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Based on observations as referenced in the Life Safety Report of survey completed on 01/24/2013, observations during tour and staff interviews, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The facility failed to ensure all preventive maintance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

~cross refer to 485.623(b)(1) - Maintenance Standard Tag C0222

2. The facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

~cross refer to 485.623(b)(5) - Maintenance Standard Tag C0226

3. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 485.623(d)(1) & (3) - Life Safety from Fire Standard Tag C0231

Based on observations during tour and as referenced in the Life Safety Report of Survey completed January 24, 2013 and staff interview, the facility failed to ensure all preventive maintance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

The findings include:

1. Observation during tour of the Ambulatory Surgery Unit on 01/23/2013 at 1345 revealed a three inch long, one inch deep tear in the stretcher mattress in Room 107.

Interview on 01/23/2013 at 1345 with the director of surgery revealed the stretcher was available for immediate patient use. Interview further revealed the tear in the mattress was an infection control issue and was not safe to use.

2. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Heating, Ventilating, and Air Conditioning system (HVAC) was non-compliant, specific findings include;
A. The HVAC system did not shut down with fire alarm activation.
B. There was not an emergency shut down switch located at a readily observed station.
C. The smoke evacuation system for the operating room area could not be tested or confirmed.
D. There was not documentation to indicate that the fire/smoke dampers had been inspected and tested within the past 6 years.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0067

3. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following kitchen hood system was non-compliant, specific findings include; documentation from 9/25/12 indicated system due hydro test.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0069

4. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following medical gas storage was non-compliant, specific findings include;
A. The outside oxygen cylinders were stored directly on the ground and will need to be protected from inclement weather. (outside tank farm)
B. Nitrous Oxide cylinders were gang chained together. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation. [NFPA 99 4-3.1.1.2 a(3)] There was not any signage on the oxygen tanks. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly. [NFPA 99 4-3.5.2.2b(2)] (oxygen storage near the morgue)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0076

5. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. Documentation for monthly load test was conducted without recording percent rated load or temperature rise. A load bank test had not been completed within the past year.
B. Documentation for weekly generator inspections was not available.

NFPA 99 3-4.4.2 Record keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.
NFPA 110 6-4.2 (1999 edition) generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
NFPA 110 6-4.2.2 (1999 edition) Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPPS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. (load bank testing)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0144

6. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following electrical item was non-compliant, specific findings include; the electrical outlets in the operating room did not have a redundant ground per NFPA 70.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0147

Based on observations as referenced in the Life Safety Report of Survey completed January 24, 2013, observations during tour and staff interviews, the facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

This standard is not met as evidenced by:

1. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following Illumination of means of egress was non-compliant, specific findings include; a single bulb fixture at the NW corner exit near the helipad. Lighting must be arranged to provide light from the exit discharge leading to the public way (parking lot). The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0045

2. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following relative humidity was non-compliant, specific findings include; percent relative humidity was not controled per NFPA 99.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0078



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3. Observation of patients' nourishment refrigerator on the Medical -Surgical Unit on January 24, 2013 at 1015 revealed 19 liquid items that were out of date: 8-Thickened Lemon flavored water dated 05/03/2012; 9-Thickened Tea flavored water date 06/27/2012; 1-Thickened Orange Juice dated 06/02/2012, and 1-Glucerna dated 12/01/2012. Further observation revealed 1 orange juice without a date, and 1 container with food with no patient label and not dated.

Interview with the Chief Nursing Officer on January 24, 2013 at 1015 revealed the refrigerator is restocked daily by dietary. The interview further revealed the items were out of date and not safe for patient consumption.

Based on observations as referenced in the Life Safety Report of survey completed 01/24/2013, the hospital failed ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

1. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following building construction type was non-compliant, specific findings include; ceiling light fixture were not boxed in (west side only).

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0012

2. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following corridor doors were non-compliant, specific findings include;
A. Corridor doors without positive latching. (The back of the doctors area across from room 121.)
B. Holes in the door where the lock set had been changed out. (Throughout the facility)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0018

3. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following smoke barrier was non-compliant, specific findings include; the one hour smoke barrier is incomplete. Barrier doesn't extend from outside wall to outside wall, and from floor to underside of floor slab above. (Back hall smoke wall)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0025

4. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following hazardous areas were non-compliant, specific findings include;
A. Door not self closing with a UL listed closure installed. (The storage room/soiled linen room across from room 119.)
B. The kitchen storage was not one hour separated or sprinklered.
C. High hazardous areas require both one hour separation and sprinklers. The boiler area was not sprinklered nor was the door to the room labeled with a 3/4 hour, C-labeled, door.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0029

5. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit access was non-compliant, specific findings include;
A. There were several doors that required more than one range of motion to exit the area. (Men and Women's restroom, room 119 and throughout)
B. There were several doors that the occupant could be locked inside the room.(Room 118, ASC directors office and throughout). This item was corrected.
C. The exit from the main corridor leading down the corridor of ER/radiology had magnetic devices on the access doors, that did not meet access control doors per 7.2.1.6.2 (This item was corrected)
D. There must be two means of egress available at all times. Exit from the ER/radiology corridor to the main corridor was not accessible during evening hours. (This item was corrected, the magnetic device was removed from the door)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0038

6. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following exit and directional signs was non-compliant, specific findings include; lack of exit signage leaving outpatient services and throughout. (facility currently identifying suites)

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0047

7. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system and it's components was non-compliant, specific findings include;
A. Horns and strobes should be provided per NFPA 72.
B. Smoke detectors should be provided per NFPA 72.
C. The visual/audible trouble signal at the Fire Alarm Control Panel (FACP) did not give a visual/audible trouble signal at a area where it was likely to be seen or heard with: loss of telephone line connection, loss of AC power, loss of battery back-up, sprinkler tamper per 9.6.3.1 and 9.7.2.1.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0051

8. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following fire alarm system was non-compliant, specific findings include;
A. During testing of the facility fire alarm system the alarm was initiated and the audible alarms were silenced, the fire/smoke doors hold open devices were re-energized with the fire alarm control panel (FACP) in active alarm.
B. Facility documents were not available for smoke detector sensitivity inspections.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0052

9. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following automatic sprinkler system was non-compliant, specific findings include;
A. Documentation for the five year obstruction test was not available.
B. The sprinkler system was tested in November 2012 and August 2012. Quarterly testing per NFPA 25 Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems (1999 edition) had not being completed.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0062

10. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following means of egress was non-compliant, specific findings include; corridor door to electrical equipment room across from room 147 swings into the corridor without a listed closure and the door does not swing 180 degrees but leaves a projection of approximately 18" into the corridor. NFPA 7.2.1.4.4 states during its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, or landing unobstructed and shall not project more than 7 in. (17.8 cm) into the required width of an aisle, corridor, passageway, or landing, when fully open.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0072

11. Based on observations, on January 23, 2013 at approximately 9:30am onward, the following master alarm was non-compliant, specific findings include; master O2 alarm was last tested on 4/20/2012 and could not be tested during the survey.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K 0140

Based on review of the hospital's policy, observations during tours, job descriptions, staff interviews, medical record review, and observations related to the Life Safety Report, the hospital's leadership failed to provide a safe care environment for patients with telemetry (heart rhythm tracing) monitors, failed to ensure pain reassessment was completed, and failed to develop and maintain the hospital's physical environment to ensure patient safety.

The findings include:

1. The hospital failed to ensure safe provision of nursing services for telemetry cardiac monitoring by qualified staff and failed to ensure pain reassessment was completed.

~cross refer to 485.635 Provision of Service Condition, Tag C0270

2. The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 485.635 Physical Plant and Environment Condition, Tag C0220

Based on policy review, job description review, staff interview, and medical record review, the hospital failed to ensure safe provision of nursing services for cardiac telemetry (heart rhythm tracing) monitoring by qualified staff and failed to ensure pain reassessment was completed.

The findings include:

1. The hospital nursing staff failed to ensure qualified staff were available to monitor patients on cardiac telemetry and failed to conduct pain reassessment.

~cross refer to 485.635 Provision of Service: Standard Tag C0296

Based on review of hospital contracts and staff interview, the hospital failed to ensure an agreement/contract for anesthesia services.

The findings include:

Review of the list of hospital contracts revealed no evidence of a contract with the certified registered nurse anesthetist providing anesthesia services.

Interview on 01/22/2013 with the hospital's administrator revealed anesthesia services are provided by a certified registered nurse anesthetist. Interview revealed a contract/agreement was pending. Interview confirmed no current agreement/contract was in place for anesthesia services.

Based upon observation review of job description and medical record, and staff interview, the hospital's nursing staff failed to ensure qualified staff were assigned and monitored the medical surgical telemetry monitoring system and failed to conduct pain reassessment for 2 of 9 patients (#3 and #33).

The findings include:

Review of the hospital's job description for a Unit Secretary (US) on 01/24/2013 revealed "POSITION PURPOSE The Unit Secretary performs a variety of clerical tasks, involved in preparing, maintaining and processing patients and patient's orders. The Unit Secretary will act as intermediary for families ... " Review of the job description revealed no evidence that the Unit Secretary's "General Responsibilities" included monitoring cardiac telemetry monitors. Review of the job description revealed no documented evidence that the Unit Secretary's "Position Qualifications" included cardiac telemetry monitor competency.

A. Observation of nursing station desk on 01/23/2013 at 1305 revealed a centralized nursing station with telemetry monitors at the far left of the desk. Observation revealed US #1 was stationed at the desk with the cardiac telemetry monitor behind her. Observation revealed the continuous cardiac tracings of 1 patient was visible on the monitor screen.

Further observation of nursing station desk on 01/23/2013 at 1320 revealed US #1 was stationed at the desk with the cardiac telemetry monitor behind her.

Observation of the nursing station desk on 01/24/2013 at 1100 revealed US #1 was stationed at the desk with the cardiac telemetry monitor behind her.

Interview with US #1 on 01/23/2013 at 1320 during an observation revealed the secretary is responsible for watching the monitor and letting the nurse know if something was different. Observation revealed no other staff were watching the monitors.

Interview on 01/24/2013 at 1120 with US #1 revealed, "I had the class on January 17, 2013 and the main thing that I was told to do was to watch the monitor and if I noticed anything different I should notify the nurse ...I was told what v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity) look like ...but I don't feel like I am fully competent to tell you what they are. Interview revealed that US#1 had been assigned the task of telemetry monitoring since 01/17/2013.

Interview on 01/24/2013 at 1150 with US #2 revealed, "I received training last week on 01/17/2013...the instructor told us what different heart signs were like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity) ...I have been watching the monitors today and I don't feel comfortable watching them ...I would not want to be responsible for it by myself ...I need assistance with it." Interview revealed that US #2 had been assigned the task of telemetry monitoring since 01/17/2013.

Interview on 1/24/13 at 11:20 a.m. with the Staff Trainer (RN#1) revealed, " I held a Basic EKG and Telemetry Monitoring class for the unit secretaries and nurses on 1/17/13 ...the training is divided into 2 parts ...the unit secretaries ( US#1, and US#2) have gone through the first part of the class and the second part has not been scheduled ...the second part consist of a test...they must have the test in order for me to say that they are competent." Interview with the Staff Trainer (RN#1) confirmed there was no documentation of competency validation and no written cardiac rhythm interpretation test for US #1 and US#2. Interview revealed, "The only validation I have done is a verbal talk back about what the rhythms are."

Interview on 01/24/2013 at 1020 with the (DON) revealed the unit secretaries monitor the cardiac telemetry monitors. Interview further revealed, "The unit secretaries receive training on what lethal cardiac rhythms are, like v-tach (ventricular tachycardia), v-fib (ventricular fibrillation) and asystole (absence of cardiac activity). The alarm is audible and the light flashes on the monitor. Interview further revealed, "They notify the nurse when an alarm goes off ...the RN ' s were not able to watch the telemetry monitors so we assigned the Unit Secretary to monitor the telemetry monitors because they are stationed at the desk." Interview revealed, " They started watching the monitors on January 17, 2013, the day of the class ...before that, the nurses were responsible for watching their patients' monitors ..."

Interview on 01/24/2013 at 1600 with the Director of Nursing revealed the hospital did not have a telemetry policy.

B. Review of hospital policy 6011.140, Pain Management, revised 10/10/2012, revealed " ...the nurses will respond to the patients report of pain...and document the response of the intervention used to relieve the pain...10 minutes after IV analgesics and 1 hour after oral analgesics ..."

1. Medical record review of patient #3 revealed a 57 year old patient admitted on 01/18/2013 for Pneumonia. Record review revealed a medical history that included Human Immunodeficiency Virus, Peripheral Neuropathy, and Splenectomy. Review of physician orders dated 01/18/2013 revealed a written order for Dilaudid (pain medication) 2 mg (milligram) IV (intravenous) as needed for pain. Review of the nursing flowsheet dated 01/19/2013 revealed Dilaudid 2 mg IV administered at 1000 a.m. Review of Nursing documentation revealed no reassessment documented by nursing staff of the patient's response to Dilaudid. Further review of the record revealed Dilaudid 2 milligrams administered IV on 01/21/2013 at 1500, 01/21/13 at 2000, and on 01/22/2013 at 0130. Review of nursing documentation revealed no reassessment documented by nursing staff of the patient's response to Dilaudid.

Interview with nursing management staff on 01/24/2013 at 1400 revealed pain should be reassessed within 30 minutes of the administration of IV pain medication and within 1 hour of the administration of oral pain medication and documented on the pain assessment/reassessment flowsheet or in the nurse's narrative notes. Interview confirmed there was no reassessment documented by nursing staff of the patient's response to pain medication. Interview confirmed nursing staff did not follow hospital policy for reassessment after pain interventions.



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2. Open medical record review of Patient #33 revealed a 63 year-old male, admitted on 01/24/2013 with fractured ribs and corneal abrasion after a motor vehicle accident. Record review revealed a physician's order for Ibuprofen (analgesic pain medication) 600 mg (milligrams) by mouth every six hours as needed for pain. Record review revealed Patient #33 was administered Ibuprofen 600 mg by mough on 01/24/2013 at 0600. Record review revealed the patient was reassessed for pain at 0830 (2 1/2 hours later).

Interview of 01/24/2013 at 0845 with administrative nursing staff revealed the patient's pain should have been reassessed within on hour of administration of Ibuprofen. Interview confirmed the nursing staff failed to follow the hospital's policy for reassessment of pain after the administration of pain medication.

Based on review of hospital policy, event report, staff interviews, and medical record review, the nursing staff failed to notify the physician immediately of acute patient patient changes for 1 of 2 patients (patient #20).

The findings included:

Review of the hospital's policy, "Changes in Patient's Condition: Notification of Physician/Provider" revision date of 10/15/12 revealed, "POLICY: The charge nurse of licensed primary nurse caring for the patient is responsible for notifying the physician or provider immediately upon any significant changes in the patient's condition which may warrant immediate intervention or change in present therapy."


Medical record review of patient #20 revealed an 88-year-old who present to the hospital's emergency department on 06/11/2012 with a chief complaint of left pelvis and hip pain. Continued medical record review revealed, the patient was admitted on 06/11/2012 at 1657 with a diagnosis of pain management post left pelvis fracture with an order for fall precaution. Record review revealed the patient was discharged on 06/15/2012 and admitted to a swing bed on 06/15/2012 at 1130 with an order for fall precaution.

Ongoing record review of the nurse's progress notes dated 06/15/2012 revealed, "0125, the patient was found on the floor on her left side complaining of left shoulder pain. The patient was assisted back to bed with myself and CNA (Certified Nursing Assistant)...0515 skin tear to left FA (forarm) dressed with tegaderm and Kerlix 4 x 4 (gauze)...Smal knot present on left upper shoulder blade. When I pressed on area, she stated, "that hurts." I reoriented patient to call for assistance when OOB (out of bed). 0540 Ultram (pain med) 50 mg po (by mouth)given for c/o (complaint of) pain left shoulder. 0615 Pain less severe @ (at) this time. X-ray to x-ray shoulder. 0730 Daughter notified of incident this am."

Further record review revealed a x-ray report dated 06/16/2012 with findings of a fractured left clavicle (shoulder bone).

Review of an event report dated 06/16/2012 revelaed at 0125, the patient fell in her room and the nurse notified the doctor at 0610 (4 hours and 45 minutes later). Record review revealed the nurse did not notify the doctor immediately after the patient fell.

Interview conducted on 01/23/2013 at 1315 with RN (Registered Nurse) #5 (involved in patient's care during swing bed stay) revealed, "at night we are supposed to wait for a doctor (ED doctor) to look at the patient before moving the patient...if a patient falls at night, we wait for dayshift to notify the family...RN/LPN (Licensed Practical Nurse) round ever one to two hours and the CNA rounds every two hours.

Interview conducted on 01/24/2013 at 0845 with RN #3 (present during fall event on 06/15/2012) revealed, "when a patient falls at night, we notify the doctor (ED doctor), and complete an incident report, and notify family during dayshift (7A-7P) hours..."

Based on medical record review and staff interview, the hospital failed to provide wound care in discharge instructions. for 1 of 6 patients (patient #20).

The findings include:

Medical record review of patient #20 revealed an 88-year-old who present to the hospital's emergency department on 06/11/2012 with a chief complaint of left pelvis and hip pain. Continued medical record review revealed, the patient was admitted on 06/11/2012 at 1657 with a diagnosis of pain management post left pelvis fracture with an order for fall precaution. Record review revealed the patient was discharged on 06/15/2012 and admitted to a swing bed on 06/15/2012 at 1130.

Continued record review of the nurse's progress notes dated 06/15/2012 revealed, "0125, the patient was found on the floor on her left side complaining of left shoulder pain. The patient was assisted back to bed with myself and CNA (Certified Nursing Assistant)...0515 skin tear to left FA (forarm) dressed with tegaderm and Kerlix 4 x 4 (gauze)...0730 Daughter notified of incident this am."

Event Report review dated 06/16/2012 revealed at 0125, the patient fell in her room and the nurse notified the doctor at 0610. Review revealed the nurse did not notify the doctor immediately after the patient fell.

Further medical record review revealed the patient had an order for skin care to the left forarm with dressing changes twice a day. Further review revealed an order dated 06/16/2012 with wound care documented on 06/16-22/2012 and on 06/24-25/2012.

Continued record review revealed on 06/25/2012 at 1020, a doctor order to discharge patient home in the care of the daughter with physical therapy and a home health referral. Ongoing record review of the patient / family discharge instructions revealed, "physical therapy and home health will contact you and patient may resume normal activities."

Interview conducted on 01/24/2013 at 0920 with RN (Registered Nurse) #4 (responsible for providing discharge planning) revealed, "...discharge planning starts on admission...nurses fill out the discharge planner review and if nothing is flagged, I still visit the patient and document no needs..." Continuing in the interview revealed the patient had a fall on 06/16/2013 and as a result of the fall, the patient acquired a left forarm skin tear." RN #4 confirmed the skin tear care was not included in the patient's discharge instructions.