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Based on observation, interview and policy review, the facility failed to ensure patients' personal information was kept out of public view for (6) patients. As a result of this failed practice, patients' confidential information was readily accessible by the public. Findings:

Random observations on the acute care unit and OB (obstetrics) unit from 11/8-11/10, revealed confidential patient information documented on I&O (intake and output) sheets and "Patient Comfort & Safety Rounds" forms located on the outside of patients' doors. The I&O forms contained the Patients' initials, totaled their fluid intake and counted how many times they had urinated or had a bowel movement. The Patient Comfort & Safety forms evaluated their complaints of pain, noted if they had been repositioned and counted how many times the Patients had urinated or had a bowel movement. Even though the Patient Comfort forms did not contain the Patients' names, it did contain their room numbers and were located right next to the I&O forms which contained the Patients' initials. Six patients were affected by this practice.

During an interview on 11/11/10 at 9:50 am, staff RN (Registered Nurse) #8 confirmed both forms were used to collect information concerning patients' pain, position, and body functions.

Review of the facility's policy and procedure "General Nursing Services Safety", last revised 2/2010, revealed "Health Information Management: 3. Ensure confidentiality of the contents of the record in keeping with the Privacy Act." (The Privacy Act prohibits disclosure of these records without the written consent of the individual.)


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Based on personnel record review, policy review, and interview, the facility failed to ensure reference checks were obtained during the hiring process for 6 (#s 5; 6; 8; 9; 12 and 18) staff. In addition, the facility failed to complete fingerprint-based criminal history checks on 3 (#s 10, 12 and 13) employees. This failed practice placed vulnerable patients at risk for abuse or neglect. Findings:

Review on 11/11/10 of the personnel records revealed the facility had not completed employment reference checks on (1) CNA (Certified Nursing Assistant) hired on 9/7/04; (1) LPN (Licensed Practical Nurse) hired on 7/15/02; (3) RNs (Registered Nurses) hired 5/1/95 7/6/06 and 8/11/08; and (1) Registered Dietitian hired on 5/17/04.

Further record review revealed the facility had not completed an initial background check for staff employee #12. In addition, the facility failed to complete background checks for (2) long term employees (#s10 & 13).

Review of the facility's "Human Resource Manual", revised 6/25/10, revealed "Employment Reference Checks: To ensure that individuals who join SEARHC are well qualified and have a strong potential to be productive and successful, it is the policy of SEARHC to check the employment references of all qualified applicants."

Further review of the Human Resource Manual revealed no requirement for criminal background checks.

During an interview with the human resource director on 11/11/10 at 10:30 am, she confirmed employees who had direct contact with patients were required to have criminal background checks when hired, and that all employees were supposed to have reference checks. The director disclosed that staff in the human resource department were new employees and that some of the missing information may be around, but that no one knew where to find it.


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Based on review of the hospital Medical Staff Bylaws, medical credentialing files, and interview, the facility failed to enforce their bylaws. As a result, four medical staff members (#s 5, 10, 2 and 7) were not attending Executive Board/Risk Management staff meetings at the required 75% rate. Findings:

Review on 11/11/10 of the physician credentialing files revealed there were 4 physicians who held key positions in the hospital's medical staff who had not attended the monthly Executive Board/Risk Management staff meetings at the required 75% attendance rate. Physician Staff #5 had a 0% attendance rate for the current year and a 20% attendance rate for the previous year. Physician Staff #10 had a 0% attendance rate for the current year and a 25 % attendance rate for the previous year. Physician Staff #2 had a 58 % attendance rate for the current and previous year. Physician Staff #7 had a 44% attendance rate for the current year.

Interview with the Medical Director on 11/11/10 at 11:50 am disclosed that when physicians failed to attend the Executive Board/Risk Management staff meeting at the required 75% attendance rate, they were in violation of the hospital's medical staff bylaws. He said one of the reasons two of the physicians had not attended the staff meeting was because they worked the night shift and the meetings were held during the day. When the Surveyor asked if the staff meeting schedule could be changed to accommodate the night shift physicians the Medical Director said he supposed they could. He added that he never really thought about doing that because he just excused the physicians from attending the meetings.

Additional review of the physician's credentialing records revealed all four of the physicians had signed their medical staff appointment letters that verified the physicians had read, and agreed to follow, the medical staff bylaws.



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Based on interview and observation the facility failed to ensure medications and supplies were maintained in secured areas. This failed practice created a risk for unauthorized access to medications. Findings:

Observation of the Pharmacy storage area on 11/10/10 at 10:20 am revealed one of the walls was shared with the dietary storage area. The shared wall did not go all the way to the ceiling but had a gap all along the top, large enough for a person to fit through. In addition, there was shelving on both sides of the wall, which could function as a ladder. During an interview on 11/10/10 at 3:00 pm, the Dietary Manager stated he had a key to the dietary storage area and that another key was kept hanging in the office so dietary staff could access the food storage. As a result, medications stored in the Pharmacy storage area were readily accessible to dietary staff.

Observation in the Dental Clinic on 11/11/2010 at 1:15 pm revealed a crash cart located in an open area that patients walked by to get to the dental exam rooms. The crash cart was unlocked. The following medications were in the unlocked cart:

6 boxes of Epinephrine (adrenergic agonist used in cardiac arrests, allergic reactions, asthma attack) 1:1000, 1 mg;

2 boxes of Sodium Bicarbonate,1 mEq/ml;

1 box of Procainamide Hydrochloride (antidysthrymic),10 ml;

1 box of Calcium Chloride 10 ml;

3 boxes of Atropine Sulfate (antidysrhythmic, anticholinergenic),1mg/10ml;

3 boxes Lidocaine (antidysrhythmic) 2%, 100 mg/5 ml;

Dextrose 50%, 0.5 G/ml;

2 vials of Vasopressin (pituitary hormone) 20 u/1 ml;

4 large packets of Nitro-Bid (Nitroglycerin Ointment 2%);

3 vials of Metoprolol (lowers blood pressure) 5 mg/5 ml;

2 boxes of Naloxone Hydrochloride (opioid antagonist) 1 mg/ml;

5 vials of Furosemide (diuretic) 10 mg/2 ml;

3 vials of Adenosine (antidysrhythmic) 6 mg/2 ml; and

3 vials of Amiodarone Hydrochloride (antidysrhythmic) 150 mg/ml.






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Based on observation, interview, and policy review, the facility failed to ensure expired medications in the pharmacy and drug storage areas were removed from stock prior to their expiration dates. This created a risk for deterioration of medications, potentially placing patients at risk for receiving subtherapeutic doses of medications. Findings:

Observation of the acute care medication cart on 11/8/10 at 2:00 pm revealed the following:

9 tablets of Codeine 30mg (narcotic pain medication), expiration date 10/31/10, and

1 bag of normal saline intravenous fluid, expiration date 10/31/10.

Observations of the medication cabinet in the obstetrics unit on 11/9/10 at 11:00 am revealed the following:

12 tablets of oxycodone (narcotic pain medication) 5 mg, expiration date 10/4/10, and

22 tablets of Ativan (antianxiety) 0.5 mg, expiration date 10/10

During an interview on 11/9/10 at 11:15 am, RN #16 confirmed that the expired medications should not have been in the medication cabinet.

Observations of the inpatient pharmacy on 11/9/10 at 2:30 pm revealed the following:

10 tablets of venlaflaxin (antidepressant), expiration date 1/21/10, and

1 500 ml bag of azithromycin (antibiotic), expiration date 11/1/10.

During an interview 11/9/10 at 2:30 pm, the Pharmacist stated nurses on the units should be checking for expired medications, but confirmed the pharmacy was ultimately responsible for ensuring expired medications were pulled.

Review of the facility's policy "Drug Procurement/Inventory Control", revised 2/10, revealed, "...All drug storage areas within the hospital will be inspected every 2 months by the pharmacy department...Expired damaged and/or contaminated medication will be removed from drug storage areas within the hospital during the Pharmacy inspection and will be returned to the Pharmacy department for proper disposal..."


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Based on review of laboratory logs, policy review and interview, the facility failed to ensure the blood bank refrigerator temperatures were checked and recorded daily. In addition, the facility failed to verify, by documenting on the daily checklist log, that the blood coagulation reagents were refrigerated. These failed practices placed patients at risk of receiving contaminated blood products and incorrect test results from the use of inappropriately stored blood and reagents. Findings:

Review on 11/9/10 from 12:15 - 1 pm of the blood bank refrigerator temperature logs revealed:

During the month of July 2010 there were 5 days when staff had not recorded the refrigerator temperatures. During the month of September 2010 there were 10 days when staff had not recorded the refrigerator temperatures.

Review of a second monthly laboratory log sheet, entitled "daily checklist", revealed a space to document that "Refrigerate coagulation reagents" (reagents used for determining coagulative properties of blood or plasma) was completed each day.

Further review of the "daily checklist" revealed that, for the time period of April 2010 through September 2010, there was no documentation that the coagulation reagents had been refrigerated on 64 days.

During an interview with the lab manager on 11/9/10 at 1 pm, he confirmed the temperature logs for the blood bank refrigerator were incomplete for the months of July and September of 2010. He further confirmed the daily checklist logs for the months of April - September 2010 were incomplete.

Review of the facility's policy "Quality Control", effective date 5/23/04, revealed "Blood Bank: Quality control is performed each day of reagent use. Quality control materials are located in the blood bank refrigerator. Quality control results are directly recorded on the blood bank Q.C. sheet. Instrument maintenance sheets are filled out whenever the respective equipment is used."



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Based on observation, interview, and policy review the facility failed to ensure dietary staff carried out their responsibilities to discard expired food, date foods, and ensure foods that were in the dry storage were protected from potential contamination. The staffs' lack of follow through for assigned duties created the potential for food borne illness and could potentially have affected the nutritional value of food for all patients receiving food from the kitchen. Findings:

Observation in the kitchen on 11/8/10 at 10:30 am revealed a metal scoop inside a large plastic food bin containing crumbs. The scoop was lying with the handle on top of the crumbs.

During an interview on 11/8/10 at 11:00 am, Cook #14 identified the crumbs as Panko (a breading used for chicken and fish).

Observation under the kitchen counters revealed :

a large clear plastic bin containing corn meal with a cup half buried in the cornmeal, and

a large clear plastic bin containing lentils with a cup partially buried upside down in the lentils.

Sitting on top of the counters were 2 8oz cans of Resource Thicken-Up (food additive used for thickening liquids), partially used, with the use by date 8/5/10.

Observations of the kitchen walk-in refrigerator at 11/9/10 at 7:00 am revealed the following items were not dated:

1 10-pound roll of ground beef sitting on a metal tray, and

1 30-pound cardboard box containing a loosely wrapped bag of chicken breasts, sitting on a metal tray.

During an interview on 11/9/20 at 7:50 am, the Dietary Manager confirmed dietary services sometimes used Thicken-Up when preparing thickened fluids for patients who had difficulty swallowing. The Dietary Manager also confirmed expired foods should not be used and scoop handles or cups should not be touching the food. When asked when the ground beef and chicken were placed in the refrigerator, the Dietary Manager stated he did not know.

Observation of the pantry in the obstetrics unit on 11/9/10 at 10:00 am revealed:

1 28 oz box of Nabisco instant Cream of Wheat, expiration date 11/18/07,

1 can Campbell's Select Harvest, Mexican style chicken tortilla soup, dated 5/20/10, and

1 15oz can Del Monte, lite freestone peaches, best by 9/21/10.

Review of the facility's "Correct Thawing Procedure" Policy, revised 6/9/08, revealed "...The cook on duty checks the menu to see what meat is needed in advance. 2. The cook removes the meat from the freezer and puts it on the bottom shelf of the freezer..."

Review of the "Food Storage" policy, revised 6/9/08, revealed "...Supplies will be stored and issued on first in first out basis..."

According to the 2009 FDA (U.S. Food and Drug Administration) Food Code:

"...3-304.12...During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored...with their handles above the top of the food within containers or equipment that can be closed..."

"...3-501.17...refrigerated, Ready-to-Eat, Potentially Hazardous Food...prepared and held in a Food Establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the Food shall be consumed on the Premises, sold, or discarded when held at a temperature of 5 [degrees Celsius] (41 [degrees Fahrenheit])..."