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A. Based on document review and interview, it was determined, for 2 of 2 clinical records reviewed (Pts. #1 & #2) for patients receiving psychotropic medications, the Facility failed to ensure psychotropic medication consent forms were completed in accordance with policy.

Findings include:

1. On 3/3/14 at 12:00 PM, hospital policy titled: "Informed Consent for Psychotropic Medication" revised 2/2012, was reviewed. The policy required, "Psychotropic medications means medication who use for antipsychotic, antidepressant, antimanic, antianxiety, behavior modification or behavioral management purposes... Psychotropic medication may be administered with the written informed consent by the adult patient..."

2. On 3/3/14 at 10:20 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 61 year old male, admitted on 2/13/14, with a diagnosis of chronic schizophrenia. Pt. #1's discharge instructions dated 3/3/14, included the psychotropic medications Pt. #1 was receiving - Abilify (antidepressant), Klonopin (sedative), and Zoloft(antidepressant). Pt. #1 had a "Consent to Medication" form which lacked the names of the psychotropic medications, date and time of the consent, and was not checked for "I agree to take the medications listed above."

3. On 3/3/14 at 10:40 AM, Pt. #2's clinical record was reviewed. Pt. #2 was a 20 year old male, admitted on 2/28/14, with a diagnosis of bipolar disorder. Pt. #2 had a "Consent to Medication" form which lacked the date and time of the consent. A box was checked, "I agree to take the medications listed above." But no psychotropic medication was included on the consent form.

4. On 3/3/14 at 10:50 AM, an interview was conducted with the behavioral health unit manager. The manager stated both psychcotropic medication forms were missing the name of the medications, date, and time. The manager stated Pt. #2 was taking Zypreza (antipsychotic).

Based on document review and staff interview, it was determined for 1 of 2 (Pt #28) clinical records reviewed for restraint usage, the hospital failed to obtain restraint renewal orders in accordance with hospital policy.

Findings include:

1. The hospital's policy entitled "Restraint Utilization" (revised 12/30/09) was reviewed on 3/5/14 and required, "Under no circumstances are PRN or standing orders utilized for application of restraints...For non-violent or non-self-destructive behavior order renewed each calendar day..."

2. The clinical record for Pt # 28 was reviewed and included Pt #28 was a 76 year old male admitted to the hospital's ICU on 11/14/13 with a diagnosis of cardiac arrest. Pt #28's clinical record included that Pt #28 was intubated and placed on a ventilator 11/14/14. The physician's order dated 11/14/13 included the invasive device protocol which included the use of restraints for prevention of tube dislodgement. The nursing notes documented soft wrist restraints in use for Pt #28 from 11/14/13 at 11:59 pm through 11/17/13 at 9:00 am, when the nurse's note indicated Pt #28 was no longer pulling at tubes. The clinical record lacked renewal of the restraint order each calendar day per policy.

3. An interview was conducted with the ICU manager (E #9) on 3/6/14 at approximately 10:00 am. E #9 stated Pt #28's clinical record lacked a restraint renewal each calendar day per the "Restraint Utilization" policy.

A. Based on document review, observation, and interview, it was determined, for 2 of 2 hemodialysis patients (Pts. #7 & #8), the hospital failed to ensure dialysate pH was tested prior to initiating dialysis treatment.

Findings include:

1. On 3/4/14 at 12:30 PM, the Braun hemodialysis machine manufacturer's instructions were reviewed, dated April 2005. The instructions required, "4.7.2 Monitoring the dialysate... To verify conductivity, pH and temperature with handheld instrument, draw sample from sample port on blue dialysate line, according to instrument manufacturer instructions, during rinsing with UFP. Recommended therapeutic ranges - pH 7.2 to 7.5..."

2. On 3/3/14 from 1:05 PM to 1:55 PM, an observational tour was conducted in in-patient dialysis unit. Five patients were receiving hemodialysis, including Pts. #7 & #8.

3. On 3/3/14 at 1:25 PM, Pt. #7's clinical record was reviewed. Pt. #7 was a 78 year old male, admitted on 2/22/14, with diagnoses of altered mental status and pneumonia. Pt. #7's physician order dated 3/2/14 at 2:12 PM, required 3.5 hours of hemodialysis treatment on 3/3/14. Neither Pt. #7's treatment sheet, dated 3/3/14, nor any part of the clinical record indicated the dialysate pH had been checked prior to Pt. #7's treatment initiation.

4. On 3/3/14 at 1:35 PM, Pt. #8's clinical record was reviewed. Pt. #8 was a 53 year old male, admitted on 3/2/14, with diagnoses of end stage renal disease and chronic heart failure. Pt. #8's physician order dated 3/3/14 at 9:00 AM, required 3 hours of hemodialysis treatment. Neither Pt. #8's treatment sheet, dated 3/3/14, nor any part of Pt. #8's clinical record indicated the dialysate pH had been checked prior to Pt. #8's treatment initiation.

5. On 3/3/14 at 1:05 PM, an interview was conducted with a dialysis nurse (E #7). E #7 stated the pH of dialysate is tested if the conductivity test is outside of the normal range, not before each patient treatment. E #7 stated she did not remember when the conductivity test was outside the normal range and the pH was last checked.

Based on document review and interview, it was determined for 1 of 2 ( Pt. #4) patient's medical records reviewed on the (4-3) medical surgical unit, the hospital failed to ensure that a plan of care was implemented in a timely manner.

Findings include:

1. On 3/3/14 the hospital's procedure entitled, "nursing documentation system" (revised 11/17/13) required, "registered nurse:"...1. conduct an admission assessment at time of patient's admission...3. select appropriate interdisciplinary plans of care (POC)...based on data..."

2. On 3/3/14 the hospital's policy titled "assessment and reassessment of patients" (revised 11/13) was reviewed and required, "...admission assessment: 1. the nursing assessment will be completed by the RN (registered nurse) as soon as possible upon arrival to the nursing unit, not to exceed four (4) hours..."

3. On 3/3/14 at approximately 10:30 am the medical record of Pt. # 4 was reviewed. Pt. #4 was an 85 year old female admitted on 3/2/14 with a diagnosis of altered mental status. Pt. #4's medical record lacked a nursing plan of care.

4. During an interview on 3/4/14 at approximately 3:00 pm, the chief nursing officer stated, "the stated practice is the nursing care plan should be initiated at the time of admission assessment."

Based on document review, observation, and interview, it was determined, for 1 of 3 anesthesia staff in the Operating Room (OR) suite 7 (E #3), the hospital failed to ensure syringes containing drawn-up medication were not held in a shirt pocket.

Findings include:

1. Hospital policy titled, "Medication Administration", revised 7/2010 was reviewed on 3/5/14 at 9:00 AM. The policy did not include instruction for storage and transportation of syringes containing medication.

2. On 3/4/14 from 7:20 AM to 9:10 AM, an observational tour was conducted in OR suite 7. At 8:34 AM, a certified registered nurse anesthetist student (E #3) entered OR suite 7 with two filled syringes in his scrub shirt pocket. E #3 administered the contents of 2 syringes to Pt. #11 at approximately 8:38 AM and 8:43 AM.

3. On 3/4/14 at 9:07 AM, an interview was conducted with E #3. E #3 stated that the medication in the syringes held in his shirt pocket were Fentanyl and Versed.

4. On 3/4/14 at 9:10 AM, an interview was conducted with the OR director. The director was informed of E #3's syringes in the pocket, but had no comment.

5. On 3/5/14 at 1:05 PM, an interview was conducted with the manager of clinical excellence. The manager stated it is not the hospital practice to carry medication filled syringes in the pocket.

Based on document review and interview, it was determined for one of one medical records department, the hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. Hospital "Medical Staff Rules and Regulations" (amended 8/2/13) required, "L. The records of the discharged patient shall be completed within a period of time that will in no event, exceed thirty (30) days from discharge. Medical records which remain incomplete for thirty days after reaching the physician file will be deemed delinquent."

2. On 3/5/14 at approximately 2:45 PM the manager of clinical effectiveness presented an attestation letter dated 3/5/14 that included, "As of this date the number of delinquent charts is 1957."

3. During an interview on 3/5/14 at approximately 1:45 PM, the Director of Medical Records stated, "A record is considered delinquent if not completed within 30 days. We went up on Cerner (new computer system) in June '13 and have had a difficult time getting records complete, but have improved."

Based on document review, observation, and interview, it was determined, for 3 of 4 Emergency Department (ED) bed mattresses, the Hospital failed to ensure mattresses were free of tears, tape, and tape residue, to enable thorough bed mattress disinfection, potentially affecting 12 patients in the ED on 3/5/14 at 10:00 AM.

Findings include:

1. Hospital policy entitled "Emergency Room Cleaning", issued on 10/1/10, was reviewed on 4/6/14 at 8:35 AM and required, "4. Using germicidal cleaner and a clean cloth, sanitize all patient contact surfaces, starting with the bed. Wipe the top and sides of the mattress..."

2. During an observational tour of the ED on 3/5/14 between 9:35 AM and 10:45 AM, the following was observed:
- room 6 - mattress torn
- room 32 - mattress with tape residue
- room 37 - mattress with tape

3. An interview was conducted with the ED director on 3/5/14 at 10:40 AM. The ED director observed and confirmed the mattresses' tear, tape, and tape residue with the surveyor, but had no comment.

The surveyors find that STANDARD, A 710, Life Safety from Fire, was NOT MET.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of Sample Validation conducted on 03/05/14, the surveyors find that the facility does not comply with NFPA 101 - 2000, the Life Safety Cod

This is evidenced by the Life Safety Code deficiencies cited under K-tags on CMS Forms 2567 for the above survey, dated 3/5/14.

A. Based on document review, observation, and interview, it was determined, for 1 of 7 operating room (OR) staff in OR suite 7 (E #2) and 1 of 6 OR staff in OR suite 6 (E #4), the hospital failed to ensure staff adherence to surgical attire in accordance with policy.

Findings include:

1. On 3/4/14 at 10:30 AM, hospital policy titled "Surgical Attire", revised 3/29/12, was reviewed. The policy required, "The [OR] procedural care unit is divided into four designated areas: unrestricted, semi-restricted, restricted, and monitored restricted... 10... Mask should not be worn hanging down from the neck... 13. All personnel should cover head and facial hair when in the semi-restricted and restricted areas..."

2. On 3/4/14 from 7:20 AM to 9:10 AM, an observational tour was conducted in OR suite 7. A certified registered nurse anesthetist (E #2) wore a dangling mask from the neck from 7:20 AM until 7:29 AM, when E #2 left OR suite 7.
3. E #2 returned and reentered OR suite 7 at 8:02 AM and tied on the mask after entering suite 7.
4. On 3/4/14 from 8:15 am - 9:30 am, an observational tour was conducted in OR suite 6. At approximately 9:00 am, E #4 (a first assist student) entered OR #6 with approximately 1-2 inches of hair exposed on both sides and the rear of the hair cover.
Surveyor: 30196

5. On 3/4/14 at 9:10 AM, an interview was conducted with the OR director. The director was informed of E #2's dangling and untied mask and stated E #2's name, but had no other comment.

B. Based on document review, observation, and interview, it was determined, for 2 of 3 operating room (OR) nurses in OR suite 7 (E #5 & #6), the hospital failed to ensure staff adherence to Association of Perioperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices as practiced by the OR.

Findings include:

1. On 3/6/14 at 8:30 AM, the AORN Perioperative Standards and Recommended Practices were reviewed. The standards required, "Recommended Practices for Sterile Technique... Recommendation VI... VI.b. Items should be delivered to the sterile field in a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field..."

2. On 3/4/14 from 7:20 AM to 9:10 AM, an observational tour was conducted in OR suite 7. Two registered nurses (E #5 & 6) opened and draped the back table with a sterile cover at 7:30 AM. Between 7:31 AM and 7:34 AM, E #5 & #6 placed sterile instruments and supplies on the sterile back table, including trocars, cords, tubing, gloves, and other supplies, approximately 20 sterile items in total. However, while placing those sterile items on the sterile field, E # 5 & #6 placed their uncovered hands and arms over the sterile field, potentially contaminating the sterile field with skin cells, hair, and other falling contaminants.

3. On 3/4/14 at 9:10 AM, an interview was conducted with the OR director. The director was informed of E #5 & 6 bare hands and arms over the sterile field, but had no comment.

Based on document review and interview, it was determined for 1 of 4 (Pt. #6) clinical records reviewed of surgical patients, the hospital failed to ensure operative reports were completed after surgery.

Findings include:

1. The hospital "Medical Staff Rules and Regulations" (amended 8/2/13) required, "Operative reports shall be dictated in the medical record within twenty-four (24) hours after surgery..."

2. The clinical record of Pt. #6 was reviewed on 3/3/14. Pt. #6 was a 79 year old female admitted on 2/26/14 with the diagnosis of fractured right humeral head. Pt. #6 had a right hemiprosthesis (surgical procedure) on 3/1/14 at 3:00 PM. The clinical record lacked an operative report as of 3/3/14 at 11:00 AM.

3. During an interview on 3/3/14 at 2:40 PM, the clinical effectiveness manager stated, "I am unable to find an operative report in the computer for this patient."

Based on document review and interview, it was determined for 1 of 4 (Pt. #10) clinical records reviewed of surgical patients, the hospital failed to ensure a post anesthesia evaluation was completed per policy.

Findings include:

1. Hospital policy entitled "Postoperative Anesthesia Care (revised 10/23/10)" required, "A post-anesthesia evaluation must be completed and documented. ... Evaluation must be completed no later than 48 hours after surgery..."

2. The clinical record of Pt. #10 was reviewed on 3/3/14. Pt. #10 was a 70 year old female admitted on 2/28/14 for a scheduled laminectomy (back surgery) which was performed that day (2/28/14). The anesthesia post evaluation was completed on 3/3/14 at 1:23 PM (72 hours).

3. During an interview on 3/3/14 at approximately 2:15 PM, the manager of nursing unit 5-2 stated, "That is the only post anesthesia note in this record (note from 3/3/14)."