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Based on observation, record review, interview, and policy review, the provider failed to ensure medications were administered according to acceptable standards of practice by one of one registered nurse (RN) (D) observed during one of one medication administration observation. Findings include:

1. Observation on 3/7/11 at 3:15 p.m. revealed RN D gave patient 23 acetaminophen 325 milligrams (mg), two tablets.

Review of patient 23's 3/7/11 post-operative orders revealed a surgeon's order for Norco (hydrocodone 5 mg/acetaminophen 325 mg) one to two tablets every four hours as needed for pain. There was no order for just acetaminophen 325 mg, two tablets.

Interview on 3/7/11 at 3:20 p.m. with RN D revealed:
*Patient 23 had requested just acetaminophen for pain.
*She had given her just the acetaminophen 325 mg portion of the post-op Norco order.
*Patient 23's surgeon had given her a verbal order that if a patient wanted just acetaminophen, it could be given.
*She would write the acetaminophen on patient 23's chart as a verbal order.
*She had not called patient 23's surgeon about the acetaminophen order but was taking that from a past conversation with the surgeon.
*There was a standing order that acetaminophen 325 mg, two tablets could be given if the patient requested.

Review of the provider's standing order book revealed:
*None of the standing orders had been dated, signed, or timed.
*Patient 23's surgeon had no standing order for acetaminophen 325 mg.

Interview on 3/7/11 at 3:30 p.m. with director of nursing B revealed:
*Each surgeon had standing orders.
*She agreed none of the standing orders had been signed, dated, or timed.
*She agreed patient 23 had no surgeon's order for acetaminophen 325 mg two tablets for pain.

Review of the provider's 9/11/03 medical staff rules and regulations revealed:
*Standing orders for certain procedures or techniques may be formulated, revised, or withdrawn only by the medical staff. Standing orders were to be reviewed biannually.
*RNs were authorized to take to take an order from a member of the staff or an allied health professional who was granted the privilege to give orders. A verbal order would be considered a written order if dictated to an authorized employee and signed by the responsible practicer.
*A practitioner's routine orders should have been reproduced in detail on the order sheet of the patient's record, dated, and signed by the practitioner.

Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with either signatures, dates, or times. A sample of 248 medical record entries revealed 97 instances where either the signature, date, or time of the entry had not been recorded. Findings include:

1. Review of 72 written physicians' orders from all patient care areas revealed 8 were not dated and 31 were not timed.

2. Review of 41 physicians' progress notes from all patient care areas revealed 3 were not dated and 9 were not timed.

3. Review of 131 miscellaneous forms regarding physician or other staff contact with the patient from all patient care areas revealed 1 was not signed, 11 were not dated, and 34 were not timed.

4. Interview on 3/9/11 at 11:00 a.m. with administrator A revealed:
*She had started on 2/28/11 to contact physicians about correctly completing medical record entries.
*She acknowledged many entries in the medical record were not being dated or timed.
*There had not been any quality improvement efforts related to dating and timing medical record entries.

Interview with business manager C on 3/9/11 at 11:45 a.m. revealed the provider did not have a policy related to signing, dating, and timing of all medical entries by physicians and other staff members.

Review of the provider's medical staff rules and regulations signed 9/11/03 revealed:
*All progress notes should have been dated and timed.
*All routine orders were to be dated and signed.
*Operative reports were to be signed.
*Discharge summaries were to be authenticated.
*The rules did not include any requirements for timing orders or notes.
*The rules did not define what was included in the elements of authentication.

Based on observation and interview, the provider failed to ensure outdated medications and biologicals were not available for patient use. Findings include:

1. Observation on 3/7/11 from 2:45 p.m. through 3:00 p.m. revealed:
*One tube of Surgilube on the top of the medication refrigerator with an expiration date of June 2008.
*One 500 cubic centimeter of lactated ringers with 5 percent dextrose intravenous (IV) fluid with an expiration date of October 2010. That IV fluid was in a drawer in the post-anesthesia care unit (PACU) station 16.
*Two tubes of Surgilube with expiration dates of July 2008 and January 2011 in PACU station 17.
*One tube of Surgilube with an expiration date of January 2011 with the emergency airway supplies in the PACU.
*One vial of Tubersol purified protein derivative (PPD) with no date that indicated when it had been opened.
*One tube of providine ointment with an expiration date of January 2011. That ointment was located in the supply cabinet in operating room 4.

Interview on 3/7/11 at 3:05 p.m. with director of nursing B revealed:
*She was not aware of the outdated Surgilube, IV fluid, and Tubersol.
*She stated the Surgilube was not used very often.
*There was no specific monitoring of expired medications, IV fluids, and biologicals.
*The only monitoring of expired medications was from the pharmacy for the Pixis and the crash cart.
*She agreed the label on the vial of Tubersol PPD read to discard after 30 days from opening.

A. Based on random observation and interview, the provider failed to maintain the following items/areas in good/useable/cleanable/durable condition:
* Three expired foam hand sanitizers were found in use throughout the facility.
* Two of three housekeeping carts had toilet paper and paper towels stored in direct contact with cleaners and chemicals.
* The wall behind the floor mop sink in the housekeeping closet of the operating room (OR) suite was damaged and deteriorated.
* The wall above the two Steris machines had areas of missing paint.
* The metal three compartment sink located in the dirty processing side of central sterilization (CS) had peeled paint and rusted metal.
* The ceiling tiles in patient care corridors were soiled.
* The return air grates above the Pyxis machine and in the dirty processing side of CS were matted with dirt and debris.
Findings include:

1. Random observation from 2:30 p.m. to 5:00 p.m. on 3/7/11 and again from 8:00 a.m. to 2:00 p.m. on 3/8/11 revealed:
a. Foam hand sanitizers were found in the following areas with the following expiration dates:
- Room 3 with patient robes; printed expiration 9/09.
- Bottom of Steris cabinet; printed expiration 4/08.
- Anesthesia work room; printed expiration 1/08.
Interview with surgical technician (ST) N at the time of the observations confirmed those findings. She stated staff would change empty canisters, but no one monitored the canisters for expiration dates.
b. Two of three housekeeping carts had toilet paper and paper towels stored in direct contact with cleaners and chemicals (photo 1). Interview with ST N at the time of the observations confirmed those findings. She stated staff knew they could not store those items together, and she assumed they had done so out of convenience.
c. The wall directly behind the floor mop sink in the housekeeping closet of the OR suite was damaged and deteriorated (photo 2). Interview with ST N at the time of the observation confirmed that finding. She stated she was aware the wall was damaged but had not submitted a work order.
d. Two of five walls of the clean processing CS area had missing and scratched paint. Interview with ST N at the time of the observations confirmed those findings. She stated it appeared a metal cart had scratched the one wall (photo 3), and the other damaged areas were from staff pulling tape off the walls (photo 4). Those walls were also covered with notes and memorandums. ST N stated she was aware those damaged walls and hanging paper created an uncleanable surface in a sterile processing area.
e. The metal three compartment sink cabinet in the dirty processing CS area had large areas of chipped paint (photo 5) the size of checkbook and the inside of those cabinets were rusted. Interview with executive director A at 11:50 a.m. on 3/9/11 revealed she was aware the metal cabinet was in bad condition. She stated they had replaced one of the work counter cabinets a few years ago but had never replaced the sink cabinet.
f. Some of the ceiling tiles in the corridors of patient care areas were soiled and stained (photos 8, 9, 10, and 11). Interview with executive director A at 11:53 a.m. on 3/9/11 revealed she was aware of the soiled ceiling tiles. She stated they had several leaks in the spring and fall, and the tiles had become damaged.
g. The return air grate above the Pyxis machine in the corridor alcove was matted and layered with dust and debris (photo 6). An additional return air grate above the washer in the dirty processing CS area was layered with dust and debris (photo 7). Interview with ST N at the time of the observations confirmed those findings. She stated it was part of the housekeeping duties to clean those air grates. However those two had apparently been missed for some time.

B. Based on policy review and interview, the provider failed to incorporate a policy for emergency services of gas, water, electricity, and fuel. Findings include:

1. Review of the policy book revealed a policy could not be located to include provisions for natural gas, potable water, electricity, and fuel for the generator. Interview with the director of safety services for the parent company at 3:30 p.m. on 3/8/11 revealed there was no memorandum of understanding between the two facilities to provide such services. Interview with executive director A at 12:05 p.m. on 3/9/11 revealed she did not have a distinct policy for implementation of those provisions for the facility.

Based on observation, record review, interview, and policy review, the provider failed to ensure medications were administered according to acceptable standards of practice by one of one registered nurse (RN) (D) observed during one of one medication administration observation. Findings include:

1. Observation on 3/7/11 at 3:15 p.m. revealed RN D gave patient 23 acetaminophen 325 milligrams (mg), two tablets.

Review of patient 23's 3/7/11 post-operative orders revealed a surgeon's order for Norco (hydrocodone 5 mg/acetaminophen 325 mg) one to two tablets every four hours as needed for pain. There was no order for just acetaminophen 325 mg, two tablets.

Interview on 3/7/11 at 3:20 p.m. with RN D revealed:
*Patient 23 had requested just acetaminophen for pain.
*She had given her just the acetaminophen 325 mg portion of the post-op Norco order.
*Patient 23's surgeon had given her a verbal order that if a patient wanted just acetaminophen, it could be given.
*She would write the acetaminophen on patient 23's chart as a verbal order.
*She had not called patient 23's surgeon about the acetaminophen order but was taking that from a past conversation with the surgeon.
*There was a standing order that acetaminophen 325 mg, two tablets could be given if the patient requested.

Review of the provider's standing order book revealed:
*None of the standing orders had been dated, signed, or timed.
*Patient 23's surgeon had no standing order for acetaminophen 325 mg.

Interview on 3/7/11 at 3:30 p.m. with director of nursing B revealed:
*Each surgeon had standing orders.
*She agreed none of the standing orders had been signed, dated, or timed.
*She agreed patient 23 had no surgeon's order for acetaminophen 325 mg two tablets for pain.

Review of the provider's 9/11/03 medical staff rules and regulations revealed:
*Standing orders for certain procedures or techniques may be formulated, revised, or withdrawn only by the medical staff. Standing orders were to be reviewed biannually.
*RNs were authorized to take to take an order from a member of the staff or an allied health professional who was granted the privilege to give orders. A verbal order would be considered a written order if dictated to an authorized employee and signed by the responsible practicer.
*A practitioner's routine orders should have been reproduced in detail on the order sheet of the patient's record, dated, and signed by the practitioner.