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Based on record review and confirmed by interview with the Director of Case Management and Discharge Planning, the Hospital failed to have a written policy and procedure to ensure the prevention of patient abuse and neglect. The findings included:

A review of the hospital's Patient's Rights brochure, given to patients on admission, indicated patients had the "right to considerate, respectful care at all times." A review of the Patient Handbook for the Fowler Wing (the hospital's Psychiatric Unit and Services) in the section titled "What are My Rights?" also indicated that patients had "the right to considerate, respectful care at all times and have reasonable requests responded to promptly and adequately within the capacity of the facility." Neither the patient brochure or the handout contained information as to the prevention of abuse and neglect within the hospital from staff, other patients, and visitors.

The facility had employee policy references to staff upholding "the values, ethics, and mission...(and) conduct of the health care profession," and offenses warranting immediate employee discharge detrimental to patient recovery."

Additionally, a review of the hospital's policy and procedures for "Event Reports" indicated that there was a "mechanism for accurately and comprehensively documenting pertinent information regarding unusual incidents, or potential incidents (near misses) involving patients, visitors, or employees... An Event is defined as a hospital-related occurrence not consistent with the desired operation of the hospital...(and) includes, but is not limited to, physical injury; equipment failures; patient dissatisfaction; and IV, medication, and treatment errors." Major events and reportable events were described as death in the course of or resulting from elective ambulatory procedures, invasive diagnostic procedures, surgical interventions performed on the wrong organ or body part, unanticipated outcomes, as well as fire, suicide, serious criminal acts and or pending or actual strike actions by employees.

Interview with the Director of Case Management and Discharge Planning on 4/8/10 at 9:00 A.M. revealed the hospital did provide information to staff concerning the identification of Child and Elder Abuse and Domestic Violence of patients who entered the Emergency Department and other hospital Departments, but that the hospital did not have a policy and procedure that specifically identified all forms of abuse (physical harm, injuries of unknown origin, pain, mental anguish) and neglect (staff neglect, harassment, and/or indifference to the infliction of injury or intimidation of one patient by another.) Staff acknowledged there was no policy or procedure, beyond that of patient complaints/grievances, that incorporated the key elements of abuse and neglect prevention (identifying abuse and neglect, screening, training, protection, investigation and reporting.)

Based on staff interviews and review of Pharmacy and Therapeutic (P&T) Committee meeting minutes and Medical Staff Bylaws at 10:00 A.M. on 4/6/2010, the medical staff failed to enforce their By-Laws:

Findings include:

1. Review of the Medical Staff By-Laws revealed requirements that the Pharmacy and Therapeutic Committee membership will include "at least two physicians......, a Pharmacist, Nurse and a Dietician." Additionally, the Medical Staff bylaws indicated that "P&T Meetings will occur every other month."

2. Review of the Pharmacy and Therapeutic Committee meeting minutes and interviews with the Director of Quality Assurance and the Director of Pharmacy, confirmed the hospital failed to ensure that the P&T Committee met with the appropriate minimum required membership of the committee.

The hospital had 16 Pharmacy and Therapeutic Committee meetings during the 25 months from 3/27/08 until 3/25/10. On the meeting dates of 11/19/09, 9/24/09, 6/25/09, 4/30/09, 6/26/08 and 3/27/08 only one physician was present and on the meeting dates of 7/30/09 and 12/28/08, no physician was present. The 9/25/08 and 3/27/08 meetings did not have any representatives from Nursing Service. The hospital's P&T Committee met with appropriate membership (according to Medical Staff By-Laws) on only 7 dates in the past 25 months: in 2008, on 11/20/08, 7/31/08 and 5/29/08; in 2009 on 5/25/09 and 2/26/09, and in 2010, on 3/25/10 and 1/28/10.

Based on record review, observations, and staff and patient interviews, the Hospital failed to develop and keep current a nursing care plan that was based on an assessment of the patients' nursing care needs and the development of appropriate nursing interventions in response to those needs, for 17 of 31 inpatients (#1, #2, #3, #4, #17, #18, #19, #20, #21, #22, #23, #24, #27 #32, #33, #36, and #38), from a total sample of 38. Findings included:

1. For Patient #2, admitted on 3/25/2010, the facility failed to develop a care plan that included interventions for the identified problems of impaired physical mobility due to pain, decreased range of motion, decreased bed mobility, (bedrest), actual pain and skin integrity-actual and potential, related to pressure ulcers and/or the presence of a surgical wound.

Patient #2, was admitted from the emergency room to the intensive care unit (ICU), and was on a mechanical ventilator with diagnoses of respiratory failure, septic shock, acute appendicitis, hypertension, and chronic lung disease. The patient was sedated on the intravenous medication Propofol, a sedative. On 3/26/2010, the patient underwent an appendectomy for a ruptured appendix and was diagnosed with peritonitis.

The care plan, dated 3/26/2010, for impaired physical mobility, had no interventions. There was a section titled "additional interventions" at the end of the comprehensive care plan that listed a multitude of interventions unrelated to identified problems. One intervention was to turn and position every four hours. However, it was unknown if this interventions was related to impaired mobility or skin integrity issues.

On 4/5/2010, at 9:00 A.M., and again at 2:15 P.M., the patient was observed in a standard size bed which he filled to capacity as he was tall and obese, weighing 286 pounds at 6 feet tall. The head of the bed was always in an elevated position so that the patient's weight was constantly on his coccyx. The patient was sedated, intubated, and had an oral feeding tube, Foley catheter and intravenous line. The patient also had bilateral wrist restraints. Between 2:15 P.M. and 3:30 P.M., the licensed staff were observed to wash the patient's feet and apply lotion. They also changed the position of the bed so the patient went into a full sitting position, but the weight remained on the coccyx.

Review of the nursing notes revealed that on 3/31/2010, nursing noted that the patient's back was red and the scrotum was red and swollen. Notes only reflected the patient was on a rotational bed. On 4/1/2010, staff documented reddened unbroken skin along the upper part of the spine. On 4/3/2010, the skin was described as "intact."

Interview with the ICU Nurse Manager (NM), on 3/5/2010, at 3:00 P.M. confirmed the mattress was a rotational mattress but due to the patient's size, rotating side to side would not relieve pressure on the patient's back and coccyx. The NM stated they could get a bariatric bed.

Interview with registered nurse (RN) #6,on 3/5/2010 at 3:15 P.M., who was caring for the patient, confirmed there was no initial written nursing care plan for the prevention of potential skin breakdown, physical immobility or actual pain. She stated staff documented the care they provided in nursing notes and did an ongoing assessment each shift. She stated for pain, they completed a pain assessment, and medicated as needed.

2. For Patient #3, the facility failed to develop a care plan that included interventions for identified problems in the nursing assessment of high risk for falls, alteration in thought processes with confusion, high risk for skin breakdown with current skin issues, potential for infection due to open areas on skin and presence of indwelling catheter and altered gas exchange due to decreased breath sounds and presence of wheezes. For example;

Patient #3 was admitted on 4/4/2010, to the ICU from the ER with diagnosis of elevated ammonia levels, acute renal failure, hypotension, diabetes and history of cirrhosis and hepatitis C. On admission, the patient was placed in bilateral wrist restraints due to confusion, and combative and abusive behavior. The patient was also sedated with the medication, Haldol, intramuscularly.

The initial nursing care plan for injury prevention, dated 4/4/2010, had a goal that the patient would be free of injuries. The only intervention was "safety precautions." Nothing else was specified. Interview with RN #13, on 4/5/2010, at 3:00 P.M. revealed that safety precautions were different for everyone. Patient #3 was medicated with Haldol as needed and Ativan, used restraints, bed rails and had 1:1 nursing, per RN #13. RN #13 confirmed that the care plan did not reflect these interventions.

The nursing care plan for skin integrity, dated 4/4/2010 also had no interventions. The nursing assessment identified the patient as having a red area on the right hip, small bruised areas on the bilateral knees and elbows and a bruise on right clavicle. Review of the nursing care plan revealed no interventions to address these problems.

Under the problem of altered thought processes, the goal was to maintain and return the patient to baseline and have the patient's ability to behave and interact with others in an appropriate manner improve. Review of the care plan revealed no interventions for these goals.

Interview with the ICU NM on 4/6/2010 at 12:00 P.M., confirmed that the care plans needed work to include nursing interventions.

3. For Patient #23, the care plan lacked interventions for problems identified in the nursing assessment; high risk for falls, high risk for skin breakdown and risk for infection due to presence of Foley catheter and right femoral central catheter.

Patient #23 was admitted on 4/2/2010, with diagnoses of intentional drug overdose, suicide attempt, depression, bipolar disorder and chronic lung disease.

The nursing care plan, dated 4/2/2010, identified anxiety/fear related to poor coping but had no interventions to address this issue. The care plan also identified high risk for injury with no interventions listed. There were no interventions for suicidal risk, high risk for skin breakdown and risk for infection.

Interview with the RN #7, on 4/6/2010 at 11:15 A.M., confirmed that there was no written care plans for the above issues. RN #7 stated that the patient was "kind of on a one to one" suicide precaution but staff did not sit in the room with her all the time. RN #7 and nursing notes confirmed the patient still verbalized suicidal ideation.

4. For Patient #24, the nursing care plan lacked interventions for problems identified in the nursing assessment of high risk for falls, high risk for skin breakdown and impaired physical mobility.

Patient #24 was admitted on 4/3/2010, with diagnoses of falls at home, old cerebral vascular accident with left hemiparesis and questionable leaking aneurysm at previous clip site. The patient had lived alone and independently at home prior to this admission.

The nursing care plan, dated 4/5/2010, identified high risk for injury as a problem but had no interventions were identified for this problem. Nursing notes reflected the use of personal alarm.

The care plan also identified impaired mobility related to decreased left sided muscle strength with increased weakness. The goal was to attain the highest degree of mobility achievable with in the confines of the disease limitations. Again there were no interventions to maintain or improve the patient's ability.

For skin integrity, the goal was listed as the patient skin integrity will be maintained and/or appropriate healing will occur. There were no interventions to achieve this goal in the plan. The nursing assessment identified the patient as having seborrheic keratosis with a dressing on the left elbow, left knee, and right hand.

5. For Patient #27, the nursing care plan lacked interventions for identified problems of fluid volume deficit, skin integrity, high risk for infection and altered nutrition.

Patient #27, admitted 4/3/2010, had diagnoses of abdominal pain and diarrhea for three weeks, dehydration, hypotension and was positive for a bowel infection secondary to clostridium difficile(c.diff). The nursing notes also indicated the patient had nausea and vomiting early in her admission.

The nursing care plan, dated 4/3/2010, identified altered bowel elimination and fluid volume deficit related to poor intake, weight loss and dehydration. The stated goal was to have the patient return to a state of adequate and stable hydration as evidenced by stable vital signs, good urinary output, good skin turgor, and normal electrolyte balance.

There were no interventions listed to meet these goals.

The nursing assessment identified the patient as being at medium risk for skin breakdown due to frequent diarrheal episodes. The goal was the patient's skin integrity would be maintained and/or appropriate healing would occur. There were no interventions planned to meet these goals.

Under the care plan for altered nutrition, dated 4/3/2010, the stated goal was to maintain adequate and appropriate intake of essential nutrients to meet metabolic needs. There were no interventions identified to meet this goal.

Interview with RN #15, on 4/6/2010 at 2:00 P.M., confirmed that the written initial nursing care plan lacked interventions.

6. For Patient #38, the nursing care plan lacked interventions for identified problems of fluid volume excess, activity intolerance and anxiety/fear.

Patient #38, admitted 4/6/2010, had diagnosis of congestive heart failure and ruled in for myocardial infarction (MI).

According to the nursing notes, the nursing care plan was initiated at 6:30 P.M. on 4/6/2010.

Review of the nursing care plan for fluid volume excess, indicated a goal of obtaining optimal fluid balance as evidenced by vital signs within normal limits, clear lung sounds, absence of pulmonary congestion, and resolution of edema.

The only intervention listed was "weights."

The goal for activity tolerance was that it would be at an "appropriate level." There were no interventions for this problem.

For the problem of anxiety/fear, the stated goal was that the patient would use effective coping mechanisms in managing anxiety. There were no stated interventions for this problem.

Observation and interview with the patient on 4/8/2010 at 9:30 A.M., revealed an alert patient, sitting in a bedside chair with both legs elevated. Both legs were observed to be edematous, with +3/4 edema. The patient had moderate shortness of breath with conversation. The patient stated "I am happy with my care and have no complaints."

Interview with RN #17, on 4/8/2010 at 9:45 A.M., revealed the patient's weight was up 1.4 kilograms since yesterday and the patient had been on intravenous (IV) Lasix (a diuretic), for the past two days.



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7. Interview with the Executive Director for Rehabilitation and the Informatics Nurse on 4/5/10, at approximately 2:00 P.M., revealed that the hospital's staff had not yet created nursing care plans for the Bronson Unit which included individualized interventions to achieve identified goals. The Bronson Unit was a rehabilitation unit which required a two to three week hospital stay.

Further interview with the Executive Director and the Informatics Nurse revealed that because the care plans for the Bronson patients needed to include the care needs which reflected the interdisciplinary approach, the care plans were taking longer to create. Findings included:
a. For Patient #17, whose record was reviewed at 9:30 A.M. on 4/6/2010, the facility failed to create a nursing care plan for the treatment of the patient's diabetes. Additionally, by the last day of survey the patient needed to be started on IV fluids for hydration. The facility failed to create a care plan to address the patient's fluid needs.
b. For Patient #18, whose record was reviewed at 3:00 P.M. on 4/5/2010, the facility failed to create a nursing care plan with goals and interventions to address the patient's diagnosis of diabetes.
c. For Patient #19, an insulin dependent diabetic, medical record review at 10:10 A.M. on 4/6/2010, revealed that the facility failed to develop a nursing care plan with goals and interventions to address the patient's diabetes.
d. For Patient #20, whose record was reviewed at 11:05 A.M. on 4/6/2010, the facility failed to develop goals and interventions for the patient's declining hematocrit and hemoglobin after the patient's recent knee surgery. On 4/5/2010, the most recent hemoglobin result was 8.6 (normal range 11.9-15.5) and the hematocrit was 25.3 ( normal range 34.9-44.9).
e. For Patient #21, a patient with a feeding tube, medical record at 1:15 P.M. on 4/5/2010, revealed that the facility failed to develop a nursing goals and interventions for care of a patient with a feeding tube.
f. For Patient #22, medical record review at 2:00 P.M. on 4/6/2010, revealed that although the patient was receiving intravenous fluids, the hospital failed to develop a nursing care plan with goals and interventions related to the nursing diagnosis of "Alteration in fluid status."



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8. For Patient #1, medical record review on 4/5/2010 at 1:00 P.M., revealed that the nursing assessment completed on 3/26/2010, indicated the patient was a risk for falls. The facility failed to develop an individualized nursing care plan with interventions related to the prevention of patient falls.

Continued medical record review revealed a Patient Treatment Plan, initiated on 3/26/2010 by the nurse. The problems identified were: Continence Management; Pain Management; and Disease Management (related to a diagnosis of acute renal failure). The facility failed to develop an individualized nursing care plan with interventions related to the above issues.

Additionally, the patient had a right upper chest catheter for administration of dialysis. The patient lacked a care plan with goals and interventions related to education and care of the dialysis catheter.

9. For Patient #4, medical record review on 4/5/2010 at 2:15 P.M., revealed that the nursing assessment completed on 3/24/2010, indicated that the patient was a risk for falls, had difficulty hearing, had issues with pain related to a left hip fracture, and was a risk for skin breakdown. The facility failed to develop an individualized nursing care plan with interventions related to the prevention of the above identified problems.

Review of the Patient Treatment Plan identified that the patient had difficulty with the following Activities of Daily Living (ADLs): Eating/Swallowing; Grooming; Bathing (including shower transfer); Dressing/undressing; Continence Management; and Mobility. The facility failed to develop and keep current, an individualized nursing care plan with interventions related to the above issues.

Interview with the Informatics Nurse at approximately 2:30 P.M. on 4/5/2010, confirmed that the patient lacked a nursing care plan.

10. For Patient #32, medical record review on 4/7/2010 at 1:30 P.M., revealed that the nursing assessment completed on 4/5/2010, indicated that the patient was a risk for falls. The facility failed to develop an individualized nursing care plan with interventions related to the prevention of patient falls.

Continued medical record review revealed the patient had surgery for a small bowel obstruction. Review of the Patient Treatment Plan revealed the following patient issues: High Risk for Infection; Impaired Mobility related to pain, range of motion limitations, transfers and ambulation; and Pain Management. The facility failed to develop an individualized nursing care plan with interventions related to the above issues.

Interviews with the 2 North Clinical Manager and Vice President of Patient Care Services at approximately 2:00 P.M. on 4/7/2010, confirmed that nursing care plans were limited and needed to be more individualized to the patient.

11. For Patient #33, medical record review on 4/7/2010 at 2:30 P.M., revealed that the nursing assessment completed on 4/4/2010, indicated the following: the patient was a risk for falls; had a non-union fracture of the left upper arm; needed assists for all ADLs; had an open, stage 2 ulcer on the posterior aspect of the left lower extremity; had pitting edema of both lower extremities; and was confused, bedridden, and at risk for skin breakdown.

Review of the Patient Plan of Care revealed that RN #14 had identified goals for the following nursing diagnoses: Infection - Actual; Pain-Actual; Impaired Skin Integrity-actual and potential; Alteration in Tissue Perfusion; and Altered Thought Processes. However, the Patient Care Plan lacked individualized interventions to achieve the goals related to the above nursing diagnoses and problems assessed by the nurse.

Interview with the 2 North Clinical Manager at approximately 2:45 P.M. on 4/7/2010, confirmed that the nursing care plan lacked interventions for the above patient issues.

12. For Patient #36, medical record review on 4/8/2010 at 9:00 A.M., revealed that the nursing assessment completed on 4/6/2010, indicated the following: the patient was a risk for falls and had chronic constipation. The facility failed to develop a nursing care plan with goals and interventions for falls and chronic constipation.

Patient interview at 10:20 A.M. on 4/8/2010, revealed that the patient had a blood sugar of over 600 on admission (normal range 80 to 125 mg/dl). The patient's blood sugar was confirmed with the Clinical Manager.

Review of the Patient Plan of Care revealed that RN #16 had identified goals for the following nursing diagnoses: Altered Glucose Metabolism; Fluid Volume Deficit; Altered Nutrition; and knowledge deficit related to diabetes and the diabetic diet. However, the Patient Care Plan lacked individualized interventions to achieve the goals related to the above nursing diagnoses.

Based on review of Hospital policy and staff interviews, the Hospital failed to have policies in place that minimized the use of verbal orders, described situations in which verbal orders may be used and described limitations or prohibitions on the use of verbal orders. Findings include:

1. Review of the facility policy on Doctor's Orders, dated 7/09, revealed no limitations on verbal orders. There were no descriptions of when verbal orders were appropriate to use except for when surgeons were in the operating room.

2. Interview with the Vice President of Patient Care Services at 1:00 P.M. on 4/7/2010, confirmed that verbal orders were being used too frequently by physicians, and that verbal orders were only supposed to be used in an emergent situation and were not to be routinely used by physicians.

See A-408.

Based on observation, record review and interview, the Hospital failed to ensure that staff followed the hospital's policy related to verbal orders for two (#2, #32) of 31 sampled inpatients. Findings include:

1. According to the Medical Staff Bylaws, last reviewed and revised in 3/2008, under the section for physician responsibilities, PR.3, verbal orders can only be dictated by the treating physician to a registered nurse, licensed practical nurse or pharmacist. Unless other specified by state law, verbal orders need to be cosigned in 48 hours.

Patient #2, admitted on 3/25/2010, to the intensive care unit had diagnoses of respiratory failure, septic shock, acute appendicitis, and chronic lung disease. The patient was admitted intubated and heavily sedated.

Record review revealed that on 4/6/2010, at 4:40 P.M., the certified respiratory therapist documented on the physicians's order sheet, accepting a verbal order from the attending physician to change the vent mode to "CPAP (continuous positive airway pressure/PSV (pressure support ventilation) as tolerated."

The respiratory therapist was not authorized by policy to accept and write verbal orders.


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2. Observation at 10:00 A.M. on 4/7/2010, revealed that RN #11 performed a dressing change for Patient #32.

Medical record review, confirmed by interview with RN #11 at 10:30 A.M. on 4/7/2010, revealed that the record lacked a physician's order for the dressing change for 48 hours since the patient's admission. When asked by this surveyor why the record lacked an order for the dressing change, the RN said, "The doctor must have given a verbal order and someone forgot to document it."

Interview with the Vice President of Patient Care Services at 1:00 P.M. on 4/7/2010, indicated that a physician's order was needed for the dressing change. The Vice President of Patient Care Services also said that verbal orders were only allowed in an emergent situation and were not to be routinely used by physicians.

3. Again, for Patient #32, medical record review on 4/6/2010 at 2:30 P.M., revealed that on 4/4/2010, verbal orders were given for the following non-critical medications by an Emergency Department physician:
a. Ativan 0.5 milligrams (mg) IV, given by the nurse at 2:43 P.M.;
b. Zofran 4 mg IV, given by the nurse at 1:38 P.M.;
c. Tylenol 500 mg, by mouth (po), given by the nurse at 1:30 P.M.;
d. Levaquin 250 mg po, given by the nurse at 1:35 P.M.; and
e. Morphine 2 mg IV given by the nurse at 1:40 P.M.

Interview with the Medical Director of the Emergency Department at approximately 12:30 P.M. on 4/8/2010, indicated that the ordering physician should have written orders for the above medications and not given verbal orders.

Based on observation and interview with the Director of Pharmacy, the facility failed to provide drugs and biologicals in accordance with applicable standards. Findings included:

Observation and interview with the Director of Pharmacy on 4/5/10 at 11:00 A.M., indicated that the Intravenous Admixture Service was not compliant with the current Standards of the United States Pharmacopoeia, Chapter 797. The hospital's pharmacists were not compliant with 247 CMR 9.01 (3) "A pharmacist shall observe the standards of the current United States Pharmacopoeia." The Intravenous Admixture Service area and preparation hoods lacked the physical requirements for USP 797 Standards for preparation of sterile intravenous solutions. The physical structure of the room lacked an "ante-room" with seamless flooring, ceiling, walls and lack of required (ISO) positive pressure requirements. The intravenous service additionally did not have a "clean room" that is to be accessed via the "ante room". The chemotherapy flue vent hood was not located in a separate "clean room," negative pressure room, that was accessed via an "ante room."

Based on observation and interview with the Director of Pharmacy, the facility failed to ensure that outdated/ beyond date of use medications and biologicals were removed from patient use. Findings included:

1. Observation and interview with the Director of Pharmacy, on 4/5/10 at 2.05 P.M., indicated that in the Bronson Unit's medication refrigerator one open multi-dose vial of Novolin R Insulin was not dated by staff with the date it was first opened. The manufacturer stated in professional literature that once the multi-dose vial was opened the bottle should be discarded after 28 days. The open and undated bottle was therefore considered outdated, as it was not dated by the nurse when it was opened.

2. Observation and interview with the Director of Pharmacy, on 4/5/10 at 2:15 P.M., indicated that in the 2 North Unit's medication refrigerator one open multi-dose vial of Novolin N Insulin was not dated by nursing staff when first opened. The manufacturer stated in professional literature that once a multi-dose vial was opened the insulin could only be used for 28 days. The open and undated bottle was considered expired as it was not dated when it was opened.

3. Observation and interview with the Director of Pharmacy, on 4/5/10 at 2:35 P.M., indicated that in the E.D. Unit's medication refrigerator one open multi-dose vial of Levemic Insulin that was not dated by staff when first opened. The manufacturer stated in professional literature that once a multi-dose vial was opened the insulin could only be used for 28 days. The open and undated bottle was considered expired as it was not dated when it was opened.

4. Observation and interview with the Director of Pharmacy, on 4/5/10 at 2:50 P.M., indicated that in the Outpatient Unit's medication refrigerator one open multi-dose vial of Tubersol Purified Protein Derivative (Tuberculin PPD) that was dated 6/19/09 by staff when first opened. The manufacturer states in professional literature that once the multi-dose vial is opened the bottle should be discarded after 30 days. The open and dated bottle was out of date.

5. Observation and interview with the Director of Pharmacy, on 4/5/10 and 4/6/10, indicated that in the following nursing units: Telemetry, Bronson, 2 North, E.D., Outpatient, Cardiology, Fowler and Surgical Day Care, the surveyor observed 14 bottles of glucometer Surestrip Pro Test Strips that were not dated when opened. The manufacturer stated that after openings the bottles are to be discarded after 120 days. The open and not dated bottles are considered beyond use date (out of date). The surveyor observed 7 bottles of glucometer Lifescan Control Solution Low and 7 bottles of glucometer Lifescan Control Solutions High that were not dated when opened. The manufacturer stated that after opening the bottles are to be discarded after 90 days. The open and not dated bottles are considered beyond use date (out of date).

Based on staff interview and review of facility documents, the Hospital failed to ensure at least 2 members of the Utilization Review (UR) Committee were doctors of medicine or osteopathy. Findings included:

During the entrance conference on 4/5/10 at 9:00 A.M., the Vice President (VP) of Patient Care Services revealed that the hospital had its own UR plan in place.

Review of the UR committee meeting minutes from 3/09 - 3/10 on 4/6/10 at 5:00 P.M., lacked evidence that there were doctors of medicine or osteopathy at these meetings.

Interview with the UR Coordinator on 4/7/10 at 4:00 P.M., revealed the UR Committee members included three nurses and two staff from the financial office. The UR Coordinator confirmed that there were no doctors of medicine or osteopathy on the committee, although
required.

Based on observations, medical record review, review of facility policies, and interviews with staff, the Hospital designated Infection Control Officer (Infection Control Nurse) failed to consistently enforce hospital policies that governed the control and prevention of infection for two of two patients (one outpatient #26, and one inpatient #33) from a total sample of 38. Findings included:

1. For Patient #26, observation of an intravenous (IV) line insertion at 10:15 A.M. on 4/6/2010, revealed that RN #5 failed to follow hospital infection control policies for hand hygiene (handwashing or using a waterless hand sanitizer) and skin preparation as follows:

a. RN #5 gathered the IV supplies and medication and proceeded to the patient's room.
b. The RN failed to perform hand hygiene when entering the patient's room, although required by the hospital's Hand Hygiene policy.
c. RN #5 also failed to perform hand hygiene prior to donning personal protective equipment (gloves).
d. When cleansing the patient's IV site, the RN used upward-and-downward strokes to cleanse the patient's skin prior to inserting the IV.
e. Interview with the Vice president of Patient Care Services on 4/6/2010, at approximately 1:00 P.M. indicated that staff were supposed to use circular motions, from the insertion site outwards, when cleansing a patients's skin, prior to IV insertion.
f. The RN failed to perform hand hygiene after glove removal at the end of the procedure.
g. Review of the policy titled Hand Hygiene at 12:00 P.M. on 4/6/2010, revealed that staff were required to perform hand hygiene before donning gloves, after glove removal, and before administering medications.

2. For Patient #33, observation of a dressing change, performed at 10:00 A.M. on 4/7/2010, revealed that RN #11 failed to follow hospital infection control policies for hand hygiene, as follows:

a. RN #11 gathered the dressing supplies and proceeded to the patient's room.
b. The RN failed to perform hand hygiene when entering the patient's room, although required by the hospital's Hand Hygiene policy.
c. After opening the clean and sterile dressing supplies (i.e., sponges, gloves), the RN failed to perform hand hygiene prior to donning the gloves.
d. RN #11 then removed the old dressing from the patient's leg. The dressing was stained with bloody drainage.
e. The RN then removed her contaminated gloves and donned sterile gloves. The RN failed to perform hand hygiene prior to donning the sterile gloves, although required.
f. The RN then proceeded to touch the contaminated outside of the saline bottle and pour saline from the saline bottle directly onto a sterile sponge. The sponge was held in the nurse's gloved right hand. The nurse used the same sponge to cleanse the patient's wound, using the gloved hand that was now contaminated from the outside of the saline bottle.
g. After cleansing the patient's wound, the RN then applied sterile sponges to the wound and secured the sponges to the wound with a dressing wrap. Again, the nurse used the now contaminated gloved hand to apply the dressing.

3. Interview with RN #11, during the dressing change, revealed that she considered the dressing change a clean vs. sterile procedure. However, review of the medical record revealed that it lacked a physician's order for the dressing change, as-well-as an order for the type of dressing (i.e., clean, sterile, or wet-to-dry), as required by facility policy.

4. Interview with the Vice President of Patient Care services at 1:00 P.M. on 4/7/2010, indicated that the nurse needed a physician's order for the dressing change.

Based on observation, record review and interview, the facility failed to maintain a complete operating room register that contained all the required information such as the full name of the circulating nurse and surgical scrub technician assigned in the room, name of the anesthesiologist and the pre and post-op diagnosis. Findings include:

Observation of the Operating Room (OR) log book, as provided by the OR nurse manager (NM), on 4/7/2010 at 10:30 A.M., revealed that only the initials of the circulating nurse and scrub technicians were indicated on the log. The NM had to identify to the surveyor who the initials belonged to.

According to review of the OR log, pre and post op diagnoses for six bariatric surgery patients, were not documented on 3/15/09. The procedures for all six patients having surgery that day were listed as either a surlaband procedure or laparoscopic adjustable gastric banding. Other information missing in the log included the names of the anesthesiologists, the patients' ages, and the patients' medical record numbers. Observation indicated that this information was written in by hand on the log for some patients.

Continued interview with the OR NM confirmed that the OR log did not contain all the information required for an OR log.

Based on record review and interview, the post operative report for two of seven outpatient records patients (#34 and #35), in a total sample of 38, were incomplete as evidenced by the missing dates, times, names of the anesthesiologists, and/or the type of anesthesia administered. Findings include:

1. Patient #34 was admitted as a day surgery patient, for a release of a left carpel tunnel compression.

Review of the postoperative note written by the surgeon, revealed no date or time the note was written and no name of the anesthesiologist who performed the regional block.

2. Patient #35 was admitted for day surgery on 4/6/2010 for right knee arthroscopy.

Record review revealed the patient had general anesthesia and was discharged home at 3:00 P.M. from the day surgical care unit.

Review of the postoperative note revealed no date or time the note was written, no type of anesthesia indicated and no estimated blood loss.

Interview with the Chief of Surgery and the OR Nurse Manager on 4/7/2010 at 10:00 A.M., confirmed it was hospital policy that all medical record entries be timed and dated.

Based on record review and interview, the Hospital failed to have adequate policies and procedures to address potential anesthesia related emergencies in the operating room. Findings include:

1. Review of the Anesthesia Department Policies and Procedure Manual on 4/8/2010 at 8:30 A.M., revealed the manual lacked protocols for supportive life functions such as cardiac and respiratory emergencies.

Interview with the Chief of Anesthesiology, on 4/8/2010 at 9:30 A.M., confirmed that these protocols were lacking.

Based on record review and interview, the Hospital failed to ensure that two of seven outpatients (#34 and #35), in a total sample of 38, received a post anesthesia evaluation prior to discharge. The evaluation was required any time general, regional, or monitored anesthesia had been administered to the patient. The evaluation must be completed and documented by a practitioner who was qualified to administer anesthesia Findings included:

1. Patient #34 was admitted as a day surgery patient, for release of a left carpel tunnel compression.

Review of the anesthesia record revealed the patient received a regional block in the left hand with application of a distal and then proximal tourniquet. In addition, the patient also received intravenous sedation.

The patient returned to the post anesthesia care unit (PACU) for recovery and then to the surgical day unit where the patient was discharge home in the care of family. Record review revealed no post anesthesia evaluation was done by a qualified anesthesiologist, as required.

Interview with PACU RN #12, on 4/7/2010 at 12:20 P.M., revealed that patients were discharged to a lower level of care from the PACU when their Aldrete score reached 9 or 10. Aldrete is a numerical score based on measurement of activity, respiration, circulation, color and consciousness. Interview with the Operating Room Nurse Manager, on 4/7/2010, at 12:30 P.M., confirmed that, per hospital policy, patients for day surgery were discharged from the Surgical Day Center "when stable" and were not seen by an anesthesiologist unless their condition warranted it.

2. Patient #35 was admitted as a day surgery patient for a right knee arthroscopy on 4/6/2010.

Record review revealed the patient had general anesthesia and was discharged home at 3:00 P.M. from the Surgical Day Center.

Continued record review revealed no post operative anesthesia evaluation was completed, as required, prior to the patient's discharge home.

3. Interview with the Chief of Anesthesia on 4/8/2010 at 9:30 A.M., confirmed that for outpatient surgical cases receiving general anesthesia, monitored anesthesia care or regional anesthesia, a post anesthesia evaluation would be required prior to discharge.