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Based on observation, interview, record review and review of facility policies, the hospital and its Governing Body failed to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for 17 of 17 patients on Suicide/Self Harm watch every 15 minutes by allowing patients access to the following:
-non-suicide resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls (A0144);
-shower water control valves which provided potential looping hazards for all patients on the units (A0144);
-lengthy cords on an entertainment center, television, and speakers which provided a potential looping hazard for all patients (A0144);
-plastic bags accessible to all patients which provided potential for suffocation (A0144);
-moveable chairs and bedside tables in patient rooms where patient's can position and stand on for hanging themselves or use as a weapon (A0144);
-anchored bedside tables positioned directly under metal window curtain brackets allowing the potential for a looping and hanging hazard (A0144);
-non-varied, predictable patient rounding by staff every 15-minutes (A0144);
-pre-printed times on the Mental Health Intervention Flow Sheet failed to include the actual time the 15-minute patient rounds were made (A0144);
Review of a consultation letter from a reputable general engineering and construction firm dated 11/30/10 identified and recommended 25 patient safety measures to create a safer environment for the protection of patients with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others. The facility assigned a priority of "5" (highest priority) to 13 of the 25 recommendations listed. However, at the time of the full survey on 1/18/11, corrections were still being implemented to mitigate the identified hazards. In some cases materials had not yet been ordered (replacement handles for hand washing sinks and shower water control valves were not ordered until 1/19/11).
The cumulative effect, severity of the situation and the potential for harm to all patients in the psychiatric area of the facility, has resulted in overall noncompliance with the Condition of Participation: Governing Body, CFR482.12 and demonstrated an unsafe patient care environment.
The facility had a total census of 92. This total included both the Barry Road Campus and the Smithville Campus.

Based on observation, record review, policy review, and interviews the facility failed to ensure patients were provided care in a safe setting for 17 of 17 patients on Suicide/Self Harm watch every 15 minutes by allowing patients access to the following:
-non-suicide resistant plumbing fixtures and exposed pipes connecting toilets to bathroom walls;
-shower water control valves which provided potential looping hazards for all patients on the units;
-lengthy cords on an entertainment center, television, and speakers which provided a potential looping hazard for all patients;
-plastic bags accessible to all patients which provided potential for suffocation;
-moveable chairs and bedside tables in patient rooms where patient's can position and stand on for hanging themselves or use as a weapon;
-anchored bedside tables positioned directly under metal window curtain brackets allowing the potential for a looping and hanging hazard;
-non-varied, predictable patient rounding by staff every 15-minutes; and
-pre-printed times on the Mental Health Intervention Flowsheet which failed to include the actual time the 15-minute patient rounds were made;
Due to the severity of the situation and the potential for harm to all patients in the psychiatric area of the facility, this resulted in overall noncompliance with the Condition of Participation: Patient Rights CFR482.13 and demonstrated an unsafe patient care environment.
The facility admitted patients with suicidal ideation, history of suicidal ideations, attempts to harm self or others, assault precautions and fall precautions.
The facility had a total census of 92. This total included both the Barry Road Campus and the Smithville Campus.

Based on review of Patient Rights documents the facility failed to provide an appropriate State Advocacy Agency phone number for grievances to all patients in both campuses, the total census was 92.

Findings Included:

1. Review of the booklet titled, "Saint Luke's Northland Hospital," (no effective date) on 01/19/11 at 11:50 AM, showed the State Advocacy Agency, Department of Health and Senior Services phone number listed as 1-800-592-0210. This number was called and it connected to a local siding and roofing business.

During an interview on 01/19/11 at 1:15 PM, Staff Y, Director of Quality and Risk Management, confirmed that the phone number was wrong and that it connected to a local siding and roofing company. Staff Y stated that all patients receive this booklet at both the Smithville and Barry Road campuses.

Based on observations, staff interviews, and record reviews the facility failed to protect patients' right to privacy by publically displaying private information regarding 14 of 14 on cardiac monitors on the BR (Barry Road) 3rd Floor Intensive Care Unit (ICU). The combined census was 92.
Findings Included:
1. During review of the facility's policy titled, "Patient Privacy and Information Security - General Guidelines," dated 08/2010, Paragraph F, #3 stated in part the following:
Patient confidential clinical information should not be displayed in public areas. For example, information outside patient room, on unit white erase boards, etc. is appropriate only if it does not indicate diagnostic specific information AND if only the patient's initials are used if possible. When patient safety is a concern, the first 3 letters of the last name and the first initial of the first name will be used. No full first or last name of the patient will be displayed where public (non-employees) can access the information.
2. During tour of the BR 3rd Floor ICU on 01/20/11 at 10:05 AM, observations showed two large cardiac monitors sitting on top of a desk/charting area at the Nursing Station. The monitors faced the hallway and could be viewed by the general public. The monitors included private information for all 14 patients monitored on the ICU. The monitors showed the patients' room numbers, the first initial of their first name and their full last name.
During an interview with the Nurse Manager of BR 3rd Floor ICU, Staff CC on 01/20/11 at 10:25 AM, he/she stated they identify patients by the first initial of their first name and the full last name to make it easy for staff caring for patient's to identify them when viewing the monitors. He/she stated the current system decreased staff confusion for identifying their patients.

Based on observation, interview, record review and review of facility policies, the facility continued to fail to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting in 9 of 10 Acute Adult Psychiatric Inpatients, 3 of 3 Adolescent Psychiatric Inpatients, 5 of 7 Psychiatric Inpatients on 3-East ( 17 of 17 psychiatric patients on Suicide/Self Harm on 15 minute watches) at the Smithville Campus. The facility had a total census of 92. This total included both the Barry Road Campus and the Smithville Campus.

Findings included:

1. Observation of 3 East, Geriatric Psych unit with census of seven inpatients on 1/18/11 at 2:48 PM, showed 16 patient rooms (301 through 312, and 315 through 318-each with a private bathroom). Observations of each room showed the following:
-Large wrist handles (five inches long) and high neck faucet (12 inches above sink) on the hand wash sink in each room;
-Long stemmed handles (three and one half inches) on the shower's water control valve in each private bathroom;
-Window curtains hung from rods mounted on steel brackets;
-Thermostat protruded from the wall one and one-half inches;
-Wall locker with a metal drawer that could be completely removed to expose sharp metal edges;
-Nightstands secured to walls and floors positioned closely to windows with hanging curtains and fixed curtain rod brackets;
-Unsecured furniture including three nightstands of heavy wood construction in rooms 311, 312, and 315.

The configuration of the long handles and high necked faucets on hand washing sinks, steel brackets suspending window curtain rods and thermostats creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation) for all patients in the facility. The metal drawer guides and exposed sharp edges created a potential hazard for self-mutilation. Heavy unsecured furniture or furnishings offer potentially deadly projectiles if thrown and can easily maneuvered and positioned under a protruding device or looped cord for choking or strangulation.

2. Observation of 2 East, Adult Mental Health unit with a census of seven inpatients on 1/19/11 at 8:30 AM, showed 16 patient rooms (201 through 212, and 215 through 218-each with a private bathroom). Observation of each room showed the following:
-Large wrist handles (five inches long) and high neck faucet (12 inches above sink) on the hand wash sink in each room;
-Long stemmed handles (three and one half inches) on the shower's water control valve in each private bathroom;
-Window curtains hung from rods mounted on steel brackets;
-Thermostat protruded from the wall one and one-half inches;
-Wall lockers in all but two rooms with a metal drawer that could be completely removed to expose sharp metal edges;
-Lighting fixtures above all bedroom sinks with sharp metal edges and non-rated safety glass;
-Fan and television mounted on the wall of the dining room with long, exposed, and unsecured electrical cords and cables;
-Nightstands secured to walls and floors, positioned closely to windows with hanging curtains and fixed curtain rod brackets;
-Dining room hand wash sink has exposed plumbing; large wrist handles (five inches long) handles and high (12 inches) neck;
-Large trash container with large (35 gallon or larger) plastic trash bag liner in the dining room;
-Removable ceiling tiles in a seclusion room located next to room 219. The lay-in tiles and structural grid of light aluminum girders with wire hangers expose patients to unsecured interstitial space above ceiling where unshielded water pipes, electrical wiring and communication cables are routed.

The configuration of the long handles and high necked faucets on hand washing sinks, steel brackets suspending window curtain rods and thermostats creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation) for all patients in the facility. The metal drawer guides and exposed sharp edges created a potential hazard for self-mutilation. Lighting fixtures above each bedroom sink on this floor are of older, square edged design, with open metal flashing on each end, and protrude from the wall about four inches, enough to pose an additional looping hazard. Heavy unsecured furniture or furnishings offer potentially deadly projectiles if thrown and can easily maneuvered and positioned under a protruding device or looped cord for choking or strangulation. The opening of the trash container in the dining room made easy access to the plastic trash bag liner, a potential suffocation risk. Exposure to water pipes and live electrical wiring in the walls or above the ceiling creates strangulation, electrocution and burn hazards.

3. Observation of 2 West Adolescent Psych unit with a census of three inpatients on 1/19/11 at 10:05 AM, showed 14 patient rooms (219 through 225, and 230 through 235-each with a private bathroom). Observations of each room showed the following:
-Large wrist handles (five inches long) and high neck faucet (12 inches above sink) on the hand wash sink in each room;
-Long stemmed handles (three and one half inches) on the shower's water control valve in each private bathroom;
-Window curtains hung from rods mounted on steel brackets;
-Thermostat protruded from the wall one and one-half inches;
-Wall locker with a metal drawer that could be completely removed to expose sharp metal edges;
-Lighting fixtures above all bedroom sinks with sharp metal edges and non-rated safety glass;
-Nightstands secured to walls and floors, positioned closely to windows with hanging curtains and fixed curtain rod brackets;
-Space behind toilet commodes in six private bathrooms, (230, 231, 232, 233, 234, and 235) that measured seven inches from the wall and 20 inches above the floor.
-Exposed plastic bags hanging from two soiled linen carts located outside of room 221;
-Exposed electrical connection due to a missing duplex outlet cover in room 223;
-Removable ceiling tiles in a seclusion room located across from room 235. The lay-in tiles and structural grid of light aluminum girders with wire hangers expose patients to unsecured interstitial space above ceiling where unshielded water pipes, electrical wiring and communication cables are routed. The seclusion room also had a missing cover to a light switch which exposed any occupants to a potential electrocution hazard.

The configuration of the long handles and high necked faucets on hand washing sinks, steel brackets suspending window curtain rods and thermostats creates looping hazards (material or a device could be looped around/over the object to be used for choking and strangulation) for all patients in the facility. The metal drawer guides and exposed sharp edges created a potential hazard for self-mutilation. Lighting fixtures above each bedroom sink on this floor are of older, square edged design, with open metal flashing on each end, and protrude from the wall about four inches, enough to pose an additional looping hazard. Heavy unsecured furniture or furnishings offer potentially deadly projectiles if thrown and can easily maneuvered and positioned under a protruding device or looped cord for choking or strangulation. The opening of the trash container in the dining room made easy access to the plastic trash bag liner, a potential suffocation risk. Exposed water pipes behind the toilets in rooms 230-235 pose a potential choking or strangulation hazard as they are at a height and width enough to loop a cord or wire for a noose. Exposure to water pipes and live electrical wiring in the walls or above the ceiling creates strangulation, electrocution and burn hazards.






29117

4. During an interview on 01/19/11 at 8:55 AM, Registered Nurse (RN), Staff W stated that patient rounds on the Adolescent unit were completed at the top of the hour and then every fifteen minutes. Note: These are predictable patient rounds. This allows potential time for self harm to be completed before the next rounds by patients at risk for suicide/self harm.

Observation on 01/19/11 at 9:35 AM, in the Adolescent Unit showed the RN had to leave the unit, exiting through closed double doors to get to the medication room. The RN is unable to visualize the unit from this room. This left one MHT on the unit caring for three Adolescent patients, one of these three patients (#117) was admitted with suicidal ideation, violent and homicidal issues. The staffing on this unit is one MHT and one RN for up to six patients. One staff pulled away with another patient creates a risk for other patients that are at risk for suicide, homicide, violence, or self harm.

5. Observation on 01/19/11 between 10:10 AM and 10:40 AM, on 3 East Unit showed ten out of 11 rooms (303, 304, 305, 306, 307, 308, 309, 310, 311, and 315) with chairs that could be easily moved and were accessible to all patients on the unit. A strong moveable object may be used as an assistive device for patients at risk for suicide/self harm.

6. Observation on 01/19/11 between 10:10 AM and 10:40 AM, on 3 East Unit showed three rooms out of 11 rooms (311, 312, and 315) with night stand tables that could be easily moved and were accessible to all patients on the unit. A strong moveable object may be used as an assistive device for patients at risk for suicide/self harm.

During an interview on 01/19/11 at 10:40 AM, Staff O confirmed the chairs and night stand tables were not secured and were accessible by all patients on the unit.

7. Observation on 01/19/11 at 10:40 AM, in the 3 East Unit group room, which is an open room patients have access to watch television on their own and is also used for groups, meals, and other activities, showed a cordless phone base with two unsecured phone cords, attached at the base. The cords were both approximately 6 feet long. Both phone cords were accessible to all patients using the group room. The cords wrapped several times around the neck of a patient could pose a potential for choking, respiratory arrest, or possible hanging.

During an interview on 01/19/11 at 10:40 AM, Staff O confirmed the length of the phone cords and that they were unsecured allowing patients on the unit access to them.

During an interview on 01/19/11 at 10:50 AM, Licensed Practical Nurse II (LPN II), Staff ZZ stated patient rounds on 3 East Unit were completed at the top of the hour and every fifteen minutes. Note: These are predictable patient rounds. This allows potential time for self harm to be completed before the next rounds by patients at risk for suicide/self harm.





12943

8. Review of facility policy "Intervention Status, Patient," revised on 12/10, showed (in part) the following:
-Section - Suicide, "Acute Inpatient Criteria" included in part: "Imminent risk, making verbal threats, intent without available means or plan, able to maintain personal safety without supervision, history of poor impulse control;" and
-Section - Suicide, "Adolescent Acute Inpatient Criteria," included in part: Refusal to comply with treatment or stay in program activities, refusal to talk with staff, doesn't want to be in treatment.
-Section - Acute Inpatient Status, included in part: Staff is aware of patient's location and mental status and is accessible to intervene when necessary for patients who are placed on Acute Inpatient status. Staff has the ability to provide assessment and interventions for up to five Acute Inpatient patients. Acute Inpatient patient continues to be assessed every 15 minutes while asleep (of note - the policy failed to state the assessment frequency while the patient is awake). The assessment shall include:
a. imminent harm to self or others;
b. ability to control impulses;
c. orientation;
d. acting out;
e. psychotic behavior;
f. history of impulse control and acts of violence in treatment;
g. safety of environment including patient belongings and room;
h. ability to maintain personal safety; and
i. ability to participate in "off unit" activities.


9. Review of admission documentation records, specifically the "Mental Health Patient Status Criteria," and the "Suicide/Mental Health Assessment," completed by an RN (Registered Nurse), and review of the daily census sheets for the following psychiatric units showed 17 of 17 patients were classified as "Acute Inpatient" for Suicide and on a Suicide/Self Harm watch every 15-minutes:

1) Adult Mental Health Unit, 2 East, showed nine of nine patients on a Suicide/Self Harm watch every 15-minutes (Total Unit Census was 10):

-Patient #108 admitted on 01/04/11, Room 208;
-Patient #110 admitted on 01/06/11; Room 211;
-Patient # 96 admitted on 01/13/11; Room 206;
-Patient #107 admitted on 01/14/11; Room 205;
-Patient #113 admitted on 01/14/11; Room 217;
-Patient #112 admitted on 01/15/11; Room 216;
-Patient #106 admitted on 01/17/11; Room 204;
-Patient #109 admitted on 01/17/11; Room 209; and
-Patient #114 admitted on 01/17/11; Room 218.

Review of the Adult Mental Health Intervention Flowsheet, used by staff to document the 15-minute checks, showed preprinted times of these checks and failed to indicate the actual time the 15-minute checks were completed.

2) Adolescent Psychiatric Unit, 2 West, showed three of three patients on a Suicide/Self Harm watch every 15-minutes (Total Unit Census was 3):

-Patient #117 admitted on 01/13/11; Room 234;
-Patient #115 admitted on 01/16/11; Room 230; and
-Patient #116 admitted on 01/18/11; Room 232.

Review of the Adult Mental Health Intervention Flowsheet, used by staff to document the 15-minute checks, showed preprinted times of these checks and failed to indicate the actual time the 15-minute checks were completed.


3) Adult Mental Health Unit, 3 East, showed five of five patients on a Suicide/Self Harm watch every 15 minutes (Total Unit Census was 7):

-Patient #123 admitted on 01/05/11; Room 311;
-Patient #124 admitted on 01/12/11; Room 315.
-Patient #121 admitted on 01/17/11; Room 306;
-Patient # 97 admitted on 01/17/11; Room 309; and
-Patient # 98 admitted on 01/17/11; Room 312.

Review of the Adult Mental Health Intervention Flowsheet, used by staff to document the 15 minute checks, showed preprinted times of the checks and failed to indicate the actual time the 15-minute checks were completed.

10. Review of the Adult Mental Health Intervention Flowsheets for all psychiatric units on 01/18/11 showed staff continued to initial preprinted times when making the 15-minute checks.

11. Observation on 01/18/11, approximately 2 PM to 4 PM and on 01/19/11, approximately 9 AM to 11 AM, for both the Adult Mental Health unit and the Adolescent Psych unit in all patient rooms showed the following:
-unsecured chairs, easily movable, with placement under looping and hanging hazards;
-metal window curtain brackets with a potential for a looping and hanging hazard;
-and light fixtures over the patient's sink with an area for securing a looping device between the light fixture and the wall.

12. Observation of the Adult Mental Health Unit dining room on 01/19/11 at approximately 10 AM, showed the following safety hazards:
-a large (approximately 30 gallon) enclosed trash container with a clear plastic trash liner. This plastic liner was accessible and could be removed from the trash container by inserting a hand through the front flap of the container;
-a wall mounted fan approximately 6 foot from the floor that was strong enough to withstand a substantial pulling down force when tested, this fan provided a looping and hanging hazard;
-window curtain brackets attached to six windows with an open space that would permit securing a loop device for hanging;
-unanchored/unsecured tables, chairs and sofas easily movable and positioned under the fan or windows providing a place for patient's to stand on top of providing a securing device for looping or hanging.

13. During an interview with Staff R, Director of Behavioral Health, on 01/19/11 at approximately 10 AM, he/she confirmed there is not a video camera in the Adult Mental Health Unit dining room and there is not a direct line of sight from the nursing station. Staff R confirmed the dining room is left open and accessible to all patients on the units. Staff R confirmed that staff are not required to be present when patients are in the dining area.

14. During an interview on 01/20/11 at approximately 3:45 PM, Staff R confirmed that the staff do not document the actual time of the patient every 15-minute checks for Suicide/Self Harm patients. Staff R confirmed the rounding times are preprinted on the Mental Health Services Intervention Flowsheet and the staff place their initials next to the preprinted times on this sheet.

Based upon observation, interview, and record review the facility failed to ensure access to patient health information was limited to those directly involved in the care of that patient. This failure potentially affected all inpatients and outpatients accessing Laboratory services and Radiology services at both campuses and potentially affected 14 of 14 patients in the Barry Road (BR) 3rd Floor Intensive Care Unit (ICU). The combined facility census was 92.

Findings included:

1. Observation during tour of the Radiology Department at the Smithville campus on 01/19/11 at 9:20 AM showed a large recycling bin filled with x-ray envelopes. Patient names and birth dates were written on the envelopes and were clearly visible.

During an interview on 01/19/11 at 9:22 AM, Staff U, Radiology Technician, stated the Radiology Department was accessible through four unlocked hallway doors. Two of the hallway doors entered directly into rooms used for radiological exams. One of the two doors entered the main hallway of the Radiology Department, and the second one entered into a former exam room, now being used as a conference room. Staff U stated that the conference room door would probably be locked at the hallway entrance, but not at the Radiology entrance. Staff U stated Housekeeping and other facility staff were not monitored while in the Radiology area.

2. Observation during tour of the Laboratory area at the Smithville campus on 01/19/11 at 10:05 AM, showed a file with lab reports for approximately 40 patients lying on a countertop. Each paper was labeled with patient name, date of birth and lab test results.

During an interview on 01/19/11 at 10:10 AM, Staff V, Care Practitioner, stated the door to the hallway was locked except when outpatients were having blood drawn, but the door exiting to the Emergency Department was never locked. Staff V stated Housekeeping and other facility staff were not monitored while in the Laboratory area.

3. Observation during tour of the Radiology Department at the Barry Road campus on 01/21/11 at 9:45 AM showed the following:
- Spiral bound log books sitting on both work stations in the Computerized Tomography (CT) Scan area. Each log book showed patient names, birthdates, and other identifiers necessary to schedule tests.
- A computer screen in an area near an unlocked hallway door displayed the name of a patient who was accessing services. This information was visible to anyone entering the area through the unlocked door.

During an interview on 01/21/11 at 10:00 AM, Staff WW, Clinical Manager for Radiology, stated the only routinely locked door in the Radiology Department was the entrance to the Nuclear Medicine unit. All other doors were unlocked, with the exception of office areas. Staff WW stated Radiology employees did not monitor the multiple entrances, but would notice if someone wandered in. Staff WW stated Housekeeping and other facility staff were not monitored while in the Radiology area.


05760

4. Review of the facility's policy titled, "Patient Privacy and Information Security - General Guidelines" dated 08/2010; Paragraph F, #2 stated the following:
When in use within the institution, health information should be kept in secure areas at all times. Health information records and computers should not be left unattended in areas accessible to unauthorized individuals. Users should log off the computer when leaving the area.
5. During tour of the BR 3rd Floor ICU on 01/20/11 at 10:05 AM, observations showed the Registered Clinical Dietitian, Staff PP, charting/reviewing a patient's medical record on a computer screen between 3rd floor ICU patient rooms #312 and 313. Staff PP stated he/she could access any section of the patient's medical record per the hall computers. The computer screen did not have a privacy screen and the patient's medical information could be easily read on the screen standing 7-8 feet away. Staff PP stated there was no way to protect patients' privacy.
Further observations in the ICU showed 5 computer screens on cabinets in the hallways with patient medical information easily viewed and visible to the general public.

Based on observation, interview and record review the facility failed to ensure multi-use medical solutions were dated, timed and initialed when opened, or discarded after use as directed in the facility policy. This practice was observed in the Emergency Department (ED), on the Medical Surgical Unit (MS), in Radiology, and Surgery. The facility census was 92.
Findings Included:
1. Observation and interview on 01/18/11 at 2:40 PM, showed one opened four-ounce bottle of Betadine (an antiseptic), one-half full, sitting on a counter in the ED. This bottle was not dated, timed, or initialed as to when it was opened. ED manager, Registered Nurse (RN), Staff OO stated this bottle of Betadine should have been thrown away or labeled with date, time and initials of the nurse who opened it.
Review of a facility policy titled, "Medication Practices," effective 12/10, showed the following:
a) Open or used single dose vials must be discarded after use or within one hour.
b) Multi-dose vials must be discarded within 28 days from opening unless the manufacturer's product information states otherwise. However, at this hospital, multi-dose vials will be disposed of, thus treated like a single dose vial.
2. Observation on 01/20/11 at 10:12 AM, showed one opened 16-ounce bottle of Alcohol, two-thirds used. This bottle was not timed, dated or initialed when opened. This bottle was located in the nurse server (a key-coded cabinet with supplies for patient use) for a random patient (patient not on our sample) on the MS unit.



29117

3. Observation on 01/20/11 at 10:01 AM, in the Fluoroscopy (A technique in radiology for immediate projection of an x-ray image on a screen for visualization by a medical care provider.) room of the pain clinic showed the following:
-Providone Iodine 10 %, an opened two-ounce bottle, with no date, time, or initials for when it was opened.
-Isopropyl Rubbing Alcohol, 70%, an opened 16-ounce bottle, with no date, time, or initials for when it was opened.

During an interview on 1/20/11 at 10:01 AM, Director of Outpatient Services, Staff EE confirmed that both bottles were opened with no date, time, or initials of when the bottles were opened.

4. Observation on 01/20/11 at 1:52 PM, in Operating Room (OR), number three, the anesthesia cart showed Diprivan 1% (A medication used in general anesthesia) 10 mg(milligrams) per ml (milliliter), an opened 20 ml bottle, with no date, time, or initials documented on the bottle of when it was opened.

During an interview on 01/20/11 at 1:52 PM, Staff EE confirmed that the Diprivan 1% bottle was opened with no date, time, or initials for when it was opened.

5. Observation on 01/20/11 at 3:45 PM, in OR, number two, the anesthesia cart showed Succinylcholine (A medication used for muscular relaxation during surgical anesthesia) an opened 5 ml bottle of 20 mg per ml, with no date, time, or initials for when it was opened.

During an interview on 01/20/11 at 3:45 PM, Staff EE confirmed that the Succinylcholine bottle was open with no date, time, or initials of when it was opened.

Based on observation and interview, the facility failed to ensure that radiologic services were performed in a manner that was free of hazards to patients, staff, and visitors. This had the potential to affect anyone entering the Radiology Units of both the Smithville and the Barry Road facilities. The combined facility census was 92.

Findings included:

1. Observation during a tour of the Radiology Department at the Smithville facility on 1/19/2011 at 9:20 AM showed two Radiology exam rooms that were unlocked and accessible from an external hallway. The unlocked doors allowed access to anyone to enter the radiology exam rooms during a procedure.

During an interview on 1/19/2011 at 9:22 AM, Staff U, Radiology Technician, stated patients were escorted into the rooms through the hallways doors, and the doors to these rooms were not routinely locked.

2. Observation during a tour of the Radiology Department at the Barry Road facility on 1/21/2011 at 10:00 AM showed a lighted sign above a doorway in a hallway outside an exam room where x-rays were performed. The sign was blinking on and off - indicating an x-ray was being performed. The door was unlocked, which allowed anyone to enter the room during the procedure.

During an interview on 1/21/2011 at 10:00 AM, Staff WW, Clinical Manager for Radiology, stated the only routinely locked door in the Radiology Department was the entrance to the Nuclear Medicine unit. All other doors were generally left unlocked, with the exception of a few offices. When asked what would happen if anyone entered a procedure room while an x-ray was being performed, Staff WW said they would be exposed to a small amount of radiation.

Based on observation, interview and record review, the facility failed to ensure patient supplies were not expired in the Pain Clinic, Endoscopy Lab, and Cardiac Cath Lab on the Barry Road campus with a census of 62. The total facility census was 92.

Findings Included:

1. Review of policy titled, "Medication Practices," effective 12/10 showed the following: "Every drug storage area within the Pharmacy and throughout the hospital, including code carts and emergency boxes, will be inspected monthly by pharmacy personnel. All expired medications will be removed from stock and stored in a designated area within the Pharmacy so they will not be dispensed for patient use. All out-of-date medications are ultimately destroyed or returned to the manufacturer for credit according to applicable state and federal laws."

2. During an interview on 01/21/11 at 10:15 AM, Director of Outpatient Services, Staff EE stated that all alcohol prep pads had been replaced (replacements were in a red and white package) due to a recent recall.

3. Review of the document titled, "Long Term Care Information Update," dated January 7, 2011 showed:
"Recall of Alcohol Prep Pads, Alcohol Swabs, and Alcohol Swab sticks
January 5, 2011 - Hartland, Wisconsin, Triad Group, a manufacturer of over-the-counter products has initiated a voluntary product recall involving ALL LOTS of ALCOHOL PREP PADS, ALCOHOL SWABS, and ALCOHOL SWABSTICKS manufactured by Triad Group but which are private labeled for many accounts to the consumer level. This recall involves those products marked as STERILE as well as non-sterile products. This recall has been initiated due to concerns from a customer about potential contamination of the products with an objectionable organism, namely Bacillus cereus. We are, out of an abundance of caution, recalling these lots to ensure that we are not the source of these contamination issues. Use of contaminated Alcohol Prep Pads, Alcohol Swabs or Alcohol Swabsticks could lead to life-threatening infections, especially in at risk populations, including immune suppressed and surgical patients. To date we have received one report of a non-life-threatening skin infection. Alcohol Prep Pads, Alcohol Swabs and Alcohol Swabsticks are used to disinfect prior to an injection. They were distributed nationwide to retail pharmacies and are packaged in individual packets and sold in retail pharmacies in a box of 100 packets. The affected Alcohol Prep Pads, Alcohol Swabs and Alcohol Swabsticks can be identified by either " Triad Group, " listed as the manufacturer, or the products are manufactured for a third party and use the names listed below in their packaging:
o Cardinal Health
o PSS Select
o VersaPro
o Boca/ Ultilet
o Moore Medical
o Walgreens
o CVS
o Conzellin

Specific customers distributing the product and selling it at the wholesale, hospital and retail pharmacy level have been notified by certified mail with instructions on how to return the product. If a consumer has any of these types of products in their possession listing " Triad Group " as the manufacturer, they should not use the product and should return it to the place it was purchased for a full refund or call Triad Group Customer Service Monday through Friday between the hours of 8:30 A.M. and 4:00 P.M. Central Time: 262.538.2900."

4. Observation on 01/20/11 at 10:25 AM, in the Pain clinic crash cart showed the following:
-two 1,000 ml (milliliter), intravenous (fluid that may be put into the vein) solutions, lot 50-036-JT expired 02/09;
-Providone-Iodine (an antibacterial solution) swab sticks 10% solution, lot # 7M41, expired 12/2010.
-Alcohol Prep pads, 21 total, blue and white packaging, no lot number available or expiration dates.

During an interview on 01/20/11 at 10:25 AM, Staff EE confirmed that the above mentioned supplies were outdated and the alcohol prep pads were the recalled pads.

Observation on 01/20/11 at 10:30 AM, in the Pain clinic blood draw tray showed 11 recalled alcohol pads, no lot number or expiration date on packages.

During an interview on 01/20/11 at 10:30 AM, Staff EE confirmed the 11 alcohol prep pads were the recalled pads.

5. Observation on 01/20/11 at 4:20 PM, in the Endoscopy (The use of a scope that goes into organs and cavities to visualize the interior of the cavity) Lab showed 110 recalled alcohol prep pads.

During an interview on 01/20/11 at 4:20 PM, Staff EE confirmed that the alcohol prep pads were the recalled pads.

6. Observation on 01/21/11 at 9:15 AM, in the Cardiac Cath Lab showed the following:
- Lidocaine Jelly 2% (a topical anesthetic) lot number 8L09A, expired on 10/2010;
-Total of 62 recalled alcohol prep pads.

During an interview on 01/21/11 at 9:15 AM, Staff EE confirmed that the Lidocaine Jelly was expired and the alcohol prep pads were the recalled pads.

Based on observation, interview, and facility policy review the facility failed to ensure staff performed hand hygiene per the facility's policy:
-when entering an isolation room for one (Patient #95) of four patients observed for nursing care while in isolation;
-when moving between contaminated and non-contaminated tasks/areas in the Laboratory, potentially affecting all staff in the Laboratory and all visitors to the Laboratory; and
-after surgical procedure for one patient (#102) of one patients observed during procdeures.

The facility also failed to:
-maintain a cleanable surface for four of twelve procedure table pads/mattresses observed; and
-ensure personal protective equipment (gowns) were utilized as intended for one of four employees observed wearing isolation gowns. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Handwashing and Handwashing Products," dated 1/2008, showed the following instructions (in part): While the use of gloves offers an additional layer of protection for both the patient and the staff member, gloves are not impervious to the transmission of microorganisms. This can occur through imperfections to the integrity of the gloves during the manufacturing process, microscopic tears during the production and packaging process, or tearing during the normal course of use. In addition, studies have shown decrease in efficacy of gloves when worn for extended periods of time. Therefore it is vital to ensure that hand hygiene occurs prior to gloving and after removal of gloves when involved in patient care activities."

Review of the facility policy titled, "Standard/Transmission Precautions," dated 1/2008, showed the following direction (in part):
- Remove gloves after use, before touching non-contaminated items and environmental surfaces, and before touching another patient. Wash hands/decontaminate hands with alcohol hand gel immediately after removing gloves, as hands can still be contaminated.
- Indirect-contact transmission involves a contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, or dressing or contaminated hands that are not washed and gloves that are not changed between patients.

Review of the facility document titled, "St. Luke's Northland Hospital Structure Standards/Scope of Services Laboratory Department 2011," not dated, showed the following instruction (in part):
- The Laboratory Department follows the basic infection control principles of the hospital to include the use of standard precautions in the event of contact with blood, body fluids or other potentially infectious material, hand washing per hospital procedure, and the reporting of communicable diseases of staff members and patients as required.

Review of the facility document titled, "Laboratory Department - Wearing of Gloves," effective June 1, 1992, showed the following instruction (in part):
- Gloves are to be worn when handling any type of patient specimens, when handling any chemical hazards, or when performing and testing.
- The gloves are to be removed before going into the clean areas of the laboratory and hospital. All gloves will be disposed of in the normal trash receptacles.

2. Observation on 01/19/11 at 11:15 AM, showed Staff V, Care Practitioner, entered the Laboratory of the Smithville campus following a blood draw procedure in the Emerency Department (ED) still wearing the same used gloves. Staff V touched the folder used to hold laboratory results, picked up a clipboard and flipped through the papers, and placed an ink pen in the pocket of his/her uniform.

During an interview on 1/19/2011 at 11:16 AM, Staff V stated, "Oh! I'd better get these gloves off and wash my hands." When asked what the procedure was for hand hygiene following a blood draw procedure, Staff V stated, "I should have taken my gloves off and washed my hands."

3. Observation on 01/20/11 at 9:50 AM, showed Staff YY, Registered Nurse (RN), entering the room of Patient #95, who was on Contact Isolation precautions. A sign posted on the room door stated, (in part): "To prevent the spread of infection, ANYONE ENTERING ROOM MUST wear gown & gloves. Wash or sanitize hands upon entering and leaving a patient's room." Staff YY did not wash or sanitize his/her hands before gowning, gloving, and entering the patient's room.

During an interview on 01/20/11 at 1:20 PM, Staff OO, Director of Inpatient and Emergency Services, stated employees were not required to perform hand hygiene before entering isolation rooms, but were required to perform hand hygiene before exiting isolation rooms.

4. Observation on 01/20/11 at 3:35 PM, showed Staff XX, Medical Technologist, conducting testing on specimens in the Hematology area of the Laboratory of the Barry Road campus. Staff XX was viewing a slide under a microscope when Staff DD, Laboratory Director, requested assistance in finding some documentation. While still wearing gloves, Staff XX searched through several overhead cabinets, drawers, and stacks of papers in the immediate work area. When the documents were found, Staff XX resumed working with specimens.

During an interview on 01/20/11 at 3:45 PM, regarding what test was being performed, Staff XX looked through the hazardous waste bin to identify the container that he/she had removed a specimen from. Staff XX then removed the item from the waste bin to show this surveyor. Staff XX then went to a countertop and touched a machine that was printing a test result. When asked why he/she did not perform hand hygiene after working with contaminated specimens and before moving into a non-contaminated area, Staff XX stated it was standard practice to do all the tests before removing gloves, performing hand hygiene, and proceeding to the paperwork portion of lab analysis. When it was pointed out that Staff XX had contaminated the cabinets, drawers, countertop and lab equipment by not taking off contaminated gloves and performing hand hygiene, Staff XX stated the work area was "wiped down every day." When asked if this included wiping down drawer and cabinet contents, printed test results, and other porous areas that had been touched with gloved hands, Staff XX replied, "No, only countertops, machinery, etc."

During an interview on 01/21/11 at 9:15 AM, Staff UU, Infection Control Nurse, stated employees are required to perform hand hygiene before entering isolation rooms. Staff UU stated Laboratory employees attend annual training on Infection Control practices, and that staff should know to take off gloves and perform hand hygiene before touching items that could not be decontaminated, such as paper.

During an interview on 01/21/11 at 2:00 PM, Staff VV, Clinical Manager for Laboratory, stated, "Everything in the Laboratory except for the Director's Office, the employee break room, and the area with two computer workstations where I work are considered contaminated. That's why we wear lab jackets and gloves the whole time we're back there. Visitors are required to do this too."


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5. Observation on 01/20/11 at 2:57 PM, showed a circumcision being perfomed on Patient #102. When the procedure was completed, both the physician, Staff CCC, and the Registered Nurse, Staff BBB, failed to perform hand hygiene after removing their gloves.

6. Observation on 01/20/11 at 3:05 PM, showed a procedure table pad in an Obstetrics Operating Room with two tears in the material, exposing a gel layer beneath the covering. One area was approximately 1/4 inch in diameter and the other area was one in in diameter. An area of adhesive residue, approximately quarter sized was noted. Staff Z, Director of Women's Services, and Staff EE, director of Outpatient Services, confimed the defective areas and agreed these defects prevented thorough cleaning of the pad.

Observation on 01/21/11 at 9:28 AM, showed a procedure table pad in the Cardiac Cath Lab (An area where patients have a catheter inserted in vessels leading to the heart.) with three tears in the material. Two areas were approximately 1/2 inch in diameter and one was the size of a dime. Staff EE confirmed there were three holes noted in the table pad, and agreed these defects prevented thorough cleaning of the pad.




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Observation on 01/20/11 at 1:45 PM showed tape residue on one of two mattresses in a two bed room in the emergency department, identified by a sign as room # 18/19. Another mattress in an adjacent room identified as room #21 had numerous chipped areas and at least three large torn, flaps of material that exposed the internal weave and foam padding. The largest torn surface areas measured approximately three inches in diameter, four inches by one and one quarter, and two inches long by one inch wide. The facility failed to provide a cleanable surface.


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7. Observation on 01/21/11 at 8:11 AM, showed Staff EEE, RN, entered Patient #4's room to administer medications. Patient #4 was on contact isolation precautions. Staff EEE put a blue plastic gown on, but failed to tie the waist ties. The waist ties dragged the floor of this isolation room.
During an interview on 01/21/11 at 12:09 PM, Staff UU, Infection Control nurse, stated the facility's universal precautions policy did not specifically address this issue; however, she would not expect the ties to drag the floor of any patient room.