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Based on document review and interview, the facility failed to ensure patient's right to formulate an advance directive in 1 (patient 2) of 7 medical records (MR) reviewed.

Findings Include:

1. Review of facility policy, Advance Directives, last approved 08/2018, indicated patients with decision-making capacity who are adults
(at least 18 years of age) or emancipated minors and are registered will be offered Advance Directive information and will be asked if they have executed an Advance Directive.

2. Review of patient 2's (MR) lacked indication the patient was offered Advance Directive information.

3. Interview on 1/30/2019, at approximately 1:51 pm, with N13 (Clinical Informatics) confirmed the above.

Based on document review and interview, the facility failed to ensure completion of History and Physical (H&P) in 1 (patient 2) of 10 medical records (MR) reviewed.


1. Review of facility policy, Medical History and Physical Examination/Reassessment, last approved 09/2017, indicated the history portion of the H&P, contains the following components as clinically appropriate to the procedure being performed but minimally must include the reason for the ordered procedure, assessment, physical.

2. Review of patient 2's (MR) lacked review of systems on History and Physical.

3. Interview on 1/30/2019, at approximately 1:51 pm, with N13 (Clinical Informatics) confirmed the above.

Findings include:

1. Review of facility policy Automated Dispensing Cabinet (Pyxis), last approved 08/2018, indicated, on all Patient Care Units medications should be removed as close to administration time as possible.

2. On 1/30/2019, at approximately 11:54 am, with N11 (Labor and Delivery/Obstetrics/Neonatal Intensive Care Manager) in the Obstetrics Unit Operating Room 2, the following was observed. Phenylephine 1mg/10ml and ephedrine 25mg/5ml laying on top of the anesthesia cart. Operating room was closed with no personnel present before entrance.

3. Interview on 1/30/2019, at approximately 11:54 am, N11 confirmed the above.

Based on document review, observation, and interview the facility failed to ensure that drugs and biologicals are securely stored in two (2) departments, radiology and obstetrics.

Findings include:

1. Review of facility policy titled, Security of Medication Storage Areas approved 06/2017, indicated that all medications will be kept secured at all times. Secured is defined as locked up or under direct visual surveillance.

2. During tour of the radiology department with employee #A3, Chief Nursing Officer, on 1/31/2019 at 10:20 am, three (3) bottles of barium sulfate HD 310 gram bottles, and three (3) bottles of nectar barium sulfate 40% 240 milliliters were found unsecured in an unlocked cabinet with no employee providing surveillance in the immediate area.

3. In interview on 1-31-2019 at 12:30 pm, employee #A8, Director of Pharmacy, confirmed that barium sulfate is a formulary medicine.

Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 ASC/HC Outpatient Surgery fire barrier wall was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops (see tag K131), failed to maintain protection of 1 of 1 Surgery Soiled Utility room in accordance of 19.3.2 (see tag K321), failed to install 1 of 1 sprinkler head deflectors within 12 inches of the ceiling. NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler (see tag K351), failed to ensure 3 of 3 multiplug and 9 of 9 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure (see tag 920). .

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to provide 1 of 1 2nd floor Med Surge Ortho Soiled Utility room which contained a laundry chute with self-closing openings. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:58 a.m., the 2nd floor Med Surge Ortho laundry chute door was open when discovered. The chute door can be opened to the point the door no longer self-closes. Based on interview at the time of observation, the Maintenance Director confirmed the laundry chute door was left open.

Based on observation and interview, the facility failed to ensure the penetration in 1 of 1 ASC/HC Outpatient Surgery fire barrier wall was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff and up to 12 patients

Findings include:

Based on an observation with the Maintenance Director on 01/30/19 at 2:35 p.m., the ASC/HC Outpatient Surgery occupancy separation fire barrier had a half inch gap around a PVC pipe above the drop ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the penetration and provided the measurement.


1. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Surgery Soiled Utility room in accordance of 19.3.2. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 1:20 p.m., the Surgery Utility room corridor door failed to positively latch into the frame. Based on interview at the time of observation, the Maintenance Director confirmed the soiled linen collection room failed to fully close and positively latch into the frame.

2. Based on observation and interview, the facility failed to maintain protection of 1 of 1 2nd floor Mechanical room in accordance of 19.3.2. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:53 a.m., the 2nd floor Mechanical room contained fuel-fired equipment. The corridor double doors contained an astragal and a coordinating device. When tested, the coordinator failed to prevent the door with an astragal to close last. Based on interview at the time of observation, the Maintenance Director confirmed the coordinating device was unable to ensure the astragal door closed last.

1. Based on observation and interview, the facility failed to install 1 of 1 sprinkler head deflectors within 12 inches of the ceiling. NFPA 13, 2010 Edition, Section 8.6.4.1.1.1 under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch and a maximum of 12 inches throughout the area of coverage of the sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 at 10:50 a.m., the 2nd floor Telecommunications room contained one sprinkler head. The sprinkler head deflector was estimated at eight feet from the ceiling. Based on interview at the time of observation, the Maintenance Director confirmed the drop ceiling was mostly removed and planned on moving the sprinkler head.

2. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 8.15.5.3 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. A.8.15.5.3 ASME A17.1, Safety Code for Elevators and Escalators, requires the shutdown of power to the elevator upon or prior to the application of water in elevator machine rooms or hoistways. This shutdown can be accomplished by a detection system with sufficient sensitivity that operates prior to the activation of the sprinklers (see also NFPA72, National Fire Alarm and Signaling Code). As an alternative, the system can be arranged using devices or sprinklers capable of effecting power shutdown immediately upon sprinkler activation, such as a waterflow switch without a time delay. This alternative arrangement is intended to interrupt power before significant sprinkler discharge.

LSC Section 9.7.3. allows alternative automatic extinguishing systems other than an automatic sprinkler system such as a water mist, carbon dioxide, dry chemical foam or a standard extinguishing system of another type in lieu of an automatic sprinkler system. Such systems shall be installed, inspected and maintained in accordance with NFPA standards and shall activate the building fire alarm system. The elevator equipment room was located in the basement and could affect any number of staff.

Findings include:

Based on an observation with the Maintenance Director on 01/31/19 at 9:52 a.m., the elevator equipment room lacked sprinkler coverage. Based on interview at the time of observation, the Maintenance Director confirmed the fully sprinklered building contained an elevator equipment room which did not contain any sprinkler protection.

Based on observation and interview, the facility failed to ensure 3 of 3 multiplug and 9 of 9 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and at least 22 patients.

Findings include:

Based on observation with the Maintenance Director on 01/30/19 between 11:04 a.m. and 2:17 p.m., the following was discovered:
a) a surge protector was powering a refrigerator in the 2nd floor Education office
b) a surge protector was powering another surge protector powering a phone charger in 2nd floor MME office
c) an extension cord was powering a refrigerator in the 2nd floor DOB
d) an extension cord was powering a lamp and a surge protector was powering a refrigerator in the OB On-call room 2
e) a surge protector was powering a microwave in the Security office
f) a surge protector was powering another surge protector powering a microwave in the Case Management office
g) three separate multiplug adapters were powering computer components in the PACU Pediatric room
Based on interview at the time of each observation, the Maintenance Director confirmed each wiring situation and attempted to fix the wiring after observation.

Based on document review and observation, the facility failed to meet the standards established in Chapter 18.3.2.7 of the 2000 edition of the Life Safety Code, in two (2) instances in one (1) facility.

Findings include:

1. Review of Chapter 18.3.2.7 of the 2000 edition of the Life Safety Code, indicates alcohol based hand sanitizer dispensers are to not be installed above, below, or laterally adjacent within one (1) inch of electrical equipment or other ignition source.

2. During tour of the radiology department control room on 1/31/2019 at 10:35 am, in the presence of #A3, Chief Nursing Officer, it was observed that an alcohol based hand sanitizer dispenser was directly above a computer that was plugged in and operating.

3. During tour of the dialysis equipment storage room on 1/31/2019 at 11:55 am, in the presence of #A3, Chief Nursing Officer, it was observed that an alcohol based hand sanitizer dispenser was directly above a functioning light switch.

Based on document review, observation and interview the facility failed to ensure implementation of policies on infection control in one facility.

Findings include:

1. Review of facility policy, Room Cleaning-Other Than Patient Rooms, approved 01/2019, indicated order of cleaning, empty and sanitize wastebaskets, high dust, damp wipe furniture, ledges, etc.

2. On 1/29/2019, at approximately, 11:49 am, in the preoperative utility closest with N5 (Registered Nurse) the following was observed. White linen cart cover with an approximately 6 inch by 6 inch (grayish brown) soiled area.

3. Interview on 1/29/2019, at approximately, 11:49 am, confirmed the above.

4. Review of facility policy, Code Blue Cart Integrity/ Supply Replacement, last approved 03/2017, indicated when items are found to be expiring, the person checking the cart will replace the item and relabel the drawer.

5. On 1/29/2019, at approximately 12:07 pm, on the Surgical Preoperative Unit with N5 the following was observed. Seven pairs of sterile gloves with expiration date of 2016, in the third drawer of the Code Blue Cart.

6. Interview on 1/29/2019, at approximately 12:07 pm, N5 confirmed the above.

7. On 1/29/2019, at approximately 2:10 pm, with N7 (Registered Nurse Surgery) in the Surgery Unit Men's Dressing Room the following was observed. The shower stall had water dripping and a black/greenish substance in and around the drain.

8. Interview on 1/29/2019, at approximately 2:10 pm, with N7 (Registered Nurse Surgery) confirmed the above.

9. Review of facility policy, Food & Nutrition Services, Environmental Services and Facility Services Responsibilities in the Nursing Unit kitchens, last approved, 07/2018, indicated, the nourishment refrigerators will be cleaned and sanitized daily by the Hostess who delivers bulk nourishments.

10. On 1/29/2019, at approximately 11:07 am, with N9 (Mother Baby Unit staff) on the Mother/Baby Unit the following was observed. The patient refrigerator had 18 inch drips on the back interior, sticky substance below the drawers, and particles on shelves.

11. Interview on 1/29/2019, at approximately 11:07 am, with N9 confirmed the above.

12. Review of Centers for Disease Control and Prevention, Guideline for Disinfection and Sterilization in Healthcare Facilities, last reviewed September 18, 2016, indicated Medical and surgical supplies should not be stored under sinks or in other locations where they can become wet.

13. On 1/30/2019, at approximately 10:35 am, in the Endoscopy Preoperative Clean Utility Unit, with N8 (Registered Nurse, Endoscopy) the following was observed. 12 bottles of 1000 ml Sterile Water and 5 bottles of Sodium Chloride directly above a shelf of sterile gastrostomy feeding tubes times 10.

14. Interview on 1/30/2019, at approximately 10:35 am, N8 confirmed the above.

15. On 1/30/2019, at approximately 12:15 pm, with N12 (Manager Intensive Care Unit, House Supervisor) on the Orthopedic Unit the following was observed. 10 bottles of Sterile Water stored directly over 4 Sterile Catheter Kits.

16. Interview on 1/30/2019, at approximately 12:15 pm, with N12 confirmed the above.