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Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated May 13, 2015.
K-0018
K-0025

Based on observation and interview, the facility failed to ensure that outdated blood specimen tubes were not available for use in the Emergency Department (ED) resulting in the potential for inaccurate test results and poor patient outcomes for all patients that present to the ED with an emergent traumatic condition. Findings include:

On 05/11/2015 at 1235, during observation and tour of the ED with the Director of Emergency Services (Staff J) revealed a small cart identified by staff J as the "Trauma Cart." She then stated, "Our nurses put this together with some supplies that they need during a trauma." Upon review of the carts contents the following outdated blood specimen tubes were found:

One (1) Blue top tube outdated 4/2012
One (1) Green top tube outdated 7/2012
One (1) Yellow top tube outdated 8/2012
One (1) Blue top tube outdated 10/2012
One (1) Green top tube outdated 12/2012
One (1) Yellow top tube outdated 1/2013
Four (4) Pink top tube outdated 1/2013
Four (4) Purple top tube outdated 4/2013.

In an interview with staff J on 05/11/2015 at 1237, when queried as to who was supposed to monitor the cart for outdated supplies, she stated, "The nurses are supposed to check it at least monthly and restock it every time they use it." Staff J then stated, "This is embarrassing that you found them in there."

Based on observations, interviews and document review, the facility failed to ensure that staff don PPE (Personal Protective Equipment)/Sterile Attire (Gown) for 2 of 3 observations resulting in the potential for spread of infectious agents to all staff and patients treated at the hospital. Findings include:

On 05/11/2015 at 1410 during observation of room 3312, identified by staff J (RN/Director of Emergency Services) as a room in use for "Contact Isolation for MRSA (Methicillin Resistant Staphylococcus Aureus)" revealed a hospital staff member in the room without a cover gown. Staff M was observed getting ready to assist the patient with walking with a walker. When staff J was queried as to what PPE the staff are suppose to wear when entering the room to provide care, she stated, "Gown and gloves."

In an interview with staff M (Physical Therapy Assistant) on 05/11/2015 at 1415, when queried as to if he was aware that he was supposed to be wearing a cover gown when providing care to a patient in isolation, he stated, "Yes, I am. I just didn't put it on."

In an observation on 05/12/2015 at 0750 in the operating room (OR), the surgeon (Staff W) was observed performing a bilateral tonsillectomy, bilateral adenoidectomy and bilateral ear tube insertions. The surgeon failed to apply a sterile cover gown before performing the surgery.

In an interview with staff Z (Director of Surgical Services) on 05/12/2015 at 0900, when queried as to what the facility policy stated about wearing a sterile gown in the OR, he stated, "He should be wearing one (a sterile gown)."

On 05/12/2015 at 1000, review of the facility's policy titled, "Aseptic Technique, #12:10:14, Effective Date: November 2014," read, "Policy/Procedure: I. Only authorized and properly attired persons will be allowed in the OR/PACU (Pre/Post-op Anesthesia Care Unit). III. Scrubbed persons should wear sterile gowns and gloves."

In an interview with staff Y (Chief of Surgery) on 05/12/2015 at 1045, when queried about the surgeon not wearing a sterile cover gown in the OR, he stated, "It is like a dentist doing oral surgery in their office, they wouldn't wear one." When informed that the facility's policy's does not relieve the surgeon from wearing one in the OR , staff Y stated, "I will speak to him and we will look into changing the policy."

Based on document review and interview the facility failed to ensure that staff completed all areas of the surgical consent for 1 of 1 (#34) opened records and 5 of 5 closed records reviewed (#35-#38, #40) resulting in the potential for all patients and /or the patient's representative, having surgery at the facility, for a loss of their right to be fully informed prior to the surgery. Findings include:

On 05/12/2015 at 0700 during review of patient #34's medical record prior to a surgical procedure, a document titled, "Consent for: Operation / Procedure Anesthesia / Treatment," was noted to have been signed by the patient's parent and the physician. The area that read, "Some significant and substantial risks of this particular operation or procedure include:" was noted to be blank.
Further review of the medical record for patient #34 at 1030 after completion of the procedure, the area was still noted to be blank.

In an interview with staff Z on 05/12/2015 at 1030, he confirmed that the area outlining risks in the document was blank and stated, "There is nothing there."

On 05/12/2015 between 1030 and 1045 during review of the electronic documentation with staff Z, revealed that the document titled, "Consent for: Operation / Procedure Anesthesia / Treatment," were all blank in the area that read, "Some significant and substantial risks of this particular operation or procedure include:" for patients #35, #36, #37, #38 and #40. The above findings were all confirmed by staff Z at the time of the record review on 05/12/2015 between 1030 and 1045.

On 05/12/2015 at 1045, review of the facility's policy titled, "Consent-Informed, #12:22:113, Effective Date: February 2015, read, "III Guidelines for Completing Consents(sic) Forms, B. The forms must be complete. 1. All blanks are to be filled in prior to the patient's (or designee's) signature, 4. Prior to the patient's (or designee's) signature, the completed form shall be reviewed for accuracy by the staff member requesting signature."