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A. Based on Hospital policy, review of clinical records and staff interview, it has been determined in 2(Pt. #3 #13) of 6 clinical records reviewed with blood administration that the Facility failed to ensure policies were always followed.

Findings include:

1. The Hospital policy titled, "BLOOD TRANSFUSION" under "POLICY: 5. The cross-match sheet...must be completed and/or signed." "Nursing will complete:" under bullet point 4, "Document: VS: Baseline: post transfusion" was reviewed on 11/9/10.

2. The medical record of Pt. #3 was reviewed on 11/8/10. Pt. #3 was admitted on 10/22/10 with the diagnosis of Left Hip Fracture. Documentation indicated that Pt. #3 received a blood transfusion on 10/22/10. The completion time of transfusion was documented with no vital signs completed.

3. The medical record of Pt. #13 was reviewed on 11/9/10. Pt. #13 was admitted on 10/18/10 with the diagnosis of Gastrointestinal (GI)I Bleed. Documentation indicated that Pt. #13 received a blood transfusion on 10/18/10. The completion time of transfusion was documented with no vital signs completed.

4. During an interview with the Chief Nursing Officer (CNO) on 11/9/10 at 3:00 PM, the above findings were confirmed.

A. Based on Hospital policy, record review and staff interview, it was determined that in 9 of 30 records reviewed (#8, #9, #13, #16, #17, #18, #19, #20, #21), the Hospital failed to ensure that telephone and verbal orders included the time in the authentication of orders.

Findings include:

1. A review of the Hospital policies and procedures was completed on 11/08/10. The Hospital policy titled "Telephone and Verbal Orders," under "Procedure, #3. The order will be signed as a verbal or telephone order and... The order must also have a date and time."

2. The medical record of Pt #8 was reviewed on 11/08/10. Pt #8 was admitted to the Hospital on 08/07/10 with a diagnosis of Pneumonia. Physician's telephone orders, dated 08/08/10 x 4 and 08/09/10 x 3, were not timed by the physician.

3. The medical record of Pt #9 was reviewed on 11/8/10. It indicated that Pt #9 was admitted on 11/5/10 with a diagnosis of Cardiomyopathy with Decompensation. In the physician orders section of the chart, 9 of 10 physician signatures did not have the time recorded that the physician signed the orders.

4. The medical record of Pt. #13 was reviewed on 11/9/10. Pt. #13 was admitted to the Hospital on 10/18/10 with the diagnosis of GI Bleed. Documentation indicated that 2 physician verbal orders dated 10/14/10, were not timed by the physician.

5. The medical record of Pt. #16 was completed on 11/09/10. Pt. #16 presented to the Emergency Department (ED) on 10/12/10 with diagnoses of Fall and Subdural Hematoma. Documentation indicated a physician order for CT scan was written with no time.

6. The medical record of Pt. #17 was reviewed on 11/9/10. Pt. #17 was admitted to the Hospital on 1/15/10 with the diagnosis of GI Bleed. Documentation indicated that physician admission orders as well as one verbal order dated 1/15/10, were not timed by the physician.

7. The medical record of Pt. #18 was completed on 11/09/10. Pt. #18 was admitted to the Intensive Care Unit on 01/29/10 with diagnoses of Pneumonia and Respiratory Failure. Documentation indicated there were a total of 14 orders written which failed to include a time of authentication.

8. The medical record of Pt #19 was reviewed on 11/09/10. Pt #19 was admitted to the Hospital on 03/04/10 with the diagnoses of Acute Respiratory Failure and Acute Renal Failure. Multiple physician's telephone orders, date from 03/04/10 to 03/08/10, were not timed by the physician.

9. The medical record of Pt. #20 was reviewed on 11/9/10. Pt. #20 was admitted to the Hospital on 7/21/10 with the diagnoses of Sepsis and Left Heel Decubitus. Documentation indicated that 2 physician telephone orders written on 7/22/10, were not timed by the physician.

10. The medical record of Pt. #21 was reviewed on 11/9/10. Pt. #21 was admitted to the Hospital on 10/26/10 with the diagnoses of Anemia and Cellulitis. Documentation indicated that a physician telephone order written 10/26/10, were not timed by the physician.

11. During an interview conducted on 11/10/10 at 11:30 AM with the CNO, the above findings were confirmed.

A. Based on Hospital Bylaws Rules and Regulations, a review of the medical records delinquency report and staff interview, it was determined that the Facility failed to ensure all medical records were completed within 30 days following discharge.

Findings include:

1. The Hospital Bylaws, Rules and Regulations were reviewed on 11/10/10. It indicated that discharge records shall be completed within 30 days of patient discharge.

2. As of 11/10/10, a written delinquency record rate was recorded at 34 delinquent records. All records were 30 days past due.

3. During an interview conducted on 11/10/09 at 11:00 AM with the CNO, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, controlled medication records, and staff interview, it was determined that the Hospital failed to ensure all controlled medication records were completed.

Findings include:

1. The Hospital policy and procedure titled, "Controlled Substances" was reviewed. It indicated under "Procedure: 11. Controlled Substance Record-Keeping b. A Drug Administration Record (Appendix E) must be maintained for all Scheduled II controlled substances floor stock in patient care areas....All requested information must be present on the form." The policy and procedure titled, "Pharmaceutical Services - Scheduled Drugs" was also reviewed. It indicated under, "Procedure: 3. Controlled daily sheets shall be audited the next available day. If discrepancies exist, a copy shall be made and kept in pharmacy till corrections to the original are made."

2. The "Daily Controlled Medication Sheet Unit - Anesthesia" were reviewed for the months of Sept, Oct, and Nov 2010. Of the 51 Sheets reviewed, 46 had only 1 signature for the "On" and "Off" signatures and 2 had neither of the required signatures.

3. The Sheet for 9/13/10 indicated that there was 1 Fentanyl injectable 100mcg/2ml. Documentation indicated that on 9/14 the 1 Fentanyl was used which would have left a count of 0. However the count is documented as 1. Then 20 Fentanyl 100mcg were added to the count and the count was recorded as 21 rather than 20.

4. The Sheets for 9/1, 9/10, 9/13, and 10/25/10 have a total of 5 controlled medications administered without the signature of the individual that administered the medication.

5. The Sheets for 10/4 and 10/5/10 were reviewed. The ending count on 10/4 for Fentanyl 100 mcg/2ml indicated that there were 11 on hand. There was no count brought forward on the 10/5 sheet. Then documentation indicated 1 Fentanyl was used and the count was documented as 11, rather than 10, which would have been the correct count.

6.. During an interview with the Chief Nursing Officer, conducted on 10/8/10 at 2:45 PM, the above findings were confirmed..

A. Based on observation and staff interview, it was determined that the Hospital failed to ensure all outdated biologicals were removed from patient use areas.

Findings include:

1. During a tour of the anesthesia department, conducted on 11/9/10 at 9:25 AM, it was observed in the Epidural Start Cart that there were 4 bags, 100ml of 0.9% NaCl all expired 9/10.

2. During an interview with the Lead Anesthetist, conducted on 11/9/10 at 9:30 AM, the above findings were confirmed.

A. Based on Hospital policy, observation and staff interview, it was determined that Dietary Supervisor failed to ensure that dietary staff followed the established food storage policy.

Findings include:

1. The Hospital dietary policies were reviewed on survey date 11/08/10. The Hospital policy titled "Food Storage", under "General Storage Policies, #4. Cover, label and date all food storage items..."

2. During a tour of the dietary department on 11/08/10, it was observed that the following items had been opened and available for use with no labeling of date opened or use by date:

1 bag each of these vegetables: carrots, cauliflower, spinach, mixed lettuce and 1 plastic container of Picante sauce, located in #1 refrigeration area

4 bags of various shredded cheeses, 1 bag of pasta, 1 bag of shrimp and 2 gallons of milk located in the dairy freezer

2 trays of frozen muffin batter located in the large freezer

2 packages of jello located on the shelf in the dry storage room.

3. During an interview with the Dietary Supervisor on 11/08/10 at 3:00 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 Sample Validation Survey conducted on November 8 - 9, 2010, the surveyor finds 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 Sample Validation Survey conducted on November 8 - 9, 2010, the surveyor finds 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 November 9, 2010.

A. Based on policy and procedure review and staff interview, it was determined that the Hospital failed to ensure the infection control program monitored the disinfection of Hospital laundry.

Findings include:

1. The Hospital policy and procedure titled "Infection Control Subject: Linen Processing/Distribution" was reviewed. It indicated under "3. Washing - ...Appropriate temperature is maintained....."

2. During in interview with the Laundry Manager, conducted on 11/8/10 at 2:45 PM, it was verbalized that the facility utilizes both chemical and temperature to disinfect the laundry. When asked for documentation that the temperatures of the washing machines were checked and the proper temperatures attained, it was verbalized that no documentation was recorded that indicated the machines were checked for temperature or that the proper temperature was achieved.