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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K11: The facility did not have a common separation wall that meet code requirements.
K12: Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K18: Positive latching was not provided on all doors to the corridor
K51: The facility did not have a reliable fire alarm system that complies with NFPA 72.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K64 Portable fire extinguishers were not properly located.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K70: Portable space heating devices were improperly installed.
K75: The facility failed to limit trash containers not to exceed .5 gallon per square foot of floor area.
K77: The facility failed to provide the medical gas system to be in compliance with NFPA 99.
K144: The facility failed to test the emergency power system weekly and monthly.
K145: The facility failed to properly identify the receptacles that are emergency power.
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
Main Hospital Building
K11: The facility did not have a common separation wall that meet code requirements.
K12: Class of Construction did not meet non-combustible standards of a Type II (2,2,2)
K18: Positive latching was not provided on all doors to the corridor
K51: The facility did not have a reliable fire alarm system that complies with NFPA 72.
K56: Sprinkler system did not meet all minimum regulations per NFPA 13.
K64 Portable fire extinguishers were not properly located.
K67: The HVAC system did not meet the minimum standards on NFPA 90A.
K70: Portable space heating devices were improperly installed.
K75: The facility failed to limit trash containers not to exceed .5 gallon per square foot of floor area.
K77: The facility failed to provide the medical gas system to be in compliance with NFPA 99.
K144: The facility failed to test the emergency power system weekly and monthly.
K145: The facility failed to properly identify the receptacles that are emergency power.
K147: Electrical system did not meet the minimum regulations for NFPA 70.

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observations and interview with facility staff the hospital failed to assure that drugs were secured.

Findings include:

During a tour of the cesarean section room in the maternity ward on 04/28/2010 at 1:30 PM it was observed by the surveyor that the top drawer of the anesthesia cart, which was unlocked, contained a bottle of Sojourn (sevoflurane) which is an inhalation anesthetic.
This observation was confirmed by RN manager B at the time. She also confirmed that all anesthetic medications should be locked in the anesthesiologist's medication cart.

Based on observations and interviews with facility staff, the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary environment for the prevention of potential contamination or infection.


Findings include:


1) During a tour of the laboratory on 04/27/2010 at 11:15 AM it was observed that the blood draw area adjacent in room 119B was unsanitary. Within the room on the exterior wall are plumbing pipes from which paint and rust are flaking. The particles associated with this corrosion make this area unsanitary and inappropriate for use as a patient care area. The preceding observation was confirmed by Lab manager D at the time of the tour.

2) During a tour of room 342, which is the ultrasound room on 04/27/2010 at 1:00 PM it was observed that there was an unused toilet waste pipe in the floor which was blocked with a rag. The waste pipe opening should be capped permanently. This was confirmed by staff A.

3) During a tour of the nursery in the maternity ward on 04/28/2010 at 1:35 PM it was observed that the filter in the Air Shields C-100 isolette was marked with the date 12/30/2002. Instructions on the isolette indicate filters should be changed at least every three months. This was confirmed by Nurse manager B.

Based on review of 8 of 30 records (# 1 through #8 ), interview with staff and review of facility policies and procedures the hospital failed to assure entries were properly timed and dated.

Findings include:

The following records were reviewed over the course of the survey on 04/27/2010,04/282010 and 04/29/2010

The hospital's policy on medical records content and completion states; "Verbal and telephone orders need to be signed, dated and timed within 24 hours of the order."

Patient (pt.) #1's medical record contained 4 telephone orders written on 02/07 which were co-signed and dated by the physician but the signature was not timed.

Pt. #2's medical record contained 2 verbal orders written on 02/16 and 02/17/2010 which were not signed within 24 hours.

Pt. #3's medical record contained a verbal order written on 10/26/2009 which was not co-signed by a practitioner.

Pt. #4's medical record contained a verbal order written on 03/05/2010 which was co-signed by the physician on 04/02, more than 24 hours after it was transcribed.

Pt. #5's medical record contained a verbal order written on 02/04/2010 which was co-signed by the physician who failed to time and date their signature.

Pt. #6's medical record contained 2 telephone orders written on 12/30/2009 which were co-signed by the physician who failed to time and date their signature.

Pt. #7's medical record contained 1 telephone order written on 11/24/2009 which was not co-signed by the physician's assistant.

Pt. #8's medical record contained 2 telephone orders written on 10/29/2009 which were co-signed by the physician who failed to time and date their signature.

These findings were confirmed per interview with director of nursing C on 04/28/2010 at 11:00 AM.

Based on review of patient right's statement, interview with staff and review of policies and procedures, the hospital failed to provide a patient rights statement describing all swing bed rights.

Findings include:

The hospital provided a sample packet of information given to patients on admission which contained a patient rights statement. The statement addressed rights associated with being an ordinary hospital patient. There was nothing in the packet addressing the unique rights of a swing bed patient. Per interview with Nurse manager B on 04/27/2010 at 1:10 PM there is no separate patient rights statement provided swing bed patients. The hospital's patient rights does not differentiate between ordinary hospital patient rights and the additional rights of swing bed patients.