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A. Based on medical record review and staff interview, it was determined in 1 of 1 (Pt #5) medical records reviewed, in which the patient received Outpatient services for daily intravenous antibiotic therapy per a Peripherally Inserted Central Catheter (PICC), the Hospital failed to ensure medications and treatments were administered/performed as ordered.

Findings include:

1. The medical record of Pt #5 was reviewed on 10/12/11. Pt #5 was admitted to Outpatient services for daily intravenous antibiotic therapy per a PICC on 10/1/11. There was no physician order for PICC line dressing or cap change weekly. Nursing documentation indicated no PICC dressing and/or cap change the week of 10/2/11. Nursing documentation indicated a PICC dressing change on 10/11/11; however, there was no PICC cap change. On 10/1/11, there was a physician order "PICC line flush: 10 ml 0.9 Normal Saline (NS) prior to infusion, 20 ml 0.9 NS after infusion followed by 3-5 ml heparin flush." The order failed to include the dose of heparin. Medication Administration Record (MAR) documentation indicated the following discrepancies: On 10/3/11, the MAR failed to indicate the doses of NS prior to or after the infusion and failed to indicate whether any Heparin was given. On 10/4/11, 10/8/11, 10/10/11, and 10/11/11, the MAR failed to indicate the doses of NS prior to or after the infusion. On 10/4/11, 10/5/11, 10/8/11, 10/10/11, and 10/11/11, the MAR failed to indicate the dose of Heparin given. On 10/7/11, the MAR indicated 10 ml of Heparin was given instead of 3-5 ml, as ordered.

2. During a staff interview, conducted with the Director of Outpatient Services, conducted on 10/12/11 at 3:00 PM, it was verbalized that PICC dressings and caps should be changed weekly and as needed and orders should have been obtained upon admission.

3. During a staff interview, conducted with the Director of Outpatient Services on 10/13/11 at 11:30 AM, the above findings were confirmed. It was further verbalized that the MAR should match the nursing notes in relation to medications given and doses administered.

A. Based on medical record review and staff interview, it was determined in 6 of 21 (Pts #1, #2, #24, #26, #27, #32) medical records reviewed, in which the patient required a Medical Screening Examination (MSE), the Hospital failed to ensure the MSE included the date and time it was performed.

Findings include:

1. The medical record of Pt #1 was reviewed on 10/11/11. Pt #1 presented to the Emergency Department (ED) on 7/18/11 with the Chief Complaint (CC) Abdominal Pain. MSE documentation failed to include a legible date and time as to when it was performed.

2. The medical record of Pt #2 was reviewed on 10/11/11. Pt #2 presented to the ED on 8/4/11 with the CC Diarrhea. MSE documentation failed to include the date and time as to when it was performed.

3. The medical record of Pt #24 was reviewed on 10/12/11. Pt #24 presented to the ED on 9/8/11 with the CC Pneumonia. MSE documentation failed to include the time as to when it was performed.

4. The medical record of Pt #26 was reviewed on 10/12/11. It indicated Pt #26 was admitted on 8/30/11 with a diagnosis of Diabetes. The signatures of the Emergency Department physician were not dated and timed.

5. The medical record of Pt #27 was reviewed on 10/12/11. It indicated Pt #27 was admitted on 8/10/11 with diagnoses of Syncope and Collapse. The signatures of the Emergency Department physician were not dated and timed.

6. The medical record of Pt #32 was reviewed on 10/13/11. Pt #32 presented to the ED on 9/19/11 with the CC Evaluation, patient out of control, history Bipolar and Attention Deficit Disorder. MSE documentation failed to include the time as to when it was performed.

7. During a staff interview, conducted with the CNE on 10/13/11 at 11:30 AM, the above findings were confirmed.

A. Based on Hospital policy,medical record review and staff interview, it was determined that in 8 of 34 (Pts #1, #2, #7, #12, #18, #24, #28 and #30), medical records reviewed, the Hospital failed to ensure all physician orders were authenticated with date and time.

Findings include:
1. The Hospital policy indicates that the physician's order shall be written legibly in ink and include a date and time of the order and signature of the physician.

2. The medical record of Pt #1 was reviewed on 10/11/11. Pt #1 presented to the ED on 7/18/11 with the CC of Abdominal Pain. The ED physician orders failed to include a date and time.

3. The medical record of Pt #2 was reviewed on 10/11/11. Pt #2 presented to the ED on 8/4/11 with the CC of Diarrhea. The ED physician orders failed to include a date and time.

4. The medical record of Pt. #7 was reviewed on 10/12/11. Documentation indicated that Pt. #7 was admitted on 10/8/11 with the diagnoses of Nausea, Vomiting, and Abdominal Pain . Pt. #7 had a Laparoscopic Cholecystectomy on 10/12/11. Documentation indicated that 2 telephone orders dated 10/8/11 were not dated or timed by the physician. Documentation indicated that one telephone order on 10/10/11 was not dated or timed by the physician.

5. The medical record of Pt.#12 was reviewed on 10/12/11. Documentation indicated that Pt#12 presented to the Emergency Department with complaint of Chest Pain on 9/7/11. Documentation indicated there was no date or time on the ED orders.

6. The medical record of Pt. #18 was reviewed on 10/12/11. Documentation indicated that Pt. #18 was admitted on 8/2/11 with the diagnoses of Gastroenteritis, Dehydration, and Acute Renal Failure. Documentation indicated that 3 telephone orders were not dated and timed by the physician

7. The medical record of Pt #24 was reviewed on 10/12/11. Documentation indicated that Pt #24 was admitted from the ED with diagnoses of Pneumonia and history of Chronic Renal Failure and Anemia. Documentation indicated there was no date or time on the ED orders and no date or time on the admission orders.

8. The medical record of Pt. #28 was reviewed on 10/13/11. Documentation indicated that Pt. #28 was admitted on 8/28/11 with the diagnoses of Septicemia and Decubitus Ulcer. Documentation indicated that the Admission orders were not dated by the physician. Documentation indicated that 3 telephone orders were not dated or timed by the physician.

9. The medical record of Pt #30 was reviewed on 10/13/11. It indicated Pt #30 was admitted on 9/16/11 with a diagnosis of Chest Pain. Physician orders, written on 9/16/11 at 0500 and 9/16/11 at 1035, were not dated or timed.

10. During a staff interview, conducted with the CNE on 10/13/11 at 11:30 AM, the above findings were confirmed.

A. Based on a review of Hospital policy, a review of Medical Staff Bylaws Rules and Regulations, medical record review, and staff interview, it was determined in 3 of 34 (Pts #3, #5, #18) medical records reviewed, the Hospital failed to ensure telephone orders were signed by the physician within 48 hours.

Findings include:

1. The Hospital policy titled "Physician Orders" was reviewed on 10/12/11. It indicated "Procedure: VI. Telephone orders for medications shall be used sparingly and authenticated within the timeframe outlined in the Medical Staff Bylaws Rules and Regulations for completing the patient's medical record."

2. The Medical Staff Bylaws Rules and Regulations were reviewed on 10/12/11. It indicated that physician telephone orders were to be authenticated within 48 hours.

3. The medical record of Pt #3 was reviewed on 10/12/11. Pt #3 was admitted to the Hospital on 10/8/11 with the diagnoses Respiratory Distress, Metastatic Cancer, and Pneumonia. On 10/9/11, there were two telephone orders , one at 2:06 PM and one at 2:30 PM, which were not cosigned by the physician as of 10/12/11.

4. The medical record of Pt #5 was reviewed on 10/11/11. Pt #5 was admitted to the Hospital on 10/1/11 with the diagnosis Chronic Infected Total Knee and was receiving outpatient intravenous antibiotics daily. On 10/1/11, there were two physician telephone orders, both at 8:00 AM, which were not cosigned by the physician as of 10/12/11.

5. The medical record of Pt. #18 was reviewed on 10/12/11. Documentation indicated that on 8/2/11 a telephone order was written by the Registered Nurse. As of survey date 10/12/11, the order was not cosigned by the physician.

6. During a staff interview, conducted with the CNE on 10/13/11 at 10:00 AM, the above findings were confirmed.

A. Based on a request for the medical record delinquency rate and staff interview, it was determined the Facility failed to ensure all medical records were promptly completed by the physicians.

Findings include:

1. On 10/12/11 a written statement of the delinquent list of medical records was presented. Documentation indicated the Facility had 621 delinquent records and two physician suspensions because of delinquent records.

2. The above finding was verified with the Chief Nurse Executive (CNE) on 10/12/11 at 10:00 am.

A. Based on a review of personnel monitoring reports and staff interview, it was determined the Facility failed to ensure all surgical personnel exposed to radiation were monitored accordingly.

Findings include:

1. The personnel monitoring reports reviewed on 10/12/11 indicated that the most current radiation dosimetry reports were dated 09/21/11 and did not include any Surgical personnel.

2. An interview with the Radiology Department Manager was conducted at 8:00 am on 10/12/11 and indicated Surgical personnel monitoring reports were initiated in September of 2011 and the results are not expected back until mid October. There was no documentation to indicate Surgical staff had ever been monitored for radiation exposure.

3. During a staff interview, conducted with the Director of Outpatient Services on 10/12/11 at 8:00 AM, the above findings were confirmed.

A. Based on policy review, observation, and staff interview, it was determined the dietary supervisor failed to ensure the dietary staff followed established policies for proper labeling of open food items and containers which potentailly affects all patients receiving dietary services as of 10/12/11.

Findings include:

1. A review of the dietary policies was completed on 10/12/11. The dietary policy titled "Food Service" under "VII. Served Food A. All stored food products are covered and labeled with the date and time of preparation."

2. During a tour of the dietary areas on 10/12/11 at 2:30 PM, it was observed the following items were opened and available for use with no date of opening, date of preparation and no date of expiration.

In the walk in cooler the following items were observed:

one large bag of cubed cheese
one large bottle of lime juice
one large container of soy sauce
one large plastic container of shredded cheese

In the walk in freezer #2

one sealed bag of meat with no identification or use by/expiration date
one prepared food entree, opened with no date of preparation, use by/expiration date

In the Deli-refrigerated unit

one large metal tray of prepared Deli sandwiches (6) with no date of preparation, use by/ expiration date

3. During an interview with the Dietary Supervisor on 10/12/11 at 3:30 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Full Survey Due to a Complaint Survey conducted on October 11 - 12, 2011, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Full Survey Due to a Complaint Survey conducted on October 11-12, 2011, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated October 12, 2011.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure outdated biologicals were not available for use in patient care areas.

Findings include:

1. During a tour of the Hospital, conducted 10/11/11 thru 10/12/11, the following outdated biologicals were observed: In the Pre-operative cart, 10- #24 gauge 3/4" Surflo Intravenous Catheters expired 4/11 and 1 Blue top Vacutainer expired 9/11. In the Cancer Care Center, 1- 118 ml Cal Stat Plus expired 10/1/11 and Ecolab Neutral Disinfectant with no date as to when it was filled and/or expired. In the Intensive Care Unit, on the patient supply cart, 11- 118 ml Cal Stat Plus expired 10/1/11. In the Emergency Department on 10/12/11 at 1:45 PM, the following outdated biologicals were observed to be outdated. One blue top Vacutainer was expired on 7/11. One arterial blood sampling kit was expired on 9/11.

2. The Hospital policy titled "Expiration Date Checking" was reviewed on 10/12/11. It indicated "Policy: III. All items in each in-house stocking area will be checked for expiration date every time the area is inventoried. The Materials Handler II will monitor these each week."

3. During a staff interview, conducted with the CNE on 10/12/11 at 2:00 PM, the above findings were confirmed.

B. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 2 of 34 (Pts #1, #2) medical records reviewed, in which the patient required IV maintenance for greater than 96 hours, the Hospital failed to ensure it's policy related to IV site changes was followed.

Findings include:

1. The Hospital policy titled "Peripheral Intravenous (IV) Therapy, Adult" was reviewed on 10/14/11. It indicated "III. Maintenance: J. Site changes are as follows: 1. Peripheral IV sites will be changed every 96 hours and as needed. 2. A physician order is required if the site is not changed at 96 hours."

2. The medical record of Pt #1 was reviewed on 10/11/11. Pt #1 presented to the ED on 7/18/11 with the CC of Abdominal Pain. IV documentation indicated that Pt #1's initial IV site was started on 7/18/11 in the ED. On 7/23/11, nursing documentation indicated that the IV site was discontinued. There was no documentation to indicate the IV site was changed within the 96 hour timeframe or that the physician was contacted for orders to keep the IV site.

3. The medical record of Pt #2 was reviewed on 10/11/11. Pt #2 presented to the ED on 8/4/11 with the CC of Diarrhea. IV documentation indicated that Pt #1's initial IV site was started on 8/4/11 in the ED. On 8/10/11, nursing documentation indicated that the IV site was discontinued. There was no documentation to indicate the IV site was changed within the 96 hour timeframe or that the physician was contacted for orders to keep the IV site.

4. During a staff interview, conducted with the CNE on 10/14/11 at 9:00 AM, the above findings were confirmed.

A. Based on a review of the Infection Prevention and Control meeting minutes and staff interview, it was determined the Hospital failed to ensure endoscopic procedures were followed postoperatively to evaluate whether or not a post-operative infection occurred.

Findings include:

1. The Infection Prevention and Control Committee Meeting minutes for August 2010 thru August 2011 were reviewed on 10/13/11. There was no documentation to indicate that endoscopic procedures were followed postoperatively to evaluate whether or not a post-operative infection occurred.

2. During a staff interview, conducted with the Infection Control Nurse on 10/12/11 at 11:15 AM, it was verbalized that no post endoscopy infection follow up is conducted with the physicians. It was further verbalized that if there is a post procedural positive C-Diff testing that it is reported to the hospital or if a test is done at the hospital and found to be positive, then the hospital will follow up on it. If the testing is done at an outlying facility, the facility usually contacts the hospital and notifys them of the results.

3. During a staff interview, conducted with the CNE on 10/14/11 at 8:30 AM, the above findings were confirmed.

A. Based on a review of Hospital policy, a review of Attest (1 hour) biological monitoring system records, and staff interview, it was determined the Hospital failed to ensure 1 hour biological monitoring results were documented for 2 out of 52 days from August 2011 thru 10/12/11, as per Hospital policy.

Findings include:

1. The Hospital policy titled "Biological Challenge Test for Immediate Use Sterilization" was reviewed on 10/12/11. It indicated "Procedure: 1. I. Obtain control (non-processed vial).... M. Document on designated form in the Department Control Book... O. Record all results... P. The final reading will be in one (1) hour."

2. The Attest (1 hour) biological monitoring system records for steam sterilization for August thru October 2011 were reviewed on 10/12/11. On 8/3/11, there was no documentation to indicate the results of the one hour reading for either sterilizer #3 or #7 and no documentation to indicate the results of the control test. On 9/23/11, there was no documentation to indicate the results of the control test.

3. During a staff interview, conducted with the Director of Perioperative Services on 10/12/11 at 3:00 PM, the above findings were confirmed.