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Based on document review and interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed on the medical/surgical unit, the hospital failed to ensure the policy for restraint usage was followed.

Finding include:

1. On 6/24/14 at approximately 2:30 PM the medical record of Pt. #1 was reviewed. Pt. #1 was a 70 year old female admitted on 6/18/14 with a diagnosis of right hip arthroplasty. Pt. #1 had a physician order on 6/19/14 for medical restraints to prevent removal of medical devices. Pt. #1 also had telephone orders to continue restraints for 6/21/14 and 6/22/14. The telephone orders dated 6/21/14 and 6/22/14 lacked a physician signature. The restraints were discontinued on 6/24/14 per physician order.

2. On 6/24/14 the hospital policy titled "Restraint and Seclusion" (revised 2/13) was reviewed and required, "... E. Orders for Restraint...order should: a) be for use of the restraints and related to a specific episode of the patient's behavior and not for an unspecified future time or episode. b) contain a starting and stopping time. c) all verbal or telephone orders must be countersigned within 24 hours."

3. On 6/24/14 at approximately 2:30 PM these findings were verified by the unit's Charge Nurse (E #7).

Based on document review, observation, and interview, it was determined, for approximately 1,000 of 1,000 index cards containing confidential patient information, in the radiology department, the hospital failed to ensure confidential patient information was secure from unauthorized use.

Findings include:

1. Hospital policy titled, "Location and Security of Medical Records", effective 2/2003, was reviewed on 6/25/14. The policy required, "It is the policy of this facility that medical records be maintained in a secure and confidential manner."

2. On 6/25/14 at 11:00 AM, an observational tour was conducted in the radiology department. A corridor used by patients and staff permitted access into an open supply area where a file cabinet, without a locking mechanism, held index cards containing confidential patient information including: patient's name, social security number, birth date, date and name of radiology procedure, and other confidential information.

3. On 6/25/14 at 11:05 AM, an interview was conducted with the lead x-ray technician (E #5). E #5 was asked to estimate the number of index cards in the file cabinet. E #5 answered "1,000" and stated the index cards were old records, no longer used.

4. On 6/25/14 at 11:50 AM, the Director of Radiology was informed of the finding and stated he would take care of it.

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 June 24 - 25, 2014, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

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 June 24 - 25, 2014, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated June 25, 2014.

A. Based on record review, observation, and interview, it was determined for 1 of 1 radiology patient (Pt. #6) being prepared for a computerized tomography (CT) scan, the Hospital failed to ensure an intravenous line (IV) insertion was performed in an aseptic manner, to reduce the risk of infection.

Findings include:

1. On 6/25/14 at 2:30 PM, hospital policy titled, "Hand Hygiene", effective 12/2004, was reviewed. The policy required, (pg. 3) "G. 2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities or from a dirty or contaminated area to one that is clean... 3. Gloves should be changed when caring for a single patient when moving from one procedure to another."

2. On 6/25/14 at 2:35 PM, hospital policy titled, "Guidelines for Infection Control in Intravenous Therapy" effective 7/2002, was reviewed. The policy required, (pg. 5) "B. Peripheral Cannula Insertion... Palpation of the insertion site may not be performed after the application of a skin antiseptic, unless aseptic technique is used... Allow the prep solution to completely dry (30 - 60 seconds) prior to proceeding with insertion..."

3. On 6/25/14 at 11:00 AM, an observational tour was conducted in the radiology department. An emergency department patient (Pt. #6) was in the CT scan room being prepared for the scan.

4. A Certified Technician (E #3) put on gloves at 11:28 AM and in the process of preparing Pt. #6 for the CT scan, E #3 touched dirty equipment including the stretcher rail, the CT machine controls, and a triangular wedge (used to position patients).

5. Still wearing the same gloves, at 11:32 AM, E #3 flushed Pt. #6's "media port" catheter with normal saline, which had been placed prior to arrival in radiology.

6. Still wearing the same gloves, at 11:33 AM, E #3 touched the contrast pump, mayo table, and picked out supplies (tape, syringe, and tourniquet) from a "universal" supply basket, touching other items in the basket.

7. Still wearing the same gloves, at 11:35 AM, E #3 applied chloraprep to Pt. #6's right arm and touched the intended IV insertion site with a gloved index finger. E #3 repeated the process of applying chloraprep and touching the site with the gloved index finger 2 more times and then inserted the IV, not waiting 30 to 60 seconds for the chloraprep to dry.

8. On 6/25/14 at 11:50 AM, an interview was conducted with the Director of Radiology (E #6). E #6 was informed of the findings and stated that the supplies in the universal supply basket were used for other patients.

9. On 6/25/14 at approximately 1:30 PM, an interview was conducted with the Infection Control Coordinator (E #8). E #8 stated that after an insertion site preparation is completed, the site should not be touched before the IV insertion.


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B. Based on observation, document review, and interview, it was determined for 1 of 8 (Pt#8 in room 221) patients rooms observed for isolation precautions, the Hospital failed to ensure the hospital staff followed the policy for contact isolation precaution.

Findings include:

1. On 6/25/14 at approximately 1:20 PM an observational tour was conducted on the medical/surgical unit. The patient in room 221 was an 81 year old female (Pt #28) admitted on 6/21/14 with a diagnosis of urinary tract infection and back pain. E #28 was on contact precaution for Vancomycin resistant enterococcus (VRE) in the urine. A physician (E #4) was observed in the patient's room without personal protective equipment (PPE).

2. On 6/25/14 the hospitals' policy titled "Contact Precautions" (revised 11/13) was reviewed and required, "...Use of personal protective equipment (PPE)...2. don gloves upon entry into the room...don gown upon entry into the room..."

3. On 6/25/14 while conducting the tour this finding was verified with the Charge Nurse (E#7) who was present during the tour.

Based on document review, observation and interview it was determined for 2 of 5 ( E #1, and E #2) staff members in operating suite (OR #5), the Hospital failed to ensure adherence to the dress code policy.

Findings include:

1. On 6/25/14 the hospital's policy titled, "Dress Code-Surgery-Anesthesia" (revised 1/14) was reviewed and required, "3...disposable scrub hats or cloth head coverage that completely cover all possible head and facial hair are to be worn by all personnel entering the OR restrictive area...3.2 clean cloth hats in good taste are allowed...when in the surgical suite, the cloth hat should be covered with a disposable head cover..."

2. On 6/25/14 beginning at approximately 9:20 am through 10:15 AM, an observational tour was conducted in operating room #5. During the tour the following were observed:

-The Surgical Scrub Technician, E #1 was observed opening sterile packs with approximately 1 -2 inches of hair exposed below the back of the head cover.

- The Certified Registered Nurse Anesthetist was providing patient care with approximately 1-2 inches of hair exposed on both sides and the back of the cloth head cover.

3. On 6/25/14 at approximately 10:30 AM these findings were confirmed with the Director of Surgical Services (E-10).