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A. Based on observation, clinical record review, and staff interview, it was determined that in 1 of 3 (Pt #18) clinical records reviewed on the 7 West Unit, the Facility failed to ensure all care was provided as per physician orders.

Findings include:

1. A tour was conducted on the 7 West Unit on survey date 5/24/10 from approximately 1:00 PM to 2:00 PM. During the tour it was observed that Pt #18 did not have seizure precautions in place as ordered.

2. The clinical record of Pt #18 was reviewed on survey date 5/24/10 at approximately 2:00 PM. Pt #18 was a 62 year old male admitted on 5/20/10 with a diagnosis of Altered Mental Status, to the Intensive Care Unit and transferred to the 7 West Unit on 5/22/10. The clinical record contained a physician order, dated 5/20/10 at 6:00 PM, that required neurological checks every 2 hours, and to place Pt #18 on seizure precautions. The clinical record lacked documentation of Pt #18's neurological checks every 2 hours as required and lacked documentation that Pt #18 had seizure precautions initiated and maintained.

3. The findings were verified by the Vice President of Patient Care Services during an interview on survey date 5/24/10 at approximately 2:30 PM.


B. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 3 (Pt #20) clinical records reviewed on the 7 West Unit, the Hospital failed to ensure that tube feedings were monitored as required.

Findings include:

1. Hospital policy entitled, "Enteral Feeding," reviewed on survey date 5/25/10 at approximately 9:30 AM required, "Purpose: To provide guidelines when tube feedings are used to meet the metabolic demands...Guidelines:...IX. Monitor the routine management of tube fed patients:..D. Intake and output."

2. The clinical record of Pt #20 was reviewed on survey date 5/24/10 at approximately 2:30 PM. Pt #20 was a 22 year old male admitted to the Hospital on 5/20/10 with a diagnosis of Advanced Stomach Cancer. The clinical record contained a physician order dated 5/22/10 at 10:15 AM that required Pt #20 to receive Jevity 1.2 at 40 to 50 ml per hour for 10 hours at night. The clinical record lacked documentation of intake and output monitoring from 8:00 AM 5/23/10 through 5/24/10 at 12:00 AM.

3. The finding was verified by the Vice President of Patient Care Services during an interview on survey date 5/24/10 at approximately 2:30 PM.


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C. Based on review of Hospital policy, clinical record review, observation, and staff interview, it was determined, that for 1 of 2 seizure patients (Pt. # 8) on the South Adult Psychiatric Unit, the Hospital failed to ensure safety devices were always implemented to prevent injury during a seizure.

Findings include:

1. On 5/24/10 at 2:45 PM, policy # 19.17 titled: "Seizure Precautions" was reviewed. The policy required: "Seizure Precautions will include but are not limited to: side rails padded... oxygen equipment at bedside."

2. On 5/24/10 at 11:05 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was a 58 year old female, admitted on 5/18/10, to room 208 bed 2 with diagnoses of Chronic Schizophrenia and history of seizures. The psychiatric evaluation dated 5/18/10, indicated that Pt. #8 had a seizure during a February 2008 hospitalization and that Pt. #8 had stopped taking her seizure medicine (Dilantin).

The Mental Health Interdisciplinary Conference form dated 5/18/10, included Pt. #8's seizure disorder problem and to "implement seizure precautions according to policy..."


3. On 5/24/10 between 10:25 AM and 11:30 AM, a tour was conducted in the South Adult Psychiatric Unit. In room 208, a mattress was placed on the floor to the right side of bed 2. On the left side of bed 2, the floor was not padded. Padded side rails were not found and oxygen equipment was not in the room.

4. These findings were confirmed with the Risk Manager and Patient Care Manager, during an interview on 5/24/10 at 10:30 AM.


D. Based on review of Hospital policies, observation, and staff interview, it was determined, that for 1 of 1 crash cart on the Neurology Step Down Unit (6W), the Hospital failed to ensure the defibrillator was functional.

Findings include:

1. On 5/25/10 at 8:35 AM, the "Code Blue" and "Emergency Medications (Crash Cart)" policies were reviewed. Both policies lacked instruction on defibrillator monitoring and no other policies addressed the issue.

2. On 5/24/10 between 1:10 PM and 2:30 PM, a tour was conducted in the Neurological Step Down Unit. The defibrillator paddle cord was not attached to the defibrillator. When the Unit Manager attempted to plug the defibrillator cord in, the paddle plates were disconnected from the handle. The Unit Manager was unable to test the defibrillator.

3. On 5/24/10 at 1:20 PM, the Code Blue Cart Check Sheet was reviewed. The check sheet included: "Equipment on top of Code Blue Cart checked" and was checked on the previous 6 shifts. (The defibrillator was placed on top of the Code Blue Cart).

A defibrillator test rhythm strip for the current shift (5/24/10 at 7:39 AM) was found and indicated: "User Test Succeeded". Yet, the defibrillator was non functional.

4. On 5/24/10 at 1:25 PM, an interview was conducted with the Unit Charge Nurse who performed the defibrillator check today. The Nurse stated she ran the strip but did not discharge the paddles.

5. These findings were confirmed with the Risk Manager and Patient Care Manager, during an interview on 5/24/10 at 1:30 PM.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that for 7 of 12 (Pt. #s 1, 2, 3, 12, 18, 21, and 24) Patient Care Plans reviewed, the Hospital failed to ensure Care Plans were complete to include interventions or desired outcomes of all disciplines involved.

Findings include:

1. The Hospital policy titled, "Interdisciplinary Care Planning/Patient Education, #21.43" was reviewed on 5/24/10 at 12:30 PM. The policy included "...The RN initiates the care plan based on identified problems using the Interdisciplinary Plan of Care form within 24 hours. Goals are established with the involvement of the patient/family... Disciplines involved in the patients plan of care will document their initial contact, and the anticipated outcomes/goals...".

2. The clinical record of Pt. #1 was reviewed on 5/24/10 at approximately 11:00 AM. Pt. #1 was a 90 year old female admitted on 5/14/10 with the diagnosis of Atrial Fibrillation. The Plan of Care initiated on 5/21/10 lacked documentation of interventions or desired outcomes for the 6 nursing problems identified.

3. The clinical record of Pt. #2 was reviewed on 5/24/10 at approximately 10:00 AM. Pt. #2 was an 83 year old male admitted on 5/17/10 with the diagnosis of Congestive Heart Failure. The Plan of Care initiated on 5/17/10 lacked documentation of interventions or desired outcomes for the identified nursing problems of "cardiovascular, fluid balance or infection control".

4. The clinical record of Pt. #3 was reviewed on 5/24/10 at approximately 10:45 AM. Pt. #3 was an 82 year old male admitted on 5/22/10 with the diagnoses of Chest Pain and history of Methicillin Resistant Staphylococcus Aureus (MRSA). The Plan of Care initiated on 5/23/10 lacked inclusion of Infection control as a nursing problem and lacked the intervention of isolation.

5. The clinical record of Pt. #12 was reviewed on 5/24/10 at approximately 2:00 PM. Pt. #12 was a 69 year old female admitted on 5/20/10 with the diagnosis of Left Total Knee Replacement. The Plan of Care initiated on 5/21/10 lacked inclusion of mobility/activity as a nursing problem. Physical Therapy was ordered and started on 5/22/10; however, PT was not included on the care plan.

6. The above findings were confirmed with the Unit Manager of 4 East on 5/24/10 at 11:30 PM and the Unit Manager of 9 East on 5/24/10 at 2:30 PM.



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7. The clinical record of Pt #18 was reviewed on survey date 5/24/10 at approximately 2:00 PM. Pt #18 was a 62 year old male admitted on 5/20/10 with a diagnosis of Altered Mental Status. The clinical record contained a Plan of Care initiated on 5/20/10 with additional problems documented as ongoing on 5/23/10. The problems identified on 5/22/10 included "comfort, fluid/electrolyte a\balance, and safety," however the plan of care lacked interventions and desired outcomes.

8. The clinical record of Pt #21 was reviewed on survey date 5/24/10 at approximately 10:00 AM. Pt #21 was a 65 year old female admitted on 5/20/10 with a diagnosis of Cardiac Arrest. The clinical record contained a Plan of Care initiated on 5/21/10. The Plan of Care contained a problem of Fluid/Electrolyte Balance that lacked documentation of interventions and a desired outcome.

9. The findings were verified by the Vice President of Patient Care Services during interviews at 11:15 AM and 2:30 PM on survey date 5/24/10.


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10. The clinical record of Pt. #24 was reviewed on 5/24/10. Pt. #24 was a 17 year old, female admitted on 5/20/10 with diagnosis of Acute Appendicitis and Appendectomy. The interdisciplinary care plan initiated on 5/21/10 failed to include interventions and desired outcomes.

11. The above findings were confirmed with the Director of Quality during interview on 5/25/10 at approximately 10:00 AM

A. Based on review of Hospital policy, review of an attestation letter from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital policy titled, "Completion of Medical Records by Medical Staff Members, #20.121" was reviewed on 5/26/10 at approximately 11:20 AM. The policy required, "Medical records must be completed and signed within thirty (30) days after discharge. A record that is not completed within thirty days of discharge will be considered delinquent".

2. The attestation letter from the Regional Director of Health Information Services was reviewed on 5/26/10 at approximately 1:00 PM. The letter included that as of survey date 5/26/10 at 11:00 AM, there were 52 incomplete records greater than 30 days post discharge.

3. The above finding was confirmed with the Director of Quality during an interview on 5/26/10 at approximately 1:30 PM.

A. Based on review of Hospital policy, observation, and staff interview, it was determined, that for 1 of approximately 40 dietary staff (E #10), the Hospital failed to ensure all staff hair was covered when working in the dietary area.

Findings include:

1. Facility policy No. 6.02, titled "Personal Appearance and Hygiene" was reviewed on 5/26/10 at 12:55 PM. The policy required: "Procedure: I... B... 1... Hair restraints are required for employees while performing tasks in the... hot and cold food production. Appropriate hair restraints include hairnets, approved caps and bonnets, chef hats and caps... 2... Beard covering or surgical mask is necessary for all positions involving contact with food."

2. On 5/26/10 between 10:10 AM and 11:30 AM, a tour was conducted in the dietary area. One Cook (E #10), with short hair and short beard, was not wearing any hair restraints on head or beard.

3. This finding was confirmed by the Director of Food and Nutrition during an interview on 5/26/10 at 11:15 AM.

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 May 24 - 26, 2010, 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 May 24 - 26, 2010, 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 May 26, 2010.

A. Based on observation and staff interview, it was determined, that for 1 of 5 refrigerators (R #1) and 1 of 2 freezers (F #4), the Hospital failed to ensure all refrigerators and freezers were working properly.

Findings include:

1. On 5/26/10 between 10:10 AM and 11:30 AM, a tour was conducted in the dietary area. The following was found:

- In walk-in refrigerator #1, water was found on top of 4 food containers (red curry paste). There was a leak from the cooling equipment above the shelves.

- In walk-in freezer #4, ice accumulation was found below a fire sprinkler head. The sprinkler head contained caulking material.

2. These findings were confirmed by the Director of Food and Nutrition during an interview on 5/12/10 at 11:15 AM.



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B. Based on observation and staff interview it was determined that for 3 of 3 storage units on 4 East, the Hospital failed to ensure supplies were maintained in a safe manner.

Findings include:

1. A tour of the 4 East nursing unit was conducted on 5/24/10 at approximately 9:15 AM. Each of the three hallways on the unit had storage cabinets by the remote Pyxis stations (locked medication retrieval area). The storage cabinets above the work areas were unlocked and contained an assortment of needles, syringes and intravenous catheters with needles in them. The work areas in the hallway were left unattended and accessible.

2. The above finding was confirmed with the Unit Manager of 4 East on 5/24/10 at 11:15 AM, during an interview.

A. Based on review of Hospital policy, observation, and staff interview, it was determined, that for 1 of 1 Surgeon (E #1), in the semi-restricted Pre-operative area, and 1 of 3 staff (E#7) in Operating Room 3, the Hospital failed to ensure infection control policies were practiced.

Findings include:

1. On 5/25/10 at 9:25 AM, the "Unrestricted, Semi-Restricted and Restricted Area" policy was reviewed. The policy required: "Semi-restricted area... Recovery Room... E. Personnel shall change into prescribed surgical attire in the locker room prior to entering the semi-restricted and restricted areas." The Pre-operative area was not included in the policy.

2. On 5/25/10 at 9:30 AM, the "Standard and Transmitted Based Isolation Precaution" policy was reviewed. The policy required: "A. 3. Wash hands / decontaminate between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environment."

3. On 5/25/10 between 7:25 AM and 7:45 AM, an observational tour was conducted in the Pre-operative Holding Area, a semi-restricted area. An Orthopedic Surgeon (E #1) entered the room in street clothes, where all staff were in scrubs and patient's visitors wore cover gowns. E #1 marked the right knee surgical site of a patient and then shook the patient's hand. E #1 did not cleanse his hand, went to the nurses station, borrowed a pen from the Scrub Nurse (E #5), and wrote notes. E #1 returned the pen back to E #5, who put the pen in his scrub shirt pocket. E #1 left the area without cleansing his hands.

4. On 5/25/10 at approximately 7:30 AM to 9:00 AM a tour was conducted in Operating room 3. E #7 was observed picking a syringe up from the floor and placing it back into the Anesthesia cart.
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5. These findings were confirmed with the Director of the Operating Area, during an interview on 5/25/10 at 8:25 AM.


B. Based on observation and staff interview, it was determined, that for 2 of 2 steam sterilizers (M #2 & 3) checked in the Sterile Processing Area, the Hospital failed to ensure dust accumulation was not found.

Findings include:

1. On 5/25/10 between 7:50 AM and 8:15 AM, an observational tour was conducted in the Sterile Processing Area. Three steam sterilizers (Ms. #1, 2, & 3) were present. The doors of M #s 2 & 3 were open. An accumulation of dust was found above the door hinge area in both machines. This created the potential for sterile package contamination upon removal from the sterilizer.

2. These findings were confirmed with the Director of the Operating Area, during an interview on 5/25/10 at 8:25 AM.


C. Based on observation and staff interview, it was determined, that for approximately 50 of 50 peel packs (size 12 x 18), the Hospital failed to ensure sterilization packaging date had not expired.

Findings include:

1. On 5/25/10 between 7:50 AM and 8:15 AM, a survey was conducted in the Sterile Processing Area. Approximately 50 of 50 peel packs (size 12 x 18), used to package surgical instruments for sterilization, included the expiration date of June 2009.

2. These findings were confirmed with the Director of the Operating Area, during an interview on 5/25/10 at 8:25 AM.


D. Based on observation and staff interview, it was determined, that for 7 of 7 filled water cups on the South Adult Psychiatric Unit, the Hospital failed to ensure water cups for medication administration, were not contaminated.

Findings include:

1. On 5/24/10 between 10:25 AM and 11:30 AM, a tour was conducted in the South Adult Psychiatric Unit. At 10:15 AM, in the medication room, 7 paper cups, each half full of water, were placed next to the hand washing sink with the potential of being contaminated.

2. An interview was conducted with the Patient Care Manager on 5/24/10 at 10:15 AM. The Manager stated that the water was to be used to administer patient medication. The finding was confirmed with the Patient Care Manager and Risk Manager, during an interview on 5/24/10 at 10:30 AM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that in 2 of 3 (OR #3 and #8) Operating Rooms observed, the Hospital failed to ensure all employees adhere to surgical dress code policies.

Findings include:

1. Hospital policy entitled, "Attire, Surgical," reviewed on survey date 5/25/10 at 10:10 AM required, "Procedure:...II. Surgical Hats/Hoods: A. All possible head and facial hair (beards) sideburns and neckline will be covered while in the restricted and sterile areas of the procedural area with lint free hats or hoods...IV. Masks: A. A single mask should be worn in a surgical environment when open supplies or scrubbed persons may be located."

2. On survey date 5/25/10 at approximately 7:30 AM to 9:00 AM a tour was conducted in Operating room 3. The following observations were made: Employee #5 and Employee #6 had hair exposed from beneath their caps, Employee 7, 8, and 9 entered the room tying their masks while sterile supplies were opened.


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3. On 5/25/10 at approximately 10:00AM, the Surgical Attire policy was reviewed. The policy included, " ...mask will cover the mouth and nose completely."

4. On 5/25/10 at approximately 7:40AM, an anesthesiologist (E#4)entered OR. #8 while tying his surgical mask.

5. The above finding was discussed with the OR Nurse Manager during an interview on 5/25/10 at approximately 8:30AM.


B. Based on review of perioperative standards(2008), observation and staff interview, it was determined that for 1 of 3 surgical preps observed (OR#8), the Hospital failed to ensure staff(E#2) adherence to hand hygiene.

Findings include:

1. Perioperative Standards titled " Surgical Hand Antisepsis" included, "All personnel should practice general hand hygiene anytime there is possibility that there has been contact with potentially infectious material. Health care workers should avoid contact with surfaces that are potentially contaminated..."

2. On 5/25/10 at approximately 7:50AM, an abdominal surgical prep was observed in OR #8. Prior to the abdominal prep for Pt. #23, the circulating nurse (E#2) contaminated her hand by retrieving an item that had fallen to the floor and without performing hand hygiene began to use Dura Prep solution on the Pt's abdomen.

3. The above finding was discussed with the OR Nurse Manager during an interview on 5/25/10 at approximately 8:30AM.

A. Based on clinical record review and staff interview, it was determined that for 1 of 2 (Pt. # 12) clinical records reviewed on 9 East, the Hospital failed to ensure physician orders were followed.

Findings include:

1. The clinical record of Pt. #12 was reviewed on 5/24/10 at approximately 2:00 PM. Pt. #12 was a 69 year old female admitted on 5/20/10 with the diagnosis of Left Total Knee Replacement. The record included a physician order dated 5/20/10 at 9:00 AM for "Occupational Therapy (OT) to evaluate and treat". The record lacked an evaluation as of survey date 5/24/10. Pt. #12 was scheduled to be discharged on 5/24/10.

2. The Occupational Therapist (E#3) for unit 9 East was interviewed on 5/24/10 at 2:15 PM. E#3 indicated that Pt. #12 had not been evaluated and would not be evaluated on 5/24/10. E#3 stated that she was "pulled to the Rehabilitation unit because there was not enough staff and that none of the patients on 9 East would be seen today by OT".

3. The above finding was confirmed with the Unit Manager of 9 East on 5/24/10 at 2:30 PM, during an interview.