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Based on tours/observation and staff interviews, the hospital failed to ensure compliance with the Condition of Participation of Infection Control by providing a sanitary environment to avoid sources and transmission of infections and communicable diseases. Specifically, tours/observation conducted in the facility found multiple conditions related to expired supplies, infection control risks, environment concerns and lack of monitoring of the environment for effective cleaning of equipment and work areas, inconsistent inspection of supplies and equipment and lack of appropriate storage carts for temporary holding of dirty patient meal trays on the patient care units. The failure to comply with the Condition of Participation of Infection Control created the potential for negative patient outcomes.

The findings were:

On 5/9/12 a tour of the facility was conducted commencing at approximately 10:30 a.m., visiting the 3rd floor unit and the Intensive Care Unit (ICU). The surveyors were accompanied by the chief nursing officer. Additional staff were present as the tour continued and they provided specific information related to findings. During the tour, the following potentially unsafe conditions were observed and witnessed/confirmed by the staff present on the tour:

1. ICU Tour:
- The medication room refrigerator contained a thermometer with the red reading area broken up so that it was difficult to get an accurate temperature reading. The manager of respiratory, lab and radiology came during the tour and replaced the thermometer to correct the situation.
-The mechanical pill crusher devise, setting on the counter by the sink, was observed to be very dirty with obvious debris on all surfaces of the crusher. The design of the devise involved placing the pill in a clear (single-use) plastic envelope that would keep the pill clean and collect the pill fragments as it was being crushed.
- The stainless steel sink in the medication room appeared dirty with a white film. The floor and baseboards at sink area were dirty with stains and white film, spray. The stainless steel paper towel dispenser also had white film, spray, and streaking on surface. Two boxes of gloves were stacked to the right of the sink on the countertop. The bottom box of gloves appeared to have gotten wet on the bottom of the box from sitting next to the sink, and then dried. The boxes of gloves and multiple open boxes of other supplies, including sterile packages of needles, were stored on the counter on both sides of the sink. There was also evidence of stains from splashing from the sink on the wall above the sink.
- The floor of the medication room appeared to have debris on the floor and there were pieces of adhesive-backed wrappers stuck on the floor in front of the sink. There were two drips of something dark, possibly medication, on the wall to the left when entering the medication room. The drips were located about 2 feet from the floor.
- The glucometer at the nurses' station appeared to have blood spray/spatters on the devise.
- The clean supplies room contained some expired supplies, including scalpels (expired 2010), needles (expired 2011), and one needle that expired 3/2010.
- A dirty patient meal tray was found sitting on the bedpan hopper in the dirty utility room. Staff stated that they had ordered racks or carts to hold trays, since that had been cited at the previous survey 3/12. The surveyors did not confirm when the racks were ordered or when delivery was anticipated.

2. Third Floor Unit Tour:
- Numerous (at least four) dirty patient meal trays were observed in the soiled utility room with some on counter, and on/near bedpan hopper and garbage containers.
- Medication room had viral test tubes stored in the medication refrigerator with an expiration date of 10/18/10.
- The medication room counter had a telephone that appeared dusty, dirty with what looked like dried blood on the top, exposed part of the receiver at ear piece area. Dried blood-like areas were 1/8th to 1/4th inch in diameter, dark brown, dark reddish in color. The area behind the phone on the countertop was dusty/dirty and looked as if it had not recently been cleaned or wiped down.
- The crash cart was inspected and the red respiratory box, which the director of nursing stated was to be checked by respiratory every month, had a check date of 4/1/12. S/he stated that s/he had personally witnessed the box being checked with the rest of the cart on 5/1/12, but acknowledged that the person checking the box had failed to change the inspection date on the box to reflect the most recent inspection.
- The nutrition room had a bank of metal kitchen cabinets. In the base cabinets under the coffee machine, the first shelf was found to be dirty and sticky with a lone individual serving box of breakfast cereal stuck to the metal surface. On the lower shelf was a very large circular brown stain that appeared to be years of dripped coffee that had pooled on the shelf and dried in many layers. The surveyor recalled to staff that s/he had made the same observation of these findings to staff during a previous survey (approximately a year ago). There was no evidence of any attempt to address the problem since that prior survey.
- In another base cabinet in the nutrition room, there was evidence that some drilling had been done to reinforce a wooden cabinet with two lengths of board. The bottom of the cabinet was covered with a thick layer of saw dust and wood shavings from the drilling.
- A metal drawer in one of the base cabinet had a few packets of condiments, a rubber band and lots of food crumbs and debris in the drawer.
- An open bag of potato chips was sitting on a shelf in an upper cabinet.
- In the janitor's closet on the floor, the floor and all surfaces and walls appeared very dirty, stained and discolored. The only thing that appeared clean in the room was the white porcelain sink. There was a gap on the floor where the floor tile stopped by the door and it was dirty concrete in about a 1-2 inch strip running under the door area. A different clean- appearing tile flooring resumed in the hallway outside of the closet.
- A broom was also stored in the janitor's closet with the other cleaning equipment.

On 5/8/12 at approximately 1:30 PM, a tour of the food and dietary area was conducted with the manager of that department. During the tour of the walk-in coolers, it was observed that a large (institutional-sized), nearly empty glass jar of minced garlic and a small jar of mustard were open with no open or discard dates on the items. The dietary manger, who was also a dietician, stated that the products should have been labeled when they were opened, so that a discard date could be established. S/he stated that those products were to be discarded 1 week after having been opened. During the tour of the kitchen area, the janitorial closet was found to contain two brooms that were use for cleaning in the food and dietary department.

On 5/09/2012 at approximately 2:45 PM, a tour the radiology department was conducted with the manager of radiology, lab and respiratory departments. The manager was a respiratory therapist, by profession. During the tour, the emergency resuscitation cart for the department was inspected. The red respiratory therapy box on the cart had a label stating that it had last been inspected on 4/1/12. The respiratory therapist stated that the respiratory department checked the box every month. S/he acknowledged that the date indicated that the box did not appeared to have been checked on 5/1/12, when the next inspection was due.

On 5/10/12 at approximately 11:00 AM, an interview with the new Infection Control Officer was conducted. During the interview, the issue of cleanliness, sanitation and infection control related findings from the tour on 5/8/12 were discussed. After the interview, s/he went to the units and personally observed the conditions described and validated the concerns expressed by the surveyors. S/he reported back that day that s/he had instituted cleaning in medication rooms, nutrition rooms and housekeeping closets. The next morning, 5/11/12, a surveyor re-toured the medication rooms and observed that the areas had been cleaned. The corporate vice president, who was present during the survey, stated at the exit conference that the other areas, including the nutrition rooms, had also been thoroughly cleaned.

Based on staff interviews and review of facility documents, the governing body failed to ensure that the contract pathologist, who served as the medical director for the laboratory, and two contract radiologists were appointed as members of the medical staff, as required.

The findings were:

On 5/7/12 during the compilation of a sample list of credential files for review, it was determined that a contract pathologist, affiliated with the hospital that provided contract laboratory services, was the medical director of laboratory services for the hospital being surveyed. It was also determined that the pathologist was also listed on the hospital's Clinical Laboratory Improvement Act (CLIA) certificate as the director of the laboratory services.

Review on 5/7/12 of the contracted radiology services provided revealed that the hospital utilized a group of radiologists to interpret all testing conducted in the facility and those radiologists were appointed to the medical staff and appeared on the complete roster of the medical staff. During an interview with the Director of Quality on 5/7/12 at 3:35 PM, it was determined that ultrasound services were provided by an outside medical services contractor that supplied the equipment and technicians to come to the facility and conduct ultrasound diagnostic testing. In addition, it was determined that the medical services contractor provided the two radiologists who interpret the ultrasound testing. Review on 5/8/12 of the roster of the medical staff for the hospital revealed that the two radiologists were not listed as members of the medical staff.

On 5/10/12 at approximately 2:50 PM, the staff member in charge of the medical staff credentialing process was interviewed and confirmed that the pathologist and the two contract radiologists had not been appointed to the medical staff.

Based on staff interviews and review of facility documents, the facility failed to maintain a complete list of all contracted services. The lists of contracted services provided were not complete in describing the scope and services for each contract.

Findings:

On 5/8/2012 at approximately 8:45 AM, a complete list of all contracted services was requested from facility staff. The list presented on this date contained no title, was five pages in length, and contained approximately 220 contracted services. Twenty six of the services listed did not contain a description of services, therefore did not describe the scope and services for these contracts.

On 5/9/2012 at approximately 2:45 PM during an interview with the Vice President of Professional Services, s/he reviewed the contract list the surveyor had been provided by staff on 5/8/2012 and stated the this list was from the business office and was not complete. S/he referred to a list of contracted services located in the Governing Board binder which was approved on 3/21/2012 and listed 75 contracted services. S/he described this list as "contracted clinical services." A complete list of all contracted services, not just contracted clinical services, was requested of the Vice President at this time. S/he stated that she would retrieve a complete list of contracted services immediately.

On 5/09/2012 at approximately 4:10 PM, the Vice President of Professional Services presented a list of contracted services that she stated was not complete as not all services utilized by the facility were listed and not all of the services listed contained a description of services provided.

On 5/8/2012 at approximately 1:40 PM a tour of the facility kitchen was conducted with the Director of Food and Nutrition. S/he stated that the major supplier of food items for the facility was "Shamrock" and that "Front Range Duct and Cleaning" was contracted to maintain the vent hood over the stove. These vendors were not found on the list of contracted services given to surveyors on 5/9/2012 at 4:10 PM.

On 5/9/2012 at approximately 10:45 AM during a tour of the 3rd floor, the Chief Nursing Officer (CNO) stated that laundry services were contracted out to "Co-operative Laundry." This vendor was not found on the list of contracted services given to surveyors on 5/9/2012 at 4:10 PM.

On 5/9/2012 at approximately 1:15 PM an interview was conducted with the CNO and the facility's wound care nurse who both stated that the contracted service for maintaining specialty bariatric beds was "Recovery Care." This vendor was not found on the list of contracted services given to surveyors on 5/9/2012 at 4:10 PM.

On 5/9/2012 at approximately 2:45 PM a tour of the radiology department was conducted. The Director of Radiology stated that "Medical Physicist Associates" was the contracted entity responsible for inspecting radiology equipment. This vendor was not found on the list of contracted services given to surveyors on 5/9/2012 at 4:10 PM.

Based on staff interviews, medical record review, and review of facility policies, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. Specifically, the supervising nurse failed to ensure that weights were obtained for sample patient #4 during hospitalization.

Findings:

On 5/8/2012 at approximately 12:00 PM, review of the medical record for sample patient #4 revealed the following:

Sample patient #4 was admitted to the medical/surgical unit on 3/10/12 for discitis at the 3rd and 4th lumbar vertebrae. Other documented co-morbidities were chronic heart failure, diabetes mellitus, and gout.

Review of the medication orders for the patient revealed an order for a diuretic, Hydrochlorothiazide, to be administered daily from 3/20/2012 through discharge date of 4/12/2012.

On 5/8/2012 at approximately 9:00 AM during an interview with the CNO, s/he stated that the facility uses Lippincott for standards of care for nursing services.

A review of "Lippincott, Manual of Nursing Practice, 8th Edition," published 2006, pages 414 -415, stated the following in pertinent parts with regard to patients experiencing heart failure:

" ...Nursing Assessment ...
5. Assess weight and ask about baseline weight ...

Restoring Fluid Balance
1. Administer prescribed diuretic as ordered.
2. Give diuretic early in the morning - nighttime diuresis disturbs sleep.
3. Keep input and output record - patient may lose large volume of fluid after a single dose of diuretic.
4. Weigh patient daily - to determine if edema is being controlled: weight loss should not exceed 1 to 2 lb (0.5 to 1 kg)/day ... "

Further review of the medical record for sample patient #4 revealed that from 4/2/2012 to 4/12/2012, the date of discharge to an acute rehabilitation facility, the patient was in the Intensive Care Unit (ICU) after experiencing "acute mental status changes." The "Critical Care Flowsheet" was utilized to document patient care in the ICU.

On 5/10/12 at approximately 12:00 PM the facility's policy titled "Critical Care Flowsheet", with a revision date of 6/10, stated the following in pertinent parts:

"...Policy: Patient Assessment A. The front page is designated for the documentation of the following information: 1. Patient weight for today and the weight and intake and output from the previous day are documented at the top of the page."

The document titled, "Wound Care Charge List" revealed that the patient was in "Specialty Bed 3" for the duration of his/her hospitalization, 3/10/2012 through 4/12/2012.

A document titled "Weight Log" was noted in the patient's record with an admission date of 3/10/2012 and an admission weight of 265 lbs documented in the heading of the log. The log contained instructions for staff on how to use the bed scale to obtain the patient's weight. The log contained the following headings for information to be completed by staff: Date, Weight, Re-Weigh, CNA Signature, and Nurse Signature. The log contained documentation for 25 days from the admission date of 3/10/2012 through the discharge date of 4/12/2012. The log contained no weights for the patient other than the initial weight of 265 lbs. Documentation by staff on 3/13/2012 and signed by a Registered Nurse (RN) indicated under the column titled "Weight" that the patient was in a bariatric bed. Documentation by staff under the weight column reflected the following comments: "scale doesn't work," "re-zero," "fix bed." On 3/24/2012 staff documented "Day supervisor notified - will call company to bring new scale." All documentation by staff reflected that the bed scale was not functioning. In no other section of the patient's record were weights for the patient documented for the dates 3/10/2012 through the discharge date of 4/12/2012.

On 5/9/2012 at approximately 1:15 PM an interview was conducted with the facility's wound care nurse and Chief Nursing Officer (CNO). Upon review of the medical record for sample patient #4, the wound care nurse stated that the patient did have an order for a bariatric bed, which was a rental bed, and s/he was not made aware that the scale on the bed was not functioning. The wound care nurse stated that she was "in charge of rental beds." Upon review of the patient's medical record, the CNO stated that s/he could not find documentation of any weights for the duration of the patient's hospitalization with the exception of the weight documented on 3/10/2012 at the time of admission.

Based on tours/observations and staff interviews, the pharmacy administrator failed to ensure that the drug storage areas in the patient care unit medication rooms were maintained in a clean and sanitary condition for preparation and storage of medications for patient use. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A 747 Condition of Participation of Infection Control for more detailed findings related to failure to ensure that medication rooms and related supplies and equipment were kept in a clean, well maintained and sanitary condition for the storage and preparation of medications.

During the tour of the medication rooms on 5/9/12 at approximatelty 10:30 AM, the pharmacy administrator was present and observed and confirmed findings in the medication preparation areas. The findings included the following:
In the medication rooms/supply rooms, supplies were found to expired, contaminated by contact with splashed or pooled water on the sink area where supplies, and the overall medication preparation areas appeared visibly dirty. There was evidence of possible blood smears and spattering around the medication preparation areas on some equipment, including the phone and a glucometer. S/he stated that the housekeeping staff were supposed to clean the room two times a day. During a tour and interview in the pharmacy on 05/10/2012, at approximately 10:10 AM, s/he acknowledged that the unclean and unsanitary conditions s/he had witnessed the day before in the medication rooms were not acceptable for safe storage and preparation of medication. S/he acknowledge joint accountability with nursing, infection control officer and plant operations/housekeeping to ensure that the medication rooms and related supplies and equipment were maintained in clean and sanitary condition.

Based on tours/observations and staff interviews, the hospital failed to ensure that the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A 747 Condition of Participation of Infection Control for more detailed findings related to failure to ensure that medication rooms, nutrition rooms, janitorial closets and dirty utility rooms were kept in a clean, well maintained and sanitary condition to prevent infection. Medication rooms and janitorial closets were observed to be dusty, dirty with debris on the floor and stains on walls and in/on storage cabinet and shelving. In addition, the tag contains findings that brooms were found to be be stored for use in the food and dietary department and the third floor patient unit, despite state licensure regulations prohibiting the use of brooms or dry dusting in hospitals.

Based on tours/observations and staff interviews, the hospital failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety and quality. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A 747 Condition of Participation of Infection Control for findings related to expired supplies, infection control risks, environment concerns and lack of monitoring of the environment for effective cleaning of equipment and work areas, inconsistent inspection of supplies and equipment and lack of appropriate storage carts for temporary holding of dirty patient meal trays on the patient care units. In addition, the tag contains findings related to failure to ensure that brooms were never utilized to clean in the facility in order to prevent airborne contamination.

Based on staff interviews and review of facility documents, including policies, the facility failed to ensure that it worked in conjunction with the Organ Procurement Organization to educate staff regarding donation issues.

Findings:

On 5/7/2012 at approximately 1:30 PM, review of the facility's policy titled, "Organ Tissue Donation," with last revision date, September, 2011, revealed the following in pertinent parts:

"...Administration
The hospital administration, nursing department and medical staff of this hospital, along with the contracted Organ Procurement Organization, are cooperatively involved in supporting the donation process. Organ Procurement Coordinators from the Organ Procurement Organization are available 24 hours a day to assist with the implementation of this policy. The hospital works with the Organ Procurement Organization to review death records to improve the identification of potential donors and to ensure that the necessary testing and placement of potential donated organs, tissues, and eyes takes place, in order to maximize the viability of donor organs for transplant and maintain potential donors while preliminary suitability is determined...

B. Routine Inquiry Upon Admission:
1. The hospital shall provide information to individuals on how to become donors and shall make available to individuals informational brochures that discuss donations.
2. On or before admission to the hospital, or as soon as possible thereafter, a member of the admissions or nursing staff or case management shall ask each patient, who is at least 18 years of age, whether they are an organ or tissue donor.
a. If the answer is affirmative, the staff member shall request a copy of the documentation of the gift (or if no documentation is available, the staff member shall request that the patient complete new documentation of the gift)...
3. The answer of the patient, an available copy of any document of gift or refusal to make an anatomical gift, and any other relevant information, must be placed in the patient's medical record...

F. Education:
It is the obligation of the Organ Procurement Organization to provide inservice education on the need and uses of organ and tissue donation and transplantation...

Attachment A
CERTIFICATE OF REFERRAL/REQUEST FOR ANATOMICAL DONATIONS...
This form must be completed on all deaths and included as part of the patient's permanent medical record."

On 5/8/2012 at approximately 10:45 AM, an interview was conducted with the Chief Nursing Officer (CNO) and the Director of Quality. Both staff members confirmed that no initial training or annual competency was conducted with staff regarding the organ/tissue donation process. Neither the CNO nor the Director of Quality could state who on staff was responsible for ensuring that staff received training regarding issues related to the organ/tissue donation process.

On 5/9/2012 at approximately 11:50 AM interviews were conducted with 3rd floor nursing staff. Staff member #1, Charge Nurse, staff members #2, #3, and #4, all RNs, stated that there was no form used to document that patients or their family members received information regarding donation of an anatomical gift or refusal to donate. Staff member #5, Case Manager, stated that there was no brochure given to patients or their family members regarding organ donation.

On 5/10/2012 at approximately 2:00 PM, an interview was conducted with the facility's Nurse Educator who stated that s/he had never seen the CERTIFICATE OF REFERRAL/REQUEST FOR ANATOMICAL DONATIONS form which is contained in the facility's policy titled, "Organ Tissue Donation." S/he stated that the only form used by staff when a patient dies is the "Record of Death" form. The Nurse Educator stated that no cooperative education with the Organ Procurement Organization regarding the donation process occurs in the facility. S/he presented a copy of slides used for education of Charge Nurses which contained no information for these nurses regarding organ donation.

Based on interviews and review of facility documents the facility failed to collaborate with the designated Organ Procurement Organization to review death records in order to improve identification of potential donors.

Findings:

On 5/7/2012 at approximately 1:30 PM, review of the facility's policy titled, "Organ Tissue Donation," with last revision date, September, 2011, revealed the following in pertinent parts:

"...Administration
The hospital administration, nursing department and medical staff of this hospital, along with the contracted Organ Procurement Organization, are cooperatively involved in supporting the donation process. Organ Procurement Coordinators from the Organ Procurement Organization are available 24 hours a day to assist with the implementation of this policy. The hospital works with the Organ Procurement Organization to review death records to improve the identification of potential donors and to ensure that the necessary testing and placement of potential donated organs, tissues, and eyes takes place, in order to maximize the viability of donor organs for transplant and maintain potential donors while preliminary suitability is determined...

On 5/11/2012 at approximately 8:30 AM an interview with the Director of Quality was conducted. S/he stated that neither the hospital nor the Organ Procurement Organization conduct death reviews separately or in collaboration in the facility.

Based on tours/observations and staff interviews, the hospital's nursing administrator failed to ensure that the drug storage areas in the patient care unit medication rooms and related supplies and equipment were maintained in a clean and sanitary condition for preparation and storage of medications for patient use in accordance with accepted standards of practice. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A 747 Condition of Participation of Infection Control for more detailed findings related to failure to ensure that medication rooms and related supplies and equipment were kept in a clean, well maintained and sanitary condition for the storage and preparation of medications.

During the tour of the medication rooms on 5/9/12 at approximately 10:30 AM, the Chief Nursing Officer (CNO) was present and observed and confirmed findings in the medication preparation areas. During the tour s/he acknowledged that the unclean and unsanitary conditions observed in the medication rooms were not acceptable for safe storage and preparation of medication. In the medication rooms/supply rooms, supplies were found to expired, contaminated by contact with splashed or pooled water on the sink area where supplies, and the overall medication preparation areas appeared visibly dirty. There was evidence of possible blood smears and spattering around the medication preparation areas on some equipment, including the phone and a glucometer. S/he acknowledge joint accountability with pharmacy, infection control officer and plant operations/housekeeping to ensure that the medication rooms and related supplies and equipment were maintained in clean and sanitary condition. S/he stated that the hospital had instituted a restriction on people going into the medication room when nurses were preparing medication to avoid interruptions that may contribute to medication errors. S/he acknowledged that they have to find a way to ensure that the housekeeping staff have enough time to get into the room and do adequate cleaning and that the nurses have to assume more responsibility for making sure the area is in good order and supplies, equipment, and medications are appropriately stored and maintained in the medication rooms.