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Based on observation, interview and review of the facility's policy, it was determined the facility failed to provide supplies, drugs, biological and equipment required by State and local law and in accordance with accepted standards of practice. Observations in the Emergency Department revealed two (2) bottles of Normal Saline irrigation opened, unlabeled and undated in the patient room cabinet, accessible for patient use. Additionally two (2) opened, unlabeled and undated vials of Normal Saline flush were observed to be in a drawer accessible for patient use.

The findings include:

Review of the facility's policy titled "Expired Medications, Policy 59" with a revision date of 04/2013, revealed outdated and/or unusable medications should be removed and stored away from usable stock until proper disposition can be effected. Further review revealed the person opening an injectable vial shall date and initial the label.

Observation during initial tour of the Emergency Department, on 04/29/14 at 8:49 AM, revealed one (1) opened, unlabeled and undated two hundred and fifty (250) milliliter bottle of Normal Saline irrigation in the cabinet of Trauma Room 2. Further observation of the medication cabinet in the nurses' station revealed one (1) opened, unlabeled and undated two hundred and fifty (250) milliliter bottle of Normal Saline irrigation; one (1) opened, unlabeled and undated bottle of Chlorhexidine Gluconate; four (4) opened, unlabeled and undated bottles of PVP prep solution and two (2) vials of Normal Saline flush opened, unlabeled and undated were observed to be in a medication drawer at the nurses' station.

Interview with the Director of the Emergency Department, on 04/29/14 at 8:49 AM, revealed the Normal Saline irrigation and vials of Normal Saline flush should have been discarded and not available for patient use. Further interview revealed the Normal Saline irrigation and the Normal Saline vials were single patient use items. Continued interview revealed the prep solution and Chlorhexidine Gluconate should have been dated when opened.

Interview with the Pharmacist, on 04/30/14 at 9:42 AM, revealed the Normal Saline irrigation and vials were single patient use items and should have been disposed of after use. Further interview revealed the Chlorhexidine Gluconate should have been label and dated when opened.

Based on observation, interview, and review of the facility's policy it was determined the facility failed to ensure food was stored in a safe and sanitary manner per federal and state licensure requirements for food and dietary personnel as well as food service standards, laws and regulations. Observation was made of opened food items with no label or date.

The findings include:

Review of the facility's policy titled "Food Storage" with a revision date of 01/2007, revealed the policy applied to the guidelines set forth for the storage of dietary supplies to prevent contamination. Further review revealed proper storage of food was essential to preserve its quality, prevent contamination and retard bacterial growth. Further review revealed all opened foods should be kept in containers that prevent contamination and absorption of humidity. Further review revealed containers should be clearly labeled with the common name of the food. Further interview revealed the facility utilized the First In - First out (FIFO) basis. Continued review revealed Maintenance of proper storage procedures were the responsibility shared by all dietary staff members.

Observation during initial tour of the kitchen, on 04/29/14 at 9:30 AM, revealed the dry food storage area to contain an open, unlabeled and undated package of dry gravy, an open unlabeled and undated package of Au Jus gravy, an opened, unlabeled and undated package of sliced almonds, an opened, unlabeled and undated package of powder artificial sweetener, an opened, unlabeled and undated package of salad toppings and two (2) opened, unlabeled and undated boxes of rice. Continued observation in the kitchen revealed three (3) opened, unlabeled and undated bottles of vegetable oil, one (1) opened, unlabeled and undated bottle of apple cider vinegar, one (1) opened, unlabeled and undated bottle of imitation vanilla; one opened canister of olive oil unlabeled and undated.

Interview with the Dietitian, on 04/29/14 at 9:30 AM, revealed opened food items should be labeled and dated to ensure items beyond their expiration date were not served to the patients. Further interview revealed all opened food items should be label and dated to ensure the facility's first in and first out policy was followed.

Based on record review, interview and review of the facility's policies, it was determined the facility failed to ensure medical records were complete, accurately documented and readily accessible for one (1) of twenty-one (21) sampled patients (Patient #21). Review of Patient #21's medical record revealed no documented evidence the facility retained a copy of the sexual assault evidence collection examination. Additionally, no evidence was found the facility staff documented the chain of custody for the collected evidence or documented the victim's advocate notification in the medical record.

The findings include:

Review of the facility's policy titled "Clinical Record Approval" with a revision date of 01/2001, revealed the records were to be legible, complete, accurately documented, readily accessible and systematically organized.

Review of the Sexual Assault Forensic-Medical Examination protocol (502 KAR 12:010), Section 2, Pre-forensic-Medical Examination Procedure, revealed prior to the Forensic-Medical examination, the facility should contact the Rape Crisis Center. Further review revealed upon arrival of the Rape Crisis Center Advocate to the facility, the facility should then ask the victim if he/she wished to have a rape crisis center advocate present for the examination or otherwise available for consultation. Further review revealed the facility staff should document that the procedures established were completed. Continued review of 502 KAR 12:010, Section 5, Storage and Transfer of Samples, revealed a Chain of custody documentation shall be maintained throughout all storage and transfer procedures. Further review revealed the examination facility shall maintain documentation regarding transfers of samples.

Review of the facility's policy titled "Suspected Sexual Assault: Examination and Treatment" with a revision date of 07/2006, revealed the facility should call the Sexual Assault Crisis line to activate sexual outreach or protective services outreach.

Review of the Sexual Assault Evidence Collection Kit Instructions, undated, revealed the kit to contain a three (3) duplicate form. Further review revealed the white copy of the form should be maintained in the hospital/physician records.

Record review revealed, the facility admitted Patient #21 to the Emergency Department on 05/11/13 at 10:03 AM, with a chief complaint of a reported sexual assault. Continued record review revealed no documented evidence was found the medical record contained the hospital/physician's copy of the sexual assault examination, per the Sexual Assault Evidence Collection Kit Instructions. Continued review of the medical record revealed no documented evidence the facility contacted the Rape Crisis Center for a Victim's Advocate to be available for the victim during the procedure per 502 KAR 12:010. Further review revealed no documented evidence was found the facility transferred the evidence collected to a law enforcement agency for analysis or maintained the evidence in a restricted access storage area. Further review revealed no documented evidence was found as to the location of the evidence.

Interview, on 05/01/14 at 9:33 AM, with the Emergency Department Registered Nurse (EDRN) #2, responsible for Patient #21's care, revealed she did assist the physician with the sexual assault evidence collection examination. Further interview revealed she submitted the hospital/physician examination copy to the medical records department with the remainder of the chart. Continued interview revealed she did not contact the Rape Crisis Center, per the facility's policy; however, she reported Patient #21 was asked if he/she wanted an advocate and the patient refused. Further interview revealed EDRN #2 did not document this refusal in the medical record. Further interview revealed she transferred the evidence collected to the local law enforcement agency; however, failed to document the chain of custody in the medical record.


Interview with the Chief Nursing Officer, on 04/30/14 at 5:28 PM, revealed the medical record should contain documented evidence of the disposition of the evidence collected and notification of the victims advocate. Continued interview on 05/01/14 at 2:00 PM, revealed the Sexual Assault Evidence Collection Kit was a "law enforcement" document and not a hospital document; therefore was not part of the medical record.

Based on interview, record review, and review of the facility's "Medical Staff Rules and Regulations", last updated 11/10, it was determined the facility failed to provide a physical examination and medical history as determined by the bylaws for one (1) out of twenty-one (21) sampled patients (Patient #13).

The findings include:

Review of the facility's Medical Staff Rules and Regulations, last update 11/2010, section Medical Records, subsection History and Physical, revealed a complete history and physical by a physician member of the Medical Staff must be on every patient's chart within 24 (twenty-four) hours of admission. A copy of a history and physical taken by a member of the medical staff 7 (seven) days prior to admission may be used if it is legible, durable, and provided no changes have occurred or provided.

Review of Patient #13's medical record revealed the facility admitted the patient on 12/31/13 following a planned surgical left hip replacement. Additional review of Patient #13's medical record revealed Progress Notes, dated 11/27/13 which was 34 (thirty-four) days prior to admission, which contained the history and physical exam of the patient as well as a plan for surgical procedure as well as the expected postoperative recovery for 12/31/13. Further review revealed no documented evidence of a current history and physical as outlined by the Medical Staff Rules and Regulations of a complete history and physical within 24 hours of admission or a copy of a history and physical taken 7 days prior to admission. Continued review of Patient 13's medical record revealed the facility re-admitted the patient on 02/18/14 following a planned surgical right hip replacement. Further review of Patient #13's medical record revealed Progress Notes, dated 01/29/14 which was 19 (nineteen) days prior to admission, which contained the history and physical exam of Patient #13 with a planned inpatient operation scheduled for 02/18/14. Still further review revealed no documented evidence of a current history and physical as outlined by the Medical Staff Rules and Regulations of a complete history and physical within 24 hours of admission or a copy of a history and physical taken 7 days prior to admission.

Interview with the Director of Medical Records, on 04/30/14 at 3:00 PM, revealed the facility accepted history and physical exams performed up to 30 (thirty) days prior to an inpatient admission. The Director of Medical Records was unaware of the timeline for history and physical exams of 7 days prior to admission and when informed stated the Medical Staff Rules and Regulations needed to be changed to reflect acceptable history and physicals performed prior to the 7 day as outlined in the bylaws of the facility.