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Based on staff interview, record review and observation the facility failed to dispose of out dated supplies, maintain sterility of supplies, and to ensure they were not available for patient use. Inspection of Emergency Crash Carts was not maintained.

On observation while touring the Emergency Room (ER) at 2:30PM on 12/06/2010 one pediatric/infant lumbar puncture trey ( used for puncturing the spinal column and withdrawing the fluid that surrounds the spinal cord), one water seal chest drainage set (used to seal tubes that would be place in the chest wall after a trauma to remove unwanted blood and air), one 32f thoracic catheter ( a tube that would be place in the chest wall after a trauma to remove unwanted blood and air ), one spinal needle ( used to puncture the spinal column to access the fluid that surrounds the spinal cord ), one feeding tube ( is placed through the abdominal wall into the stomach for a source of feeding), one Exuderm wound dressing ( a dressing used on open wounds) were all found to be out of date.

Further observation while touring the Emergency Room (ER) at 2:30PM on 12/06/2010 one pickup ( a tweezers like tool used to hold the skin while sewing it), four individual packages of hemostats ( used to clamp off a bleeding vessel), one small loop curette ( multi purpose tool used for scrapping or cleaning areas like wounds or ear cannel's) were all found no longer sterile in old, brown and water stained packages.

Review of the Emergency Room's Crash Cart ( A rolling cart that house the major drugs and equipment needed to care for a patient with a life threatening event) Inspection Form reveled in the month of March on the AM shift the cart had been checked 29 of 31 days. On the PM shift of March it was checked 23 of 31 days. In April the cart was checked AM shift 26 of 30 days and PM shift it was checked 24 of 30 days. May the cart was checked in the AM shift 29 of 31 days and PM shift 19 of 31 days. June the cart was checked in the AM shift 22 of 30 days and PM shift 28 of 30 days. July the cart was checked in the AM shift 30 of 31 days and PM shift 30 of 31 days. August the cart was checked in the AM shift 29 of 31 days and PM shift 31 of 31 days. September the cart was checked in the AM shift 28 of 30 days and PM shift 29 of 30 days. October the cart was checked in the AM shift 30 of 31 days and PM shift 26 of 31 days. November the cart was checked in the AM shift 30 of 30 days and PM shift 25 of 30 days. For the first five days of December in the AM shift the cart was checked 3 of 5 and PM 1 of 5 days.

As per the Crash Cart Inspection Form " A monthly inspection of the entire contents for the cart must be performed and documented." Their were no monthly verification of inspection of entire contents for any of the month reviewed.

On observation of the ER crash cart it was found to be open and not secured.

Observation of the Broselow Pediatric Resuscitation Supply Cart was also done and the following issues were identified: 3 Intravenous Delivery Sets had expiration dated of 03/08 and the packages had been opened and taped back together; 1 Intravenous Delivery set had an expiration dated of 09/12 but the package had been opened and taped back together; 1 Intubation Kit had an expiration date of 01/09 and the package had been opened and taped back together; 1 Oxygen Delivery set had an expiration date of 05/11 but the package had been opened and taped back together; 1 Oxygen Delivery set had an expiration date of 05/15 but the package had been opened and taped back together: 1 Endotracheal Tube set had expiration date of 01/09 and the package had been opened and taped back together.

As per the Crash Cart Inspection Form " Designated pharmacy personnel will double check to make sure replacement medications are stocked, if not they will replace the medications and attach a Pharmacy Green Seal ensuring the integrity oft contents."

Interview at 2:30PM on 12/06/2010 of staff #2 confirmed the supplies were out of date, the sterile supplies' packages were compromised and the Emergency Room Crash Cart was not secured .

Based on observation and interview the facility failed to maintain the oxygen supplies in a safe manner based on 40 of 40 "H" cylinder oxygen tanks stored.


During a tour of the building on 12/7/2010 at 3:30 PM the oxygen supply for the hospital was observed to be outside the building. The storage area was a concrete floor with chain link fencing around it and a metal roof. Within the storage area 20 "H" cylinder oxygen tanks were observed individually chained to a steel bracket for immediate use. Facing these oxygen tanks were 40 "H" cylinder oxygen tanks that were full. They were secured with one chain around the entire group. The chain link door to the room was not locked. During 3 return visits to the oxygen storage area the door remained unlocked.

An interview on 12/7/2010 at 3:00 PM with the maintenance supervisor revealed the 20 "H tanks were directly connected to the oxygen supplied to the hospital. The 40 "H" tanks were for rotation as needed. The supervisor was not aware the storage area was to remain locked.

Based on observation and interview the facility failed to secure hospital trash in a manner that would inhibit animal or human foraging in 1 of 1 dumpster.


During a tour of the building on 12/7/2010 at 3:30 PM the dumpster was observed empty. The dumpster was also observed with a loose fitting lid. There was metal and wooden debris around the dumpster and paper residue on the ground around the dumpster. There was a three sided fence that blocked the view from the patient rooms but did not secure the front of the dumpster area from foraging.

An interview was conducted on 12/7/2010 at 3:00 PM with the maintenance supervisor who commented "It's always been that way"

Based on observation and interview the facility failed to maintain the patient nutritional care area and respiratory storage area in clean and orderly manner.

On observation at 2:45 PM on 12/06/2010 while touring the Medical Floor the patient nutrition area was found to have dirty flours, dirty refrigerators, dirty shelves with cluttered with employee cook pans and utensils. The area contained a mixture of stored employee food and patient foods. The area contained two refrigerators one identified as the employees' and the second as the patient refrigerator. On inspection of the employee refrigerator it was found packed with open, uncovered containers of food. The patient refrigerator was found with 3 containers of 2% milk that expired on 12/04/2010, one 4 oz open container of Mott's Apple Sauce with no label of date or time opened, one opened 2% carton of milk with no date or time opened.

Observation of the Employee Lounge that doubles as a storage area for patient respiratory supplies was found cluttered with open containers of employee food sitting on the table.

On interview with staff #2 while touring confirmed that these areas are used for both the patient and employee. She also confirmed the areas were dirty and cluttered and in need of cleaning.

Based on policy review and interview the facility failed to involve nationally accepted references in 2 of 2 emergency utilities, such as gas/water supplies for the hospital during a disaster.


A review of the External/Internal Disaster Plan Manual on 12/7/2010 at 10:00 AM did not reflect any nationally accepted references such as the Federal Emergency Management Agency (FEMA) for insuring adequate utilities such as gas/water during external or internal disasters.

An interview on 12/7/2010 at 3:00 PM with the Safety Officer reflected the hospital was recently connected to the city emergency water supply but had no reference for how much water could actually be supplied to the hospital.

Based on policy review and interview the facility failed to develop an ALL-Hazard disaster preparedness plan in joint effort with community, regional or national emergency partnership in 3 of 3 entities referenced.


On 12/7/2010 at 10:00 AM a review of the External/Internal disaster plan manual dated February 6, 2001 revealed the there was no information in the policy for communications with the local authorities, the Regional Advisory Counsel (RAC) or the Federal Emergency Management Administration (FEMA)

Interview on 12/7/2010 at 10:00 AM with the Safety officer revealed no drill had been scheduled or documented for hospital staff. He had not been in contact with local authorities or the RAC regarding the All-Hazard Disaster Plan and FEMA had not been referenced on recommended supplies for water or gas during a disaster.
An interview with the Administrator on 12/7/2010 at 4:00 PM revealed there had been no communication with the local disaster management authority regarding the Hospital's plan. The RAC had not been involved in the development of the All-Hazard disaster plan and an actual drill involving the local community response had not been held.

Based on record review and interview, the facility failed to document a delineation of privileges for 1 of 6 (# 12) active medical staff.

Findings include:

Review of medical staff appointment and re-appointment records revealed staff #12 had no documented delineation of privileges for the current appointment period. Interview with Administrator on 12/8/2010 in the board room confirmed the lack of documented delineation of privileges for this staff member.

Based on staff interview, observation and review of policy and procedure (P&P), the facility failed to date and initial multi-dose vials/bottles and properly dispose of outdated drugs to ensure they were not available for patient use.

Review of the Pharmacy standards of practices. The United States Pharmacopeia Chapter 797 revealed " Multiple-dose containers (e.g., vials) are formulated for removal of portions on multiple occasions because they contain antimicrobial preservatives. The beyond-use date after initially entering or opening (e.g., needle-punctured) multiple-dose containers is 28 days (see Antimicrobial Effectiveness Testing <51>), unless otherwise specified by the manufacturer. "

On review of policy, revealed that multidose vials (bottles of medication that can be used for more than one injection) are to be dated at the time it is opened. Policy reads, multidose vials are good for 90 days.

On observation while touring the Emergency Room (ER) at 2:30 PM on 12/06/2010 two 10 milliters (ml) vial of 1% Xylocaine and two 20ml vials of 2% Xylocaine (used to inject under the skin to cause a numbing effect before sewing the skin) were not dated when opened. These10ml and 20ml vials of Xylocaine do not contain preservative and are not considered multidose and should be discarded after the first use. One 50ml vial of 0.5 % Sensorcaine (used to inject under the skin to cause a numbing effect before sewing the skin) were not dated when opened. Five 4 ounce (oz) bottles of Hibiclense, four 4oz bottles of Iodine, four 4oz bottles of Dyna Hex and two 8oz bottles of Hydrogen Peroxide (all used for cleaning wounds) was open and not dated. Six 500mls bottles of Normal Saline and five 500mls Sterile Water (both used for cleaning wounds) were open and not dated. One bottle of 1/2 inch Plain Packing and one bottle of 1 inch Plain Packing (used for packing into open wounds to assist in healing) were open and not dated.

Interview at 2:30PM on 12/06/2010 in the ER staff #8 communicated that the policy on open containers was to date and initial the medications and bottles when opened and discard after 30 days.

On observation while touring the Medical Floor's Medication Room at 2:30 PM on 12/06/2010 30mls of 20% Acetylcysteine (used to liquefy mucus while taking breathing treatments) were observed open and not dated. Humulin 70/30, Humulin N, Levemir, Apidra (medications used by diabetics for injections (shots) to control blood sugars) were not dated when opened.

On observation while touring the Medical Floor's Medication Room at 2:30 PM on 12/06/2010 two 5mg/ml injection containers of diazepam (medication used to control anxiety and used as a muscle relaxant) was expired 11/2010.

Interview at 2:30 on 12/06/2010 of staff #10 was not familiar with the policy or process on how to handle out of date drug.

Interview at 1:00PM on 12/08/2010 in the Pharmacy, Staff #7 communicated that the policy on open containers was to date and initial the medication and bottles when opened and discard them after 90 days. She reported the policy on out of date drugs was to return them to the pharmacy and the pharmacist would take care of returning them to the company or he would dispose of them.

Interview at 1:00PM on 12/08/2010 of the Pharmacist by phone, he was asked about the policy on open containers and he communicated that the medications should be dated, initialed by the person opening the medication and should be discarded after 30 days of the open date. He reported that the policy on outdated drugs is to return them to the pharmacy.

Based on record review and interview the facility failed to investigate 27 of 27 Incident Reports related to medication errors and implement a facility wide process for reporting medication errors. .

Review of the pharmacy policy, "Medication Errors", Policy V, revealed the following: C. Complete a medication error report and deliver copy to Director of Nurses and to the Administrator. D.The Director of Nurses shall report the error to the Consultant Pharmacist at the pharmacist's next scheduled visit. E. The Director of Nurses and Consultant Pharmacist shall review the error and determined that appropriate action was taken.

Review of nursing policy, Section:___ HP 3.072, " Incident Reports, " revealed a conflicting process of incident reporting as described in the pharmacy policy. Nursing policy read " Do not make a copy of report " and " Route the report when completed to the Director of Nurses " . No process for follow up revealed in policy.

A reviewed of 64 incident reports, 27 of the incident reports were related to medication errors. The reports were written between 06/07/2010 and 12/01/2010. No evidence of follow up of the incident reports was found.

Interview at 1:00PM on 12/08/2010 of the Pharmacist by phone was asked about the 27 medication errors and the follow up. He reported the Director of Nurses had not made him aware of the medication errors.

Interview at 3:00PM on 12/08/2010 in the Administrative Conference Room the Director of Nurses confirmed the incident reports had been done by the staff and collected with no other follow up.

Based on record review, the facility failed to maintain completed medical records. 2 of 15 records had incomplete Emergency Room (ER) Physician records. 2 of 15 records had no time noted on the ER Physician record. 3 of 15 records contained illegible physician writing. 7 of 15 records had physician progress notes with no time noted. 8 of 15 records had registered nurse entries with no time noted. 4 of 15 records had signatures, dates, or times missing from physician (MD) or registered nurse (RN) entries. 1 of 15 records had an incomplete ER Physician History and Physical. 3 of 15 records had blank Intervention/Physical Assessment forms. The facility also failed to assure physician (MD) orders were properly dated and timed. 8 of 15 charts had MD orders with no time noted. 3 of 15 charts had MD orders with no date. Lastly, the facility failed to assure verbal orders were authenticated appropriately. 2 of 15 charts had verbal orders that were not countersigned by a physician. 3 of 15 charts had verbal orders that were not countersigned within 48 hours of being written.


Findings include:

Review of medical records revealed the following. The ER Physician record (patient #1) had no documented review of systems. The ER Physician record (patient #5) titled " Emergency Department Physician H&P " was blank, except for the patient ' s account number, name, birth date, date seen, and medical record number. Blank sections were: Medications, I.V. Fluids, Diagnosis, Differential, Treatment/Course, Condition on Discharge, ED Physician Signature, Time Out, Nurses Signature, Referred To, Staff Physician Signature, and Disposition/Meds/FU. The physician (MD #13) authenticated this record.

There was no time noted on the ER physician (MD #11) form on the records of patients #2 and #10.

The physician (MD #13) handwriting was illegible on the following ER physician records: #4 on the history and physical-dispo/meds/fu section, #5 on the clinical impression section, and #7 on the dispo/meds/fu section.

Physician progress notes lacked a time entry on the following charts (chart # followed by the number of instances times were lacking):
#8- x1
#9- x3
#10- x8
#12- x3
#13- x9
#14- x7
#15- x3

The following registered nurse entries lacked a time entry on the following charts:
#8- D/C Instruction Sheet x1
#9- Intervention/Physical Assessment on 10/5
#9- Nurses Note on 10/6
#9- D/C Instruction Sheet x1
#10- Skin Assessment x4
#11- Intervention/Physical Assessment on 11/19 x2
#11- Skin Assessment x5
#12- Intervention/Physical Assessment on 11/19 x2 and 11/24 x1
#12- Skin Assessment x8
#12- Physical Assessment on 11/29 and 11/30
#13- Intervention/Physical Assessment on 9/30, 10/5, 10/8, 10/9, 10/10, 10/11
#13- Skin Assessment x10
#13- Physical Assessment on 10/8
#13- Nurses Note on 10/10
#14- Skin Assessment x7
#14- Intervention/Physical Assessment on 9/1 and 9/7
#14- Physical Assessment on 9/2
#15- Physical Assessment on 8/23
#15- Intervention/Physical Assessment on 8/23 and 8/24
#15- Skin Assessment x12

The following charts had signatures, dates, or times missing from physician (MD) or registered nurse (RN) entries:
#10- Medicine Reconciliation form with no signatures, dates, or times by RN or MD
#12- Medicine Reconciliation form with no date or time by RN or MD
#12- No date on Activities Care Plan
#13- RN Physical assessment on 10/4 with no signature, date, or time
#14- Medicine Reconciliation form with no time by RN or MD
#14- Physical Assessment no RN signature, date, or time on 8/31

Three charts had blank Intervention/Physical Assessment form (#10 on 11/25, #14 on 8/27, and #15 on 8/27). These forms were to be completed by the RN.

Chart review revealed the following MD order entries with no times noted (chart # followed by the number of instances times were lacking):
#8- x4
#9- x3
#10- x7
#11- x8
#12- x19
#13- x15
#14- x3
#15- x14

Chart review revealed the following MD order entries with no dates noted (chart # followed by the number of instances dates were lacking):
#11- x2
#12- x2
#15- x5

Chart review revealed that patient #10 had three orders that were not countersigned by any physician. Patient #15 also had three orders that were not countersigned by any physician.

Chart review revealed that patient #8 had one verbal order that was not countersigned within 48 hours by MD #12. Chart #9 had one verbal order that was not countersigned within 48 hours by MD #13. Chart #14 had three verbal orders that were not countersigned within 48 hours by MD #15 and one verbal order that was not countersigned within 48 hours by MD #20.

Based upon record review and interview, the facility failed to include review of clinical records in the annual program evaluation.

Review of the document titled "Annual Review of Services - 2009" revealed there had been no documented review of clinical records associated with the annual program evaluation.

An interview was conducted with the Administrator on 12/8/10 at 4:30 pm. The Administrator confirmed that a clinical record review was not included as a part of the annual program evaluation.

Based on policy review and interview the facility failed to annually review and revise policies based on 4 of 4 department policy manuals reviewed.


A review of policies obtained from the safety Officer on 12/6/2010 at 10:00 AM revealed policies last review dated 6/98. The present safety officer was not listed in the manual.

A review of the dietary manual on 12/6/2010 at 10:00 AM, obtained from the dietary department revealed the manual was last dated as reviewed in 2000.

A review of the administrative policy manual on 12/6/2010 at 10:00 AM had a cover sheet dated 2010 however, numerous hand written corrections were observed in the manual. Policies were observed dated 2009.

A review of the policy manual for the Nursing Department, on 12/6/2010 at 10:00 AM, revealed the Nursing Department manual was dated 1998.

An interview with the Administrator revealed an accurately dated manual was kept in the administrative office however the working manuals were kept on the floor and had not been updated annually.

Based on observation and data reviewed the facility failed provide an effective quality assurance program to identify problems through on-going monitoring in 4 of 4 departments cited.

During a tour of the Emergency Department (ED) on 12/6/2010 at 10:00 AM surgical instruments were identified in a cabinet. The bag containing the instruments were brown. There was water stain on the bagged instruments and when the instruments were moved they were noted to have a brown ring around them with in the bag. An Emergency Room Nurse was asked if surgical instruments were ever used in the ED the reply was "yes". When the ED nurse was told the instruments were not considered sterile with brown rings and water marks on them the reply was "they're not?"

During a tour of the building on 12/6/2010 at 11:00 AM a refrigerator located within the laboratory, noted to have a "NO FOOD" sign on the front door, was found to have 1 frozen pizza, 2 cups of ice cream, 2 tubs of strawberry cream cheese, 1 half pint of milk and 2 bottles of water. When the laboratory supervisor was brought to view the refrigerator she stated. "I told them to clean everything up. I forgot about the fridge."

During a tour of the radiology department on 12/6/2010 at 11:30 am, ALL radiology rooms were found to have food stored in the cabinets. A small refrigerator with staff food was located in the MRI/CT control room.

An interview with the house supervisor confirmed departmental rounds were not being made.

During a tour of the building on 12/7/2010 at 3:30 PM the dumpster was observed empty. The dumpster was also observed with a loose fitting lid. There was metal and wooden debris around the dumpster and paper residue on the ground around the dumpster. A three sided fence blocked the view from the patient rooms but did not secure the front of the dumpster area from foraging.

An interview was conducted on 12/7/2010 at 3:00 PM with the maintenance supervisor who commented "It's always been that way"

Based upon record review, the facility failed to ensure activities occurred as stated on the Activities Care Plan for 4 of 4 (#12, #13#14, #15) patients reviewed.

Review of medical record for swing bed patient #12 revealed patient was admitted on 11/20/10 and discharged on 12/2/10. Review of the Activities Care Plan revealed the patient would have a one on one exercise program but there was no frequency for the exercise to be provided.The Care Plan further stated that patient would be provided in room, one on one activities in her room but no frequency for the activities to be provided. Further review revealed an Activity Planning Sheet dated 11/22/10 with instructions for staff to carry out a "Time to Talk"activity, an Activity Planning Sheet dated 11/29/10 with instruction for staff to carry out a "Walk Around" activity, and a Planning Sheet dated 12/1/10 with instructions for staff to carry out a "Deep Breathing Exercise" activity. There was no other documentation in the record that activities had been provided for the patient.

Review of medical record for swing bed patient #13 revealed patient was admitted on 10/4/10 and discharged on 10/11/10. Review of the Activities Care Plan revealed the patient would practice deep breathing three times a day and patient would be encouraged to take breathing treatments. Further review revealed a Activity Planning Sheet dated 10/4/10 with instructions for staff to carry out a "In and Out"(deep breathing)activity, a planning Sheet dated 10/7/10 with instructions for staff to carry out a "Let's Talk About It" activity, a Planning Sheet dated 10/8/10 with instructions for staff to carry out a "Weekend -My Time"activity, and a Planning Sheet dated 10/11/10 with instructions for staff to carry out a "Get Up and Move" activity. There was no other documentation in the record that activities had been provided for the patient or that the Activities Director had provided daily contact with the patient to de-escalate behaviors.


Review of swing bed admission for patient #14 revealed patient was admitted on 8/30/10 and discharged on 9/8/10. The Acitivities Care Plan dated 9/1/10 revealed patient would participate in one on one exercise activity at least once a week to promote better circulation. The Care Plan also revealed that the Activities Director would talk with patient once a day to calm patient to decrease hitting and spitting at staff. Further review of the record revealed a activity planning sheet dated 9/1/10 with instructions for staff to carry out a "kick ball" activity. There was no other documentation in the record that activities had been provided for the patient or that the Activities Director had provided daily contact with the patient to de-escalate behaviors.

Review of medical record for swing bed patient #15 revealed patient was admitted on 8/25/10 and discharged on 8/30/10. Review of the Activities Care Plan revealed the Activity Director would talk with patient at least twice a day to attempt to de-escalate hitting and biting staff members. The Care Plan further stated that patient would be provided in room, one on one activities in her room weekly.
Further review revealed an Activity Planning Sheet dated 8/26/10 with instructions for staff to carry out a "Talking Fun"activity. There was no other documentation in the record that activities had been provided for the patient or that the Activities Director had provided daily contact with the patient to de-escalate behaviors.