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A complaint survey that ended 4/30/12 identified hospital non-compliance with tag number A-700, the Condition of Participation (CoP) at 42 CFR (Code of Federral Regulations) 482.41, Physical Environment. However, based on review of documents and staff interview during this survey, the Governing Body of the hospital failed to act timely to assure the hospital achieved and maintained compliance for this same CoP.

(A Condition of Participation is hospital function that is required by Federal regulations as necessary to ensure patients receive care and services in a safe manner.)

Findings include:

- Review on 7/12/12 of the policy number II.E. titled "Governing Body, References: Contracted Services (482.12(E) Standard)" revised on 10/11/2011 states "The governing body shall be responsible for services furnished in the hospital whether or not they are furnished under contracts...shall ensure that a contractor of services...furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services."

- The hospital failed to obtain a signed contract between the diesel powered generator's vendor and and the hospital to maintain the temporary generator and 96-hours of fuel supply as required. See further evidence written at A-084.

- The hospital continues to be not in compliance with the CoP at tag number A-700, Physical Environment, as cited on a complaint survey that ended on 4/30/12. See further evidence written at A-700 and A-703.

The cumulative effect of the failure of the Governing Body to act timely did not assure the hospital achieved and maintained compliance with all Conditions of Participation and resulted in the hospital's inability to provide care to patients in a safe environment.

The hospital has 26 beds with a census of 16 patients. Of these patients, one patient needed the use of a ventilator patient and another patient required routine suctioning by an electric-powered machine. The ventilator and suction machine were needed for these patients to maintain their airway and ability to breathe.

Based on observation, document review and staff interview, the hospital failed to obtain a signed contract between the diesel-powered generator's vendor and the hospital to maintain the temporary generator and 96-hours of fuel supply as required to provide essential life support during power failures.

During a survey that ended on 4/30/12, surveyors identified non-compliance with the Condition of Participation A-700, 42 CFR 482.41 Physical Environment, when an emergency generator failed to have at least 96-hours of on-site fuel. Investigation during the survey that ended 7/12/12 identified continuation of this problem.

The the failure to provide emergency power and onsight fuel storage that would last at least 96-hours resulted in the hospital's inability to ensure the health and safety for all patients of the hospital.

See the Life Safety Code deficiencies for the survey that ended 7/9/12 and A-703.

The hospital reported a census of 16 patients. Two current patients were dependent on life supportive equipment to maintain their airways and ability to breathe. Based on observation, document review and staff interview, the governing body failed to approve and sign a contract for the temporary emergency generator and failed to ensure the hospital maintained and contracted with an entity to replenish onsite emergency fuel to provide 96-hours of uninterrupted power to essential life support equipment during a power failure. The failure to provide emergency power and fuel services could cause vital life support equipment not to function and potentially endanger all patients of this hospital.

Finding include:

- The complaint survey that ended 4/30/12 identified the hospital failed to have onsite fuel storage that would be used by an emergency generator for life support and life safety equipment.

- Review on 7/12/12 at 2:30pm of the hospital's "Contract Services" policy and procedure titled "Contracted Clinical Services Approval & Evaluation Process" instructs the Medical Staff, Administrative Staff and Department Directors in conjunction with the Corporate Office to evaluate all contracted clinical services. The procedure directs that recommendations made by the medical and administrative staff and department directors be taken to the Chief Executive Officer (CEO) for approval. The procedure process under "D" states, "Contracted Clinical Service will not be provided without a written agreement between the Hospital and the Clinical Service Vendor. Agreements may not be fully executed until appropriate Corporate approval is obtained." Procedure "E" directs that all contracted services will be approved by the Medical Executive Committee and the Governing Board.

- On 7/11/12 at 3:00pm, Administrative staff C provided surveyors an e-mail which contained a proposed contract (dated 5/4/12 to 6/1/12) with a quotation for a diesel-powered emergency generator. However, the contract lacked the hospital's name and address or an authorized signature and date.

- When interviewed on 7/12/12 at 9:00am, Administrative staff C stated hospital staff were trying to acquire a written contract from the vendor for the generator. On 7/12/12 at 11:45am Administrative staff C confirmed the hospital failed to acquire a lease agreement for the emergency diesel generator with an adequate fuel supply tank, and acknowledged the governing body failed to meet and approve the emergency generator agreement dated 5/4/12.

Although requested on 7/12/12, hospital staff failed to provide a copy of the lease agreement or fuel supply contract or governing body minutes for the proposed 5/4/12 lease agreement.

Based on observation, document review and staff interview, the hospital failed to consistently implement policy and procedures when staff (1) identified a maintenance problem and (2) failed to remove all debris and long term, built-up grime from the floors when cleaning rooms.

Findings include:

- Observation of contract cleaning staff L on 7/11/2 at 8:00am revealed staff terminally cleaning patient room #514 ("terminal cleaning" is a phrase used to mean the room was cleaned after a patient was discharged or moved from the room). The room had two dented gouges; one quarter-size and one 2-inches by 2-inches, that left the wood frayed, a potential safety issue for patients who may scrape their skin.

Review on 7/11/12 at 4:00pm of "Facility Support Policy-Procedure Number: LC128, issued November 9, 2008" from the contracted cleaning company revealed contracted cleaning staff should complete a maintenance request form and place the request in the hospital maintenance log binder in the Housekeeping Closet for any observed maintenance problem. However, investigation on 7/11/12 revealed Staff C failed to complete a maintenance request form identifying patient room #514 had two gouges of the wood.

- The environmental tour with maintenance staff H on 7/11/12 at 10:15am revealed the hospital's 20 room area that included patient and ancillary rooms had multiple wall surfaces and doors with deep gouges and areas that need repair. Examples include:

1. The ceiling in the therapy room had an approximate 2-foot area of separation from the wall that gaped 3/8-inch adjacent to the therapy mattress bed.
2. The therapy gym had two walls with cracks that extended the length of each wall.
3. The covering on the therapy mattress had 3 gouges with the inside stuffing exposed rendering the surface non-cleanable.
4. Room #514's ceiling had a 3-inch by 6-inch area of missing ceiling textured surface that exposed the wallboard above the patient bed. The surrounding area of the ceiling textured appeared loose. Staff had placed a push pin into the ceiling textured surface to hold the textured surface up against the ceiling wallboard.
5. In the shower room, located between room's 507 and 508, the wall adjacent to the shower was cracked with a rough texture and had missing ceramic tiles.
6. Room #515- The wall behind the head of the bed had a two-inch by two-inch gouged area.
7. Room #518- The entry door had one foot gouged area.

- Maintenance staff H interviewed on 7/11/12 at 10:20am stated staff had not submitted a request to repair door surfaces. Staff H indicated the hospital had multiple surfaces gouged by beds and equipment throughout the hospital.

- Observations in patient room #514 on 7/11/12 at 10:15am with maintenance staff H after staff L cleaned revealed loose debris on the floor in the corners of the room. The floor had a dark, long-term build-up of grime at the base of the walls that extended out approximately six-inches into the room.

Review on 7/11/12 at 4:00 pm revealed contracted cleaning company A's cleaning policies for discharged patient room cleaning directed cleaning staff to dust mop and then scrape all corners and edges with a grout brush to remove any build-up of debris or grime in the corners and mop the room's floor. Staff L failed to follow this procedure when cleaning room 514 on 7/11/12 at 8:00am.

Maintenance staff H interviewed on 7/11/12 at 10:18am verified cleaning staff should sweep to remove all the debris from patient care areas (i..e., therapy gym, shower room, hallways and patient care rooms). Staff H reported the cleaning company is responsible for the hospital's floor care and verified the hospital has a problem with "dirt build-up" on the floor at the base of walls that extended into the rooms after staff cleaned the rooms.

The hospital reported a census of 16 patients. Based on observation, document review and staff interview, the hospital failed to maintain 96-hours of backup emergency fuel for their diesel-powered generator as required by the National Fire Protection Association (NFPA) 110, 1999.

Findings include:

- The generator and fuel storage specifications reviewed on 7/11/12 revealed the hospital had a portable temporary diesel generator installed on 5/4/12. Hospital staff indicated the manufacturer's specifications revealed the temporary generator had a 130-gallon fuel tank which would supply 43.91 hours of emergency power.

On 7/12/12 at 3:15pm, State Fire Marshal E verified the hospital's fuel tank connected to the generator would not supply the required 96-hours of emergency power.

Administrative staff C, interviewed on 7/12/12 at 11:55am, verified the hospital lacked a contract to replenish the hospital's fuel supply for the emergency generator. Administrative staff C acknowledged the fuel storage tank did not meet the NFPA requirement and the hospital would need to acquire an additional fuel storage tank to meet the 96-hour requirement.

The hospital reported a census of 16 patients. Based on observation, document review and staff interview, the infection control (IC) officer failed to assure staff followed the hospital's policy and procedures for cleaning and disinfecting glucometers (an instrument to measure blood sugar) and using of chemicals to disinfect surfaces following manufacturer's instructions. These practices placed all patients of the facility at potential risk for acquiring an infection from a current or discharged patient.

Findings include:

- The hospital's policy titled "Cleaning, Disinfection and Sterilization of Patient Care Items and Equipment", step 4. c., reviewed on 7/12/12 at 12:20pm, directs staff to clean the glucometer with a disinfectant.

Observation on 7/10/12 at 11:00am revealed nursing staff J performed a blood sugar check on patient #8. Staff J placed the glucometer without a protective barrier on the side of the sink, the patient's over-the-bed table, and back of the side of the sink while performing the test. These surfaces may have bacteria present and, therefore, are not considered a "clean" surface. Staff J then returned the glucometer to the top of the portable over-the-bed table and moved to patient #11. Staff J failed to assure the glucometer or the portable table was properly disinfected prior to use with another patient to minimize the transmission of bacteria from one patient's room to another.

Nursing staff J performed a blood sugar check on patient #11. Staff J placed the glucometer without a protective barrier on the soiled linen hamper, on the patient's bed for the test, and on the hamper again. Then staff J placed the glucometer on the portable over-the-bed table, returned the glucometer and cart to the nurse's station, ready for the next's patient's use without first disinfecting the machine or table. Like the example above, the surfaces in the patient's room are not considered "clean" and nursing practice may allow the transmission of bacteria from one patient's room to another.

Oobserved on 7/9/12 at 3:57pm revealed that nursing staff O performed a blood sugar check on patient #13. Staff O took the glucometer supply case (a case that held the glucometer, the lancelet sticks, the test strips, and wipes) into patient #13's room and placed the case on the soiled laundry hamper without a protective barrier. Staff O then removed the glucometer and performed the test. Staff O returned the glucometer back to the case on top of the hamper. Staff O then took the case outside of patient #13's room and placed it on a portable over-the-bed table ready for the next patient's use without disinfecting the glucometer or the table.

Staff A, the infection control officer, confirmed the hospital lacked a plan to observe staff practices with the glucometer to assure hospital policies and procedures are followed.

- Review on 7/11/12 revealed the manufacturer's directions for use of Virex 256 cleaner which directs staff, "to disinfect hard, non-porous surfaces, the treated surfaces must remain wet for 10 minutes."

Observation of contract cleaning staff L on 7/11/2 at 8:00am revealed staff terminally cleaning patient room #514 ("terminal cleaning" is a phrase used to mean the room was cleaned after a patient was discharged or moved from the room). At 8:15am staff L put on disposable gloves, removed Virex 256 cleaning spray from the housekeeping cart and sprayed the top of the mattress of the patient bed. Staff L lifted the mattress up and sprayed the Virex on the bed frame and underside of the mattress. Staff L stated the mattress is not removed from the bed frame. The mattress began to dry at 8:16am and was completely dry at 8:17am (approximately two minutes after initial spraying). Staff L reported the Virex cleaner requires 15 minute wet "contact time to kill germs".

Continued observations of staff L at 8:18am revealed they sprayed Virex 256 on the top of the over-the-bed table and immediately wiped off the surface with a cleaning cloth. Staff L then reached down to the floor (considered a potentially contaminated surface) and picked up two small trash cans, sprayed the inside and outside surfaces with the Virex, and sat them on the over-the-bed table (potentially recontaminating the table if it had been disinfected). Staff L then proceeded to use the same cleaning cloth to wipe the cleaner from the inside and outside of the trash cans. Next staff L sprayed the bedside table and used the same cleaning cloth to immediately wipe the cleaner off the table. Staff L failed to keep the surfaces wet for 10 minutes to ensure adequate disinfection of all surfaces and failed to clean from the potentially cleanest surface to the dirtiest.

Review of 7/11/12 at 4:00pm revealed contracted cleaning company A's cleaning policies for terminally cleaning a discharged patient's room revealed the policies lacked infection control directions to change their cleaning cloths and gloves between contaminated surfaces.

Administrative staff C also observed staff L clean the patient room on 7/11/12 at 8:40am. Staff C indicated Staff L should not put the trash cans on the clean table top or use the same cleaning cloth for all the surfaces.

The hospital reported a census of 16 patients. Based on observation, staff interview and document review, the hospital's Quality Assessment/Process Improvement (QAPI) program:
- failed to develop a plan to achieve and maintain compliance with Condition of Participation (CoP) A-700, 42 CFR 482.41, Physical Environment cited on a complaint survey (#56676) completed on 4/30/12; and
- failed to develop and monitor quality indicators for housekeeping and maintenance services provided at the hospital.

The hospital's failure to identify and review opportunities for improvement and changes that could lead to improvement with housekeeping and maintenance of the hospital and achieve and maintain compliance with Life Safety Codes had the potential to affect all patients.

Findings include:

- Review of the hospital's policy/procedure titled "Quality Assurance/Performance Improvement Plan: Introduction, Policy" states, "The hospital will assess all areas of hospital services and operations."
Review on 7/11/12 at 2:00pm of the QAPI information provided by hospital staff for the last 4 quarters (a one-year period) revealed the hospital reviewed Hospital Quality Assurance/ Quality Measures and selected nursing task performance criteria. Data was collected, measured, and analyzed for medical records, including assessments, physician orders, medications, restraint usage, nutrition, patient and family education, chart audits, ventilator usage, patient rights, blood transfusions, acute transfers central lines,dialysis, hospice, code blue and human resource/employee health information; hospital safety; laboratory; some aspects of infection control (although not the disinfection of blood glucose monitors - see tag A-0739); staffing effectiveness; and contracted services for radiology, laboratory, dialysis, fire monitoring and dietary services. However, the QAPI information did not include documentation of data from the contracted housekeeping service or maintenance of the building, deficiencies identified during the survey.

Administrative staff B, interviewed on 7/11/12 at 2:00pm and 2:30pm, acknowledged the hospital failed to include all contracted services in the QAPI review. Administrative staff B confirmed the hospital did not review the contracted housekeeping services to monitor and evaluate the effectiveness of the contracted cleaning services to ensure clean, sanitary and safe hospital environment for patients (see the deficiency at A-749). Administrative staff also acknowledged the QAPI process failed to ensure and maintain compliance with Condition of Participation (CoP) A-700, 42 CFR 482.41, Physical Environment, cited on a complaint survey (#56676) completed on 4/30/12 for lack of diesel fuel to operate the emergency generator for at least a 96-hour period following Life Safety Code and related National Fire Protection Association regulations.

The 26 bed hospital reported a census of 16 patients. Based on document review and staff interview, the hospital failed to assure the Quality Assurance Performance Improvement (QAPI) program developed a plan to achieve and maintain compliance with Condition of Participation (CoP) A-700, 42 CFR 482.41, Physical Environment cited on a complaint survey (#56676) completed on 4/30/12. The hospital's failure to review and identify opportunities for improvement and changes that will lead to improvement also affected the hospital's contracted services.

Findings include:

- Review of the QAPI plan, reviewed on 7/11/12 at 2:00pm, revealed the "Quality Assurance/Performance Improvement Plan: Introduction, Policy" directs, "the hospital will assess all areas of hospital services and operations".

- The logs of QAPI projects, reviewed on 7/11/12 at 2:00pm revealed the hospital failed to include the contracted emergency generator and fuel in the Quality Assurance review. The hospital's failure to maintain the temporary generator and 96-hours of fuel supply as required to provide essential life support during power failures resulted in the hospital's inability to ensure the health and safety of all patients at the hospital.

Administrative staff B, interviewed on 7/11/12 at 2:30pm confirmed the hospital failed to identify the need for QAPI review of the contracted back-up generator and fuel.