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Based on policy review, tour of medical records department, and staff interview, the hospital failed to ensure medical records were completed promptly after discharge and failed to ensure the manager of medical records had a mechanism in place to determine the current number of delinquent medical records. The hospital census at the time of the survey was 202.

Findings include:


The medical records department failed to ensure medical records were completed promptly after discharge no later than 30 days. The medical records department manager was interviewed on 01/17/12 and was unable to provide surveyors with the number of current delinquent medical records. Please see A0438 for further information.

Based on policy review, tour of medical records department, and staff interview on 01/17/12 in the afternoon hours, the department failed to ensure medical records were completed promptly after discharge no later than 30 days.

Findings include:

A tour of the medical records department was completed on 01/17/12 in the afternoon hours. A tour was completed in the medical records storgage area as well. An interview was conducted with the manager of the medical records department, Staff T. The interview revealed Staff T was unable to provide a current number of delinquent records at the time of interview. An official number of delinquent records was received on 01/18/12 in the late morning hours. The number of delinquent records was 1580, which was 19% of the medical records.

Based on observation of the dietary unit, review of job descriptions and staff interview the hospital dietary staff failed to ensure the dietary manager followed the responsibility of monitoring daily management of the dietary service in relation to food storage and preparation. The patient census was 202.

Findings include:

The job description of the food service manager, (Position Title :GM 2, Multi-Service) was reviewed on 01/17/12. The responsibilities of the position included: "directs one or more of the following daily:food service, housekeeping and/or custodial service operations in order to provide quality products and services. Maintains and implements sanitary and safety conditions and training to adhere to auditing procedure and statutory regulations."

A tour of the dietary department was conducted on 01/11/12 at 2:30 PM with two surveyors, staff G (registered and licensed dietician), staff F (director of dietary) and staff H, (executive chief). The following observations were made as follows:
A carton of half and half milk was observed open with no date of opening in the walk- in refrigerator.
An open container of cheese was observed open with no date of opening in the walk- in refrigerator.
An open container marked as chopped garlic was not dated with no date of opening and an expired date on the container.
Two plastic scoops for the ice machine were placed directly on top of the ice machine and not covered or protected from dust.
An opened bag of frozen vegetables was observed stored on a shelf of the walk- in freezer.
An opened bar of butter was observed on a shelf of the walk-in freezer.
An opened pureed strawberry dessert was observed on a shelf in the walk-in freezer.
A large shoulder of pork was observed in the walk-in freezer. This roast was contained in a plastic bag with the top opened to the air. Staff H stated "probably frost bitten".
Metal containers were observed on the drying tray in the upright position. Staff H stated the containers should be turned upside down to dry.
Water pitchers (six large and one small ) were observed in the upright position on the drying shelf.
One metal pan was observed in the upright position on the drying shelf.
The food processor, described by staff G as just cleaned, was observed on the countertop of the kitchen with the paddle and base wet and positioned in the upright position. Staff G when questioned about the position took the wet paddle and base and placed on a paper towel to dry.
A clear container with liquid was observed on the food preparation area that was not marked with any identification of the liquid. Staff H stated this liquid was olive oil.
Frozen beef patties were observed in a box with the lid open to the air in walk-in freezer #2.
Frozen hot dogs were observed in a box with the lid open to the air in walk-in freezer #2.

There were two dietary aides, staff I and staff J, at the food service preparation line placing food items on the services line for delivery to inpatients. These two staff were observed by two surveyors, staff F, staff G and staff H. Staff J was observed pouring soda pop from a mangled can into a plastic glass container and placed on a patient food tray. Staff I and staff J stated they did not have a concern, when questioned, using this can of soda pop to deliver to the patients. Staff G removed the soda can and container of soda from the delivery and disposed of it.

The above findings were shared on interview with staff W ( director/ vice president of accreditation and out patient patient safety) , staff V ( vice president of ambulatory services) , staff X ( vice president of patient care services/chief nursing officer), and staff U ( accreditation manager) on 01/12/12 at 1:40 PM.

Based on observations made during the Life Safety Code tour and staff interview and verification, it was determined that the facility failed to meet the provisions applicable to Ambulatory Health Care Occupancies of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The facility failed to provide a smoke barrier with a one hour fire resistance rating in the ambulatory surgical center.

The facility has a capacity of 254 patients with a total patient census of 202 at the time of the survey. The surgical center performed 1800 patient procedures in 2011.

Findings include:

Refer to K130 regarding failure to provide a smoke barrier with a one hour fire resistance rating in the ambulatory surgical center.

Based on observational tour of the surgical suites, interview review of cleaning schedules, and review of policies for surgical/invasive claming, the facility failed to follow current facility policy related to the cleaning of the surgical suites. This affected five of the ten surgical suites and had the potential to affect all patients undergoing surgical procedures. The patient census was 202.

Findings include:


A tour of the surgical services was conducted on 01/12/12 at 2:20 PM. Staff O (operating room, pacu interim manager), staff P (director of peri -operative and cardiovascular surgery, staff Q (operating room educator, and , staff S (clinical advocate) accompanied the two surveyors.

Surgical Suite #2 was toured on 01/11/12 at approximately 02:30 P.M. A layer of dust was noted on top of both of the Skytron surgical lights directly above the operating table. Dust was also noted on surfaces of the video tower. Thick clumps of dust particles were noted as a surveyor hand wiped over the surfaces of the video tower. Further inspection revealed a layer of dust on the computer keyboard, the power box for the surgical lights and a 1 inch ledge along the wall. The surgical suite cleaning log was reviewed at this time. Initials were noted on dates when the suite was cleaned. It was further noted that the most recent date with initials was 01/07/12. The staff member assigned to clean the surgical s-uites on the day of 01/11/12 was interviewed at 02:30 P.M., stating: "I was very busy yesterday and did not get the chance to clean this room." Dust was also noted on the top of Skytron lights and video towers of surgical suites #3, #4, #5, and #6. The current facility policy (sodexo)-Method of the Week for cleaning the surgical suites was reviewed on 01/12/12. The policy instructs staff members to follow a terminal cleaning at the end of the day, weekly cycle cleaning and to clean between cases.

The above findings were shared on interview with staff W ( director/ vice president of accreditation and out patient safety) , staff V ( vice president of ambulatory services), staff X ( vice president of patient care services/chief nursing officer), and staff U ( accreditation manager) on 01/12/12 at 1:40 P.