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Based on review of documents and interview, it was determined for 1 of 2 (Pt. #15) clinical records reviewed in the new life center, the Hospital failed to ensure the patient had a history and physical performed.

Findings include:

1. On 12/9/13 at approximately 10:00 AM the clinical record of Pt. #15 was reviewed. Pt. #15 was a 23 year old female admitted on 12/7/13 to the labor and delivery unit with a diagnosis of abdominal pain. Pt. #15 had a delivery by cesarean section performed on 12/7/13. Pt. #15's clinical record lacked a completed history and physical.

2. On 12/9/13 the hospital's "bylaws, rules, and regulations for the medical staff" (approved 7/16/13) was reviewed and required, "8. A...The history and physical examination (H&P) for each patient shall be done no more than 30 days before or twenty-four (24) hours after an admission or registration, but prior to surgery...or other high risk procedure, and placed on the medical record...prior to any of the above procedures..."

3. On 12/9/13 during record review with the nurse manager of the new life center, the nurse manager could not locate an H&P within the record and confirmed the clinical record lacked a completed history and physical for Pt. #15.

Based on document review and interview it was determined in 1 of 1 (Pt #25) patient with a nasogastric feeding, the Hospital failed to ensure the patient's gastric residual was assessed as required.

Findings include:

1. Hospital policy entitled, "Tube Feeding," (effective date 1/30/13) required, "Procedure: Refer to Lippincott for Nursing Procedures."

2. Lippincott 2013, required, "Implementation: If you're administering a continuous feeding, ...Measure the GRV (gastric residual volume) every 4 hours for the first 48 hours."

3. The clinical record of Pt #25 was reviewed on 12/12/13. Pt #25 was a 70 year old female admitted on 5/8/13 with a diagnosis of thalamic hemorrhage. The clinical record of Pt #25 contained a physician's order dated 5/10/13 for continuous feeding via nasogastric tube at 20 milliliter (ml) hour and increase 20 ml every four as tolerated until goal of 55 ml was met. Pt #25's tube feeding was initiated on 5/10/13 at 8:30 PM at 20 ml an hour. Nursing documentation indicated that Pt #25's gastric residual was not checked until 5/12/13 at 2:00 PM (17.5 hours).

4. On 12/12/13 at approximately 9:45 AM the Director of Regulatory Compliance, stated during an interview that Pt #25's gastric residual was not checked every 4 hours and should have been.

Based on document review and interview, it was determined in 8 of 25 (Pt #1, 12, 13, 14, 15, 21, 22, and 23) clinical records reviewed, the Hospital failed to ensure the patient's care plan was completed, current and updated.

Findings include:

1. Hospital policy entitled, "Interdisciplinary Plan of Care," (effective 1/3/11) required, "Policy statement: All disciplines involved in the care of a patient,...provide collaborative input into the development, implementation, modification and maintenance of the patient's plan of care...D. Interdisciplinary Plan of Care...1. It is the responsibility of the admitting nurse to initiate the Plan of Care once the admission assessment is completed. c. Patient Problem List: 4). It is the responsibility of all associates utilizing the plan of care to keep the problem list up to date."

2. The clinical record of Pt #1 was reviewed on 12/9/13. Pt #1 was a 98 year old female admitted on 12/4/13 with a diagnosis of fracture left hip. The clinical record of Pt #1 contained documentation that Pt #1 underwent a left hip pinning procedure on 12/4/13, was placed into contact precautions for ESBL (Extended spectrum beta-lactamase) on 12/5/13 and received a blood transfusion on 12/7/13. The clinical record of Pt #1 contained a Multidisciplinary Plan of Care dated 12/3/13 that lacked the patient's surgery, contact precautions, and/or blood transfusion.

3. The Unit Manager (E #1) of 4 west stated, during an interview on 12/9/13 at approximately 11:00 AM, that the patient's care plan should have included that the patient was on isolation, had received blood, and had surgery.


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4. On 12/9/13 at approximately 10:00 AM the clinical record of Pt. #14 was reviewed. Pt. #14 was a 27 year old female admitted on 12/8/13 with a diagnosis of [placental] membrane rupture. Pt. #14's clinical record lacked a POC initiated on admission.

5. On 12/9/13 at approximately 10:15 AM the clinical record of Pt. #15 was reviewed. Pt. #15 was a 23 year old female admitted on 12/7/13 with a diagnosis of abdominal pain. Pt. #15 had a delivery by cesarean section on 12/7/13. Pt. #15's POC was not initiated on admission and was not individualized to include the cesarean section delivery (surgical incision).

6. The nurse manager stated the nursing care plan is not initiated until the delivery of the baby and they (the staff) have 24 hours to complete the POC.

7. On 12/9/13 at approximately 1:00 PM the clinical record of Pt. #12 was reviewed. Pt. #12 was a 91 year old female admitted to the intensive care unit (ICU) on 11/27/13 with a diagnosis of weakness, fatigue, altered mental status, acute renal failure, and hypothermia. Pt. #12 was transferred to the medical/renal unit on 12/1/13. Pt. #12's plan of care (POC) lacked update upon transfer to include the change in mental status, and wound intervention that were initiated in the ICU. The POC also lacked care goals for Pt. #12's renal failure.

8. On 12/9/13 at approximately 1:30 PM the clinical record of Pt. #13 was reviewed. Pt. #13 was a 48 year old male admitted on 12/8/13 with a diagnosis of tracheo-bronchitis. Pt. #13's clinical record lacked a POC initiated on admission.

9. The above deficient practices were verified by the nurse manager of the oncology/renal units (2A/2B).


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10. The clinical record of Pt #21 was reviewed on 12/12/13. Pt #21 was a 40 year old male admitted on 10/17/13 with diagnoses of renal insufficiency and hyperglycemia. Pt #21's clinical record contained a physician's order dated 10/17/13 for a Diabetic 1800 calorie diet. Pt #21's patient care plan dated 10/17/13 failed to include Pt #21's therapeutic diet order.

11. The clinical record of Pt #22 was reviewed on 12/12/13. Pt #22 was a 53 year old female admitted on 9/21/13 with diagnoses of small bowel obstruction and abdominal pain. Pt #22's clinical record contained documentation of a physician's order dated 9/23/13 that required Pt #1 receive, "Adult Parental Nutrition". Pt #22's care plan failed to include an update to include the parenteral nutrition.

12. The clinical record of Pt #23 was reviewed on 12/12/13. Pt #23 was a 53 year male admitted on 10/23/13 with diagnoses of alcohol withdrawal and anemia. Pt #23's care plan dated 10/23/13 failed to include a care plan for alcohol dependence.

14. On 12/12/13 approximately 9:45 AM the Director of Regulatory Compliance, stated during an interview the care plans were not updated to reflect individualize patient care.

Based on document review and interview, it was determined in 1 of 1 Medical Record Departments, the Hospital failed to ensure all clinical records were completed within 30 days of discharge.

Findings include:

1. The Hospital's Bylaws, Rules and Regulations For the Medical Staff dated September 24, 2013 required, "page 47: E. Failure to Complete Medical Records: 1. An automatic suspension of a Member's privileges to admit, consult and schedule surgical and other invasive procedures shall be imposed for failure to complete medical records within the time period set forth in the current policy and procedure manual of the Medical Record unit."

2. Hospital policy entitled "Physician Suspension," (created 5/6/13) required, A. General Requirements: 2. An automatic suspension of a Member's privileges to admit, consult and schedule any procedures shall be imposed for failure to complete medical records requirements twenty-two (22) days post-discharge."

3. On 12/10/13 at approximately 12:00 PM the Director of Health Information Maintenance (HIM) presented an attestation letter indicating that as of 12/10/13 that Hospital had 4 delinquent medical records.

4. The Director stated during an interview on 12/10/13 at approximately 10:30 AM that the records should have all been signed by the physician.

Based on document review, observation and interview, it was determined for 2 of 2 (E #7 and #8) outpatient x-ray technologist, the Hospital failed to ensure staff wore an exposure meter badge.

Findings include:

1. The Hospital policy titled "Radiation Safety", (effective 2/19/13), was reviewed on 12/12/13, required, " All persons who could be exposed to more than 10% of the allowed whole body exposure dose (500 mrems per year) will be issued a radiation monitoring badge."

2. During an observational tour of the outpatient imaging department, on 12/11/13 between 9:55 AM and 10:20 AM. The lead x-ray technologist and an x-ray technician were observed not wearing a radiation exposure badge.

3. The Lead X-ray Technologist, interviewed during the observational tour, stated that the staff in the outpatient radiology do not wear exposure badges, and were told it was not necessary since the outpatient services did not include fluoroscopy.

Based on document review, observation and interview, it was determined the Facility failed to ensure all food was stored appropriately as required by Hospital. This potentially affected all 236 patients on census.

Findings include:

1. The Facility policy titled, "Receiving and Storage" (revised 4/13), reviewed on 12/10/13, required, "Storage Standards: ...Store all food products... at least 6 inches above the floor. Inspect packaging to make sure it is intact(since being placed into storage) and free of bulges, ...rips, cracks, holes or evidence of tampering.... After opening, store all "in-use" foods or products in the original packaging when possible and in a manner that protects the product from outside contamination, (for example: a bag of opened brown sugar wrapped with plastic wrap and properly labeled, or in a clean and sanitized storage container...."

2. During an observational tour of the Food and Nutrition Services on 12/10/13 at approximately 11:00 AM the following was observed:
* 7 trays of bread and buns were stored on the floor.
* 1, approximately 25 lb, box sugar, open and unlabeled.

3. The Food Service Manager and the Store Room Clerk were present during the observational tour on 12/10/13 at approximately 11:10 AM. The Manager stated the clerk was in the process of moving the bread and should not be stored on the floor, and the Clerk stated the box of sugar should not be open or unlabeled.

Based on observation, document review, and interview it was determined for 1 of 1 pediatric crash cart in the pediatric emergency department, the Hospital failed to ensure the crash cart was checked daily as required. This potentially could have affected the 38 pediatric patients treated on 12/11/13.

Findings include.

1. On 12/11/13 at approximately 9:45 AM the pediatric emergency department was toured. During the tour the pediatric crash cart (braslow cart) checklist log was reviewed. The log required daily checks; however, the log lacked documentation that the cart was checked on 12/10/13.

2. Hospital policy entitled, "Crash Cart Policy," (effective 1/6/13) required, "Procedures: 1. External Integrity - when your department is operational, general maintenance of the crash cart includes: a. Daily verification of a successful defibrillator self test as indicated by checking the appropriate box on the crash cart checklist...b. Completion of the crash cart checklist...d. Upon completion of this procedure, the hospital personnel will sign/date the checklist and document the control number on the red tag."

3. During an interview on 12/11/13 at 10:00 AM the Director of Emergency/EMS/Trauma Center was interviewed. The Director stated that the crash cart may have been checked on 12/10/13, but the signature is lacking so checking could not be verified.

Based on observation and interview, it was determined for 1 of 1 (E#6) staff in the Food and Nutrition Services, the facility failed to ensure supplies were handled appropriately to prevent cross contamination.

Findings include:

1. During an observational tour of Food and Nutrition Services on 12/10/13 between 11:00 AM and 12:00 PM, E #6 was observed removing patient hot food orders tickets coming out of the ticket machine. Approximately 10 of the 21 tickets (each measuring approximately 2 1/2 x 5 inches) touched the floor while E #6 was separating the tickets, and then hung the tickets on a ticket holder directly above open hot food trays. Each ticket was then placed on the patient food trays. This potentially cross contaminated 21 food trays being prepared during the observation.

2. During the observational tour the Production Retail Manager was asked if the tickets falling to the floor and then using it on the patient food tray was acceptable, the Manager stated no. The above finding was discussed with the Manager on 11/10/13 at approximately 11:45 AM.

A. Based on document review, observation and interview, it was determined for 1 of 3 operating rooms (OR #3), the Facility failed to ensure staff adherence to surgical attire in accordance with policy.

Findings include:

1. On 12/10/13 at approximately 9:00 AM, Facility policy titled,"Attire in the Surgical Suite" was reviewed. The policy effective 07/13/13 required,"Hair of personnel is to be covered at all times...a mask should be worn securely enough to prevent exhaled air around the edges...all personnel entering the restricted areas of the surgical suite should have all jewelry removed."

2. On 12/10/13 at approximately 7:32 AM, Physician Assistant (E# 2) entered OR #3 while holding a surgical mask to her face. The strings of surgical mask were untied.

3. On 12/10/13 at approximately 7:45 AM, a Neurotransmitter technician (E#3) entered OR #3 with hair exposed beneath the surgical cap and while wearing ear rings.

4. On 12/10/13 at approximately 9:00 AM, the Manager of Surgery (E#4) was interviewed. E#4 stated AORN (Association for periOperative Registered Nurses) standards and hospital policy require staff to wear surgical masks, confine hair within a surgical cap and confine jewelry.

B. Based on observation and staff interview, it was determined for 1 of 6 staff (E#2) observed in OR #3, the facility failed to ensure patient supplies were not potentially contaminated. This failed practice placed 3 patients on the schedule for room #3 at risk for potential infection.

Findings include:

1. On 12/11/13 at approximately 10:45 AM, Facility policy (effective 02/14/2011) titled, "Scope of Care OR Service" was reviewed. The policy required,"The operating room staff provides perioperative care following established hospital policies and procedures developed to meet AORN...standards."

2. On 12/11/13 at approximately 11:00 AM, page 91 of 2012 AORN (Association of periOperative Registered Nurses) standards were reviewed. The standards required, "Perioperative members should understand the professional responsibility to ensure that contamination of the sterile field is remedied immediately and to make certain that any item for which sterility is in question is not used."

3. On 12/10/13 at approximately 7:40 AM, E#2 retrieved a package of 3M steri drape (an adhesive, fluid-resistant plastic drape) from a clean supply cabinet in OR #3. E#2 accidentally dropped the package on the floor, and failed to dispose of the contaminated item. The item was instead placed on a computer board.

4. On 12/11/13 at approximately 10:00 AM, the Director of Surgery (E#5) was interviewed. E#5 stated the item should have been thrown away after being dropped on the floor.