 2017, additional observation revealed that both panels had been secured.

At approximately 10:20 AM, on March 9, 2017, an interview was conducted with EMP51. When asked which Department is responsible for ensuring the security of electrical panels, EMP51 stated, "Building Services." When asked if Building Services monitors electrical panel security, EMP51 stated, "We haven't been ... I didn't know that lock [Panel One] was missing. ... Even though the public has access to that area, we are checking public corridors."

At approximately 11:48 AM on March 9, 2017, in response to a request for a policy regarding security of electrical panels, EMP18, confirmed that such a policy did not exist.


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A-0716

1. On March 8, 2017, at approximately 9:30 AM, Operating Room #3 was observed to have a 30 ounce bottle of Germ X sitting on the Anesthesia cart. The label on the bottle indicated, "... Flammable: Keep away from heat and flames ... ."

2. On March 8, 2017, at approximately 9:45 AM, EMP24 confirmed that the other ORs [OR1 and OR2] have unsecured alcohol bottles on the Anesthesia carts as well.

3. Tour of the Emergency Care Center (ECC) was conducted between 11:45 AM and 12:45 PM on March 8, 2017. During the tour, observations were made of six (outside Room 2, outside Room 4, outside Room 5, outside Room 6, outside Room 8, outside Room 9), wall-mounted alcohol-based hand rub dispensers that did not have provisions to prevent leaks that could lead to falls.

EMP14, present during the ECC tour, confirmed the findings at the time of the observation.


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A-0724

1. A tour of the Emergency Care Center (ECC) was conducted between 11:45 AM and 12:37 PM on March 8, 2017.

Observation of the Clean Utility Room revealed an ice machine that had a rough, white substance on the right side of the machine, by an opening in the side of the machine. Additional observation of the ice machine revealed a pink substance accumulating within the drip tray, and a pink substance and rust accumulating around the dispenser spout. Two preventative maintenance stickers were noted on the machine, one from 2002, and one from 2005.

Upon review, at approximately 12:44 PM on March 9, 2017, of Maintenance Logs for the ice machines, it was noted that the Logs did not contain documentation of required maintenance/cleaning of the ice machine located within the ECC Clean Utility Room.

2. During a tour of the Maternity Unit on March 8, 2017, from 1:20 PM to 1:35 PM, the ice machine was noted to have water dripping from the ice dispenser tube and the catch tray had hard, white, chalky-colored material in the bottom of the catch tray, as well as a rust-colored substance. The ice dispenser tube also had a white, chalky-colored material in the inside of the tube.

EMP21 verified the appearance of the ice dispenser tube, the catch tray and acknowledged the constant water dripping from the dispenser tube. It was also noted and confirmed by EMP21 that the preventative maintenance sticker on the ice machine was out of compliance.

3. During a tour of the Dietary Department on March 8, 2017 from approximately 2:45 PM to 3:25 PM, it was noted the preventative maintenance stickers were out of compliance on all but two pieces of Dietary equipment being utilized in the kitchen. The equipment in question is utilized in food preparation, cleaning of food, cleaning of plates, cups and eating utensils, and/or the storage of the patients, staff and/or visitors food. The ovens, steamers, exhaust hoods, cooking grill, refrigerators, freezers, dishwashers, food transportation carts, garbage disposal, ice machine and coffee dispenser had preventative maintenance stickers that ranged from 2011 to 2014. The sticker on the exhaust hood was bubbled and the date was not readable.

4. A preventative maintenance sticker was not visualized on the ice machine or on the inline filter to the ice machine. The outer container that housed the ice machine water filter had a black cobweb dangling from it, and the filter inside was a dark-brown color.

EMP49 confirmed the lack of preventative maintenance stickers on the ice machine and filter as well as the outdated preventative maintenance stickers on the other Dietary equipment. EMP49 stated, "I know for a fact that the coffee company checks and maintains their machines. I'm pretty sure they keep a log." When asked where the logs were, EMP49 indicated that the EMP50 normally takes care of all that information, however, EMP50 was not available during the tour.

5. Between 9:30 AM and 11:45 AM on March 9, 2017, tours were conducted of the Medical Group satellite locations, including the Internal Medicine practice on the 3rd floor of the hospital; the Family Medicine practice on the 2nd floor of the hospital; and the Family Medicine and Surgical Medicine practices in the St. Clair Building. Tour of these areas revealed preventative maintenance stickers that were out of compliance on the following: staff refrigerators, microwaves, coffee pots, and/or medication/vaccination refrigerators. The dates identified on the preventative maintenance stickers ranged from August 2008 through July 2015.

The above findings were confirmed by EMP46 and EMP47, at the time of the observations.

6. An interview was conducted with EMP34 and EMP51 between 10:00 AM and 10:25 AM on March 9, 2017. When asked if regular monitoring is performed of the pressure differential of the negative pressure patient care rooms, EMP51 stated, "Any time there has been a problem, we go and check it." EMP51 confirmed that the facility's Building Services does not conduct regular monitoring of the pressure differential in the negative pressure patient care rooms.

7. At approximately 11:40 AM on March 9, 2017, EMP18 confirmed that the facility did not have Quality Tracking for the Building Services Department performance of assigned duties. EMP18 stated that this was not the focus of the FY2016 Quality Data.

8. At approximately 12:14 PM on March 9, 2017, EMP18 confirmed, in response to a request, that the facility did not have a policy for the monitoring of the pressure differential of the negative pressure patient care rooms.

Based on a review of facility documents, medical records, and employee interview (EMP), it was determined that Warren General Hospital failed to transfer a patient with the necessary and appropriate medical information to another acute care facility for one of five transfer medical records (MR2).

Findings include:

Review on March 9, 2017, of Transfer Policy, dated August 1, 2011, revealed, "Policy: This policy applies to patient transfers (i) to another acute care hospital, (ii) to a different level of care (ex. Rehabilitation hospital or skilled nursing facility), and (iii) back to the patient's originating facility (ex. A skilled nursing facility) ... The Nursing Unit will prepare and send the appropriate documentation to the receiving facility. This documentation will include a. Face Sheet b. History and Physical. c. Progress Notes. d. Diagnostic test results ... ."

Review at approximately 5:00 PM on March 9, 2017, of Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations, updated March 27, 2015, revealed, "... C. Transfer Orders ... 3. To Other Healthcare Facilities ... The receiving institution will be furnished copies of an appropriate medical summary and other pertinent records. ... 4. To Nursing Homes. ... In lieu of a Discharge Summary accompanying the patient, licensed caregivers may complete the "Physician Interagency Transfer Out" form or a form designed by receiving facility ... ."

1. Review of MR2 on March 6, 2017, at approximately 1:00 PM, revealed that the patient was transferred to another acute care facility on February 16, 2017. There was no documentation that the patient's medical records were sent to the receiving hospital.

2. On March 8, 2017, at approximately 1:00 PM EMP18 confirmed that there was no documentation that the medical record was sent to the appropriate facility on transfer for MR2.