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Based on a review of laboratory records and interview with the laboratory manager (employee #2) on September 27, 2011, the facility did not ensure that the blood supply was appropriately stored to prevent deterioration, including documenting refrigerator temperatures. The facility also did not ensure that the reagents used to perform type and compatibility testing were within their expiration dates.

Findings include:

1. The thermograph chart and written records did not match. A review of July 2011 Blood Bank Inventory and Temperature Maintenance Log showed the refrigerator chart temperatures recorded for July 1 to 13 and 15 to 28 were at 3 degrees C (centigrade) and July 14 and 29 to 31 were at 2 degrees C while the thermograph chart recorded between 0 and 1 degree C. The printed range on the log sheet for the refrigerator was 2 to 6 degrees C. There were no corrective actions noted for the out-of-range records.

2. A review of August and September 2011 Blood Bank Inventory and Temperature Maintenance Logs showed the refrigerator chart temperatures recorded for August 2 to 31 and September 1 to 28 were at 1 degree C. The printed range on the log sheet for the refrigerator was 2 to 6 degrees C. There were no corrective actions noted for the out-of-range records.

3. Vials of expired typing reagents were found when the Blood Bank refrigerator was checked. BioClone anti-A reagent, lot #BAA581A, expired on 7/16/11 and anti-B reagent, lot #BBB773A, expired on 7/23/11.

Based on observation and interview the facility failed to ensure trash from isolation rooms was disposed of properly.

Findings include:

On 9/26/2011 during the initial tour, at approximately 11:00 AM, a black trash bag was observed to be taped to the handrail outside of room 53. The patient in room 53 was on isolation. The trash bag was observed to be hanging open from the handrail.

Outside of room 57, a large trash barrel on wheels was observed at the end of the hall. The patient in room 57 was also on isolation.

On 9/26/11 at 11:10 AM, the infection control coordinator (Employee #10) was interviewed and reported the trash was supposed to be inside of the isolation room.

On 9/27/11 at 8:30 AM, a black trash bag was observed to be taped onto the handrail outside of room 59. The patient in room 59 was on isolation.

Based on observation, policy review, and staff interviews, the facility failed to ensure drugs and biologicals were properly secured (locked) in the acute care nursing unit.

Findings include:

On the initial tour of the facility on 9/26/11 at approximately 10:45 AM, as well as throughout the survey ending before noon on 9/29/11, the medication room located on the acute unit was observed propped open and accessible to those (all staff and visitors) in the vicinity. There was a sign on the door that read "Authorized Personnel Only."

The medication room was located directly to the right upon entrance to the nurses' station and was easily accessed, upon entrance to the station from the hallway.

Staff (nurses, nurse's aides, unit clerk, physician's, therapists, housekeepers, etc...) were observed going in and out of the nurses' station in the course of completing their work. On multiple observations there were either no staff at the nurse's station or staff were not in complete view of the medication room. There was no staff member observed to be continually monitoring the medication room as staff came and went.

On the morning of 9/27/11, the Physical Therapist (PT-Employee #7), was observed going into the open acute care medication room. Staff in the vicinity did not appear to notice the therapist going in and out of the room. In addition none of the staff working at the nurses' station or those in close proximity, attempted to question or stop the therapist from entering the medication room.

Inspection of the medication room, on 9/28/11, revealed the following:
1) The medication room door was propped open with two sharps containers on the floor, both containers had various items within the containers, including used needles and syringes. The lid on one of the containers was not secured, the items inside could have easily been accessed or spilled out.
2) There was a plastic container on the counter top with multiple drawers marked with patient names. The drawers contained patient medications which had been brought from home and were currently being administered to the patients on the acute care unit. The plastic container had no locking capabilities.
3) There was a clear plastic bag on the counter top with one other patient's five prescription bottles which were full of medication.
4) There was one bag of 9% Sodium Chloride on the counter top.
5) Taped on an upper cabinet door was a vial of Naloxone (Narcan) with a needle and syringe.

On the morning of 9/28/11, an interview was conducted with the Chief Nursing Officer (CNO-Employee #4). The CNO indicated the medication room on the acute care unit was warm and stuffy, and she had worked with the facility's pharmacist, who had contacted the State Board of Pharmacy for approval to leave the medication room door open. The CNO indicated with the medication room door left open, the medication room was supposed to be monitored by the unit clerk. When asked why the physical therapist would be in the medication room, the CNO indicated she thought the therapist might have some their supplies in the room.

On the morning of 9/28/11, in an interview with several pharmacy staff, the staff indicated "authorized staff" allowed in the acute care medication room was limited to the the registered nurses, licensed nurses and pharmacy staff.

On the afternoon of 9/28/11, an interview was conducted with the Pharmacy Manager (PM-Employee #5). The PM indicated there had been separate discussions with the CNO and the State Board of Pharmacy regarding leaving the acute care medication room open. The PM indicated he had been advised by the Board, if the door was to be left open it would require constant visual monitoring. The PM agreed the unit clerk was not probably the appropriate staff member to monitor the medication room and that the room was not under constant surveillance. The PM indicated he was aware of the plastic container being used for patient medications and the disposition of the container.

Neither the CNO or the PM could verify or provide evidence they had received permission from the State Board of Pharmacy to leave the acute care medication room door open.

In review of the facility's pharmacy and nursing policies, including hard copies, soft copies (maintained online) and draft policies awaiting board approval, a specific policy or policies identifying the responsible party for oversight, management of medication and biologicals, required maintenance, identification of "authorized personnel," etc..., in relation to the acute care medication room, could not be found.

On the morning of 10/4/11, an interview was conducted with the State Board of Pharmacy inspector. The inspector confirmed medication room door were to be kept closed and locked at all times, access was to be limited to authorized staff only. The inspector agreed that a physical therapist should not have been in the medication room. The inspector indicated requests such as being allowed to leave a medication room open and unlocked, would have been reviewed by either or both of the Board's General Council and Executive Secretary and would have been followed up in writing by the board. The inspector indicated he did not recall any requests of this nature from the facility.

Based on observation and staff interview, the facility failed to identify concerns and to maintain a clean, orderly and safe environment in various locations of the facility.

Findings include:

On the initial tour of the facility, the following was observed on the acute care unit:

1) A trash bag was taped to the hand rail outside an isolation room.
2) An isolation trash can was stored in the hallway outside a second isolation room.
3) A sharps container was stored on the floor of the shower room.
4) Four bottles of cleaning products were stored unsecured on top of the ledge of the shower surround. One of the bottles was not appropriately labeled as required - the word " bleach" had been hand written on the bottle with no other information, i.e. percentage, warnings, etc ... The shower room door was continually left open.
5) Two Sharps containers were on the floor holding the medication room door open.
6) Unsecured patient medications were stored on the counter top in the medication room which was continually left open and unattended.
7) Two arm chairs, a bed and a crib were stored in the hallway.
8) The door to the supply room was frequently left open with no one in attendance.

During part of the tour the surveyors were joined by the Infection Control Coordinator (Employee #10). The coordinator removed the trash bag that had been taped to the hand railing. The shower room, isolation room and supply room findings were discussed with and confirmed by the coordinator.

On the second day of the survey another trash bag was observed taped to the handrail outside a third isolation room. The observations in the shower room, equipment in the hallway, the medications and door to the medication room were unchanged.

On the morning of 9/28/11, in an interview with the Chief Nursing Officer (CNO-Employee #4), the medication room door being left open was discussed. The CNO confirmed the medication room door was left open at all times.
It was noted, the door to the supply room was frequently found left open with no one in attendance, the medications on the counter and status of the medication room door remained unchanged throughout the survey period.

On the initial tour of the facility, the following was observed in the obstetrics (OB) unit soiled utility room and testing room:

1) The following items were stored on the floor next to the hopper: seven cans of paint, a fly swatter, a vacuum, a mop, IV pole, and toilet bowl brush.
2) An open box of clean gloves was stored on the back ledge of the hopper.
3) A newborn bassinet was stored in the soiled utility room - a mop head and trash bags were stored in the bassinet.
4) A set of metal stirrups were stored above the sink.
5) Prenatal training material and equipment were stored in the soiled utility room
6) Multiple boxes of housekeeping supplies were stored in the soiled utility room.
7) A gallon bottle, with a hand written label "Formalin 10%" did not include the appropriate label requirements, i.e. precautions, etc ... The Formalin, which is a preservative of consisting of formaldehyde and methanol, was stored next to the counter along with a number of clean basins.
8) Various equipment, including a number of IV poles were stored in the testing room.

The surveyors were accompanied by the on duty OB Nurse. The nurse acknowledged the observation and findings.

The Condition of Organizational Structure is not met based on the following deficiencies:
Based on policy review and interview, the facility failed to ensure operational policies were reviewed and updated on an annual basis (C 241).

The cumulative effect of these systemic practices resulted in the failure of the facility to adequately provide necessary services for the care and safety of its patients.

Based on policy review and interview, the facility failed to update its operating policies to reflect current facility practices.

Findings include:

A review of the facility's policies revealed there was no documentation that the governing body or the medical staff had reviewed or approved any of the policies. Many of the policies had dates from 1998 to 2008 without review dates.

An interview with the quality assurance coordinator (Employee #1) revealed that the facility was in the process of updating and computerizing its policies and several departments had not completed the process.

A review of the record of Patient #14 revealed the patient did not receive nutritional counseling which could be traced to a nutritional screening policy which did not address specific diagnoses, nor did it trigger the need for nutritional counseling for a diagnosis of acute pancreatitis.

A new policy developed in June 2011 by the facility dieticians to prevent such occurrences was not in place at the time of the survey nor was it approved by the medical staff or the governing body.

This condition of participation is not met based on the following:
Based on observation, interview and policy review, the facility failed to ensure: rules for storage, handling, dispensation and administration of drugs and biologicals (C 276); a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients (C 278); nutritional needs of inpatients were met (C 279); and patient care policies were reviewed at least annually (C 280).

The cumulative effect of these systemic practices resulted in the failure of the facility to adequately provide necessary services for the care and safety of its patients.

Based on observation, policy review and staff interview the facility failed to ensure the security of drugs/medications. Additionally, the facility failed to identify and develop protocols related to the security of drugs and biologicals to ensure patient safety, to enforce current policy related to the storage of medications, and to remove expired medications.

Findings include:

During the course of the survey, patient medications were observed left out unsecured and unattended on the acute care unit medication room counter top. The door to this medication room was propped open at all times, allowing easy access to the room and its contents. Unauthorized staff were observed independently going in and out of the medication room.

In an interview conducted with the Chief Nursing Officer (CNO-Employee #4) on 9/28/11, the CNO indicated the medication room on the acute care unit had been warm and stuffy, and she had worked with the facility's pharmacist, who had contacted the State Board of Pharmacy for approval to leave the medication room door open. When asked why the physical therapist would be in the medication room, the CNO indicated she thought the therapist might have some supplies in the room.


On the afternoon of 9/28/11, an interview was conducted with the Pharmacy Manager (PM-Employee #5). The PM indicated there had been separate discussions with the CNO and the State Board of Pharmacy regarding leaving the acute care medication room open. The PM indicated he had been advised by the Board, if the door was to be left open it would require constant visual monitoring. The PM did not confirm if the Pharmacy Board had approved the medication room to be left open. The PM indicated he was aware of the patient medications being kept on the counter and the door to the medication room being left open. In discussion of the physical therapist being in the medication room, the PM shook his head in disbelief.

None of the staff interviewed recalled how long the practice of leaving the medication room door open or of keeping resident medications on the counter top had been in place. There was no indication that the maintenance department had been contacted or involved in evaluating or correcting concerns related to the air flow or temperature conditions of the room.

There was no evidence the facility had maintain a daily log of the acute care unit's medication room temperatures.

Review of the facility's policy dated 4/17/01, titled Proper Storage of Drugs, indicated it was the facility policy to ensure all drugs are stored at proper temperatures in all drug areas of the hospital including the acute care nursing unit.



23119

On 9/26/11, an observation of the emergency adult and pediatric crash carts was done in the emergency room. The following was observed:

1 bag 5% Dextrose, expiration date 9/1/2011 (Pediatric crash cart)
6 children's chewable aspirin 81 milligrams, expiration date of 8/2011 (adult crash cart)

An emergency room registered nurse, Employee #6, was interviewed and confirmed the medications should have been removed from stock.

Review of the facility policy, Crash Cart Monitoring: Contents/Operation with an effective date 12/18/2007 revealed:

"A. 3. The crash cart will be opened at least once near the end of a calendar month to remove outdates and do a complete inventory of the crash cart contents."

Based on observation, policy review and interview the facility failed to ensure: 1) infection control policies and procedures were in place; 2) staff adhered to procedures for handling of trash and linens from isolation rooms; 3) appropriate glove usage; 4) housekeeping supplies were appropriately stored; 5) housekeepers followed infection control protocols; 6) protocols were followed to minimize the spread of infection and cross contamination; and 7) barriers were used to minimize construction dust in the hallways.

Findings include:

Isolation

On 9/26/11, a trash bag was observed taped to the handrail outside of isolation room 53. On 9/27/11, a trash bag was observed taped to the handrail outside of isolation room 59. The trash bags were for discarded gowns and gloves and the bags were observed to be open and hanging from the handrail. Outside of room 57 (another patient in isolation), a large trash barrel was observed in the hall.

On 9/27/11, a used yellow disposable isolation gown was observed hanging on the open door to room 57.

On 9/27/11, a used yellow disposable isolation gown was observed laying on the unoccupied bed in room 59. The patient in room 59 was on isolation.

Review of facility policy, "Handling and disposition of infectious waste" with an effective date of 10/25/2004 revealed the policy statement, "It is the policy of (hospital name) that we handle and dispose of infectious waste in a safe and proper manner."

Under procedure was listed:

"A. Infectious waste must be placed in the proper containers, i.e., red barrels, red bags, or sharps containers."

On 9/26/11, a housekeeper (Employee #8) was interviewed and reported she used different products for cleaning the isolation rooms, but mostly used Virex 256. The housekeeper reported she did use a bleach solution at times, but was not able to explain when she would use the bleach solution. Review of the Virex 256 information revealed it was effective against many bacteria, anti-biotic resistant bacteria, viruses, fungi and yeast, and mold and mildew. The listing did not include Clostridium difficile in the list of bacteria.

On 9/27/11, the Director of Housekeeping (Employee #9) was interviewed and reported most of the cleaning of the isolation rooms was done with either Cavicide or Virex 256. Review of the Cavicide label revealed the product was effective against the vegetative form of clostridium difficile (C diff), but not effective against the spores.

On 9/26/11, the Infection Control Coordinator (Employee #10) was interviewed and reported the waste containers for the isolation rooms should be inside of the room. Employee #10 indicated she did not know what products housekeeping was using for the cleaning of the isolation rooms. Employee #10 reported there were currently no patients in the facility in isolation for C diff.

On 9/28/11, the Infection Control Coordinator (Employee #10) was interviewed regarding infection control protocols and indicated the facility followed Centers for Disease Control (CDC), Association for Professionals Infection Control (APIC), Association of Operating Room Nurses (AORN) and Occupational Safety and Hazard Administration (OSHA) standards for infection control and safety. Employee #10 indicated the facility had received recommendations regarding infection control from the state Health Division Office of Epidemiology Infection Prevention and Control team several months ago.

Employee #10 reported the new employees received infection control training in orientation. While discussing the repeated infection control violations by staff members during the week, Employee #10 indicated the facility usually did not have three patients in isolation at the same time, and she did not know why it was happening. Review of the infection control manual with Employee #10 failed to reveal specific guidelines for different types of isolation.

On 9/28/11, the Chief Nursing Officer (CNO - Employee #4 ), was interviewed and confirmed they were in the process of re-writing their infection control policies.

On 9/27/11, upon entry to the facility there was construction being done on the main public entrance corridor. The area had all ceiling tiles removed and construction workers were working in the ceiling with no provisions for fugitive dust and noise control. This main corridor led to acute patient care rooms within fifty feet of the construction area.



26252

Biohazard Sharps Containers

One sharps container was observed on the floor of the shower room and two sharps containers were on the floor of the acute care unit medication room. All of the containers had sharps materials in them. A lid on one of the sharps containers in the medication room was not completely secured to the container.

Staff Observations

On 9/26/11 at 11:15 AM, a Physical Therapist (PT-Employee #7), was observed exiting from patient room #54 wearing a pair of blue gloves. The therapist approached the nurses' station, provided some information to staff at the station, then proceeded down the hallway with the gloves on.

On the morning of 9/28/11, a Registered Nurse (RN-Employee #11), was observed preparing an insulin injection. With the needle inside the vial of insulin the nurse left the medication room at a rapid pace, and went across the hallway in to an isolation room. Shortly after going into the room, the nurse returned to the doorway, needle still in the vial, and asked another Registered Nurse (RN-Employee #12) who was in the process of gowning up prior to going into the isolation room, to check the insulin dosage. After checking the insulin dosage and continuing with the needle in the vial RN- Employee #11 went back into the medication room then proceeded down the hallway at a rapid pace into another patient room to give the insulin injection.

A short time later RN-Employee #11 was observed coming out of a patient's room down the hallway and going into the medication room with a pair of blue gloves on. This surveyor then accompanied the nurse to observe blood sugar checks. Two separate observations were made.

During the first observation the RN-Employee #11, gloved up in a pair of blue gloves, without putting a barrier down, the nurse placed the glucometer and bottle of test strips directly on the patient's bedding (draw sheet and incontinent pad). In the process of getting a test strip out, all of the test strips fell out onto the bedding. Right after reading the test results, the nurse removed a blood saturated piece of gauze from the patient's arm (from lab work having been drawn). After completing the test the nurse cleaned off the glucometer, and put the test strips back in the bottle and then put the bottle into her pocket. Before leaving the room, the nurse placed the soiled gauze and lancet in a sharps container located in the patient's room. Remaining in the same gloves, the nurse left the patient's room and returned to the nurse's station. Shortly after returning to the nurse's station and going into the medication room the nurse removed the gloves and washed her hands.

Continuing with the RN-Employee #11, the second observation was made. Upon arriving at the second patient's door, which was an isolation room, the nurse hesitated and asked this surveyor if she needed to gown up. The nurse indicated she had been told by physical therapy because the patient's area of infection (wound to lower extremity) was covered, and since she was only going in to do a simple procedure, it wasn't necessary to gown up. The nurse still hesitated, when this surveyor asked who was the authority or infection control coordinator, and suggesting checking with the coordinator, the nurse simply looked at this surveyor and proceeded to go into the room. The nurse put on a clean pair of blue gloves, then proceeded to put the glucometer and the same bottle of test strips directly on the bed next to the patient. When the nurse had completed the testing she cleaned off the glucometer and placed the bottle of test strips in her pocket. Prior to leaving the room the nurse placed the lancet in the sharps container, removed her gloves and washed her hands. The nurse returned the glucometer and bottle of test strips to the medication room.

It was noted all three isolation rooms on the acute care unit were clearly marked with the type of precaution, i.e. " Contact" and had signs clearly posted on the doors "Gown and Gloves."

Later in the afternoon, the infection control observations and findings were discussed with the RN-Employee #11. When discussing the situation of going from the medication room into an isolation room with the insulin, then down to the hallway to administer the medication the nurse did not appear to understand the potential for cross contamination or the potential safety concerns of a possible needlestick. When discussing putting equipment directly on patient's bedding, the spilled test strips and coming out of the room with gloves on after removing and handling the blood stained gauze, the nurse simply looked at this surveyor and stated "well I did wash my hands when I took my gloves off." The nurse did not seem to recognize the test strips had been cross contaminated, to understand the potential for spreading infection, or to recall the basic infection control measures in trying to prevent the spread of infection, i.e. 1) using surface barriers under equipment, 2) removing gloves and washing hands in the immediate area, etc. The nurse offered that she did not usually work in the acute care unit, but usually worked in surgery.

In a discussion with the Chief Nursing Officer (CNO-Employee #4) on the above infection control observations, the CNO indicated her expectation was when the nurse went into the isolation room she should have gowned up. The CNO agreed putting the equipment and supplies directly on the patient's bed was not appropriate, the test strips should have been discarded and her expectation was staff should use the patient's overbed tables to place equipment or supplies. The CNO did not understand the need to put down surface barriers and indicated the tables were clean.

On the morning of 9/28/11, just before noon, a certified nursing assistant (CNA-Employee #13), was observed coming out an isolation room. The CNA had on a set of blue gloves and a yellow isolation gown, which was not secured closed. The CNA was holding a large bundle of soiled linen. The CNA held the soiled linen against her body as she proceeded across the hallway and put the linen in a yellow barrel. When the CNA was asked why she came out of the room to dispose of the linen she indicated it was because the barrel was not outside the isolation room door (in the hallway), where it was supposed to be. When asked if doing things differently what she would do, the CNA indicated she would have done the same thing. The CNA did not seem to understand the principles of following required infection control practices or measures to minimize exposure or prevent potential spread of infection. The CNA indicated she was in a hurry, needed to go to lunch and did not have time to discuss the observations further. As the encounter was ending the Infection Control Coordinator (Employee #10) approached and when the observations discussed with the coordinator, the coordinator shook her head in disbelief.

As the conversation continued with the Infection Control Coordinator, a Physical Therapy Assistant (PTA- Employee #14), was observed, with the Coordinator, coming down the hallway removing a pair of blue gloves. When the PTA was asked where she had come from and what she was doing, the PTA indicated she just left a patient's room, had forgotten some equipment and was going to the supply room. When asked why she was wearing the gloves the PTA indicated any time she gave care or was assisting a patient in the course of her duties she was told to wear gloves. The PTA did not seem to understand when it was necessary to wear gloves, or where and when to remove/dispose of gloves, and that hands should be washed after removing gloves in the immediate area. Following the discussion the PTA proceeded into the unlocked and unmonitored supply room.

Review of the facility's policy and procedure updated 11/8/94, titled "The Exposure Control Plan" indicated employees were to wash their hands immediately or as soon as feasible after removal of gloves.

On the morning of 9/27/11, following the first surgery of the day, the Housekeeper (Employee #15) was observed cleaning the surgical suite. The housekeeper was wearing a white pair of tennis shoes without shoe covers. The same housekeeper was later observed in the hallway outside the acute care unit with the same tennis shoes and no shoe covers. The housekeeper did not have a separate pair of shoes reserved for the surgical area.

On the morning of 9/27/11, while observing in the surgical/recovery area, the surgeon (Employee #16) was observed scrubbing in for the second surgery of the day. The surgeon did not rinse off the cleanser and continued into the surgical suite to perform surgery. The observation was discussed with the Operating Room Nurse Manager (OR Manager- Employee #17), the manager indicated she was aware of the surgeon's practices and agreed the surgeon should have rinsed hands after scrubbing. The manager indicated the facility followed Association of Operating Room Nurses (AORN) standards and guidelines in the surgical and operating unit.

Review of the facility"s current policy dated 10/14/10 titled "Surgical Hand Scrub" indicated: "Skin is a major source of microbial contamination in the surgical environment. Althought surgical team members wear sterile gloves, the skin of their hands and forearms area cleaned routinely to reduce the number of microorganisms in the event of glove tears. The policy went on to describe the purpose of surgical hand scrub was to remove debris and transient microorganisms from the nails, hands and forearms, reduce the resistant microbial count to a minimum, and inhibit rapid rebound growth of microorganisms.

Additional review of a policy, under current review and forth coming approval, titled "Surgical Hand Scrub," referenced AORN, indicated in detail, both the purpose of the policy and procedure including rinsing off after scrubbing.

Food In Work Areas

On the initial tour of the facilty an open can of cranberry juice was observed on a housekeeping cart. The following two days an opened package of crackers/cookies and a drinking cup were observed in a janitor's closet. On one occassion candy was found on another housekeeping cart. The findings were discussed and acknowledged by the Housekeeping Supervisor (Employee #9).

Based on record review, policy review, and interview, the facility failed to provide nutritional consulting for 1 of 21 patients ( Patient #14).

Patient #14

Patient #14 was admitted to the facility through the emergency room on 7/1/11 with diagnoses including acute pancreatitis, abdominal pain, and hypertension.

Patient #14 was admitted to the medical floor placed on pain medication and discharged on 7/7/11. A review of the nutritional screening form revealed there was no trigger indicating a need for nutritional consultation.

An interview with the facility dieticians on 9/28/11 revealed there was a new policy developed in June of 2011 to provide the nursing staff with guidelines for ensuring that such patients as #14 received nutritional counseling by the dieticians. The dieticians indicated the policy had not been approved by the medical staff as of 9/28/11. The dieticians indicated Patient #14 should have received a dietary consult based on the diagnosis and current policy as well as the new policy.

Based on policy review and interview the facility failed to ensure policies were reviewed at least annually.
Findings include:

Review of the infection control manual revealed a signature page from 2005. The page was found in the beginning of the manual and advised, "The following policies/procedures have been continuously in use and have been reviewed and updated, revised or amended as necessary." There was not a page documenting review or that updating had been done since 2005. Review of the infection control policies, including hard copies, soft copies (maintained online) failed to reveal updated policies and procedures for maintaining specific types of isolation.

The following policies were examples of current policies in need of updating or revision:

1. The Exposure Control Plan had an effective date of 6/10/92, with updates on 8/17/93 and 11/08/94. There were no further updates or revisions.

2. Care and Cleaning of Endoscopes was updated on 5/21/93. There were no further updates or revisions. The facility was no longer using the equipment described in the policy. There was no newer policy to reflect the current practice observed for cleaning of endoscopes.

On 9/28/11, the Infection Control Coordinator was interviewed and reported she did not know the last time these policies had been reviewed, but they were working on new infection control policies.

An interview with the quality assurance coordinator (Employee #1) revealed the facility was in the process of updating and computerizing its policies and several departments had not completed the process.

Based on a review of laboratory procedures and interview with the laboratory manager (Employee #2) on September 27, 2011, the laboratory instructions for the handling and processing of tissue specimens did not include steps for the transportation, receipt, and reporting of tissue specimen results.

Findings include:

A complete written procedure for the handling and processing of tissue specimens and reports was not available. The missing elements to this procedure were transportation, receipt and reporting of tissue specimen results.

Based on document review and interview, the facility failed to ensure failed to ensure their patient shielding equipment (aprons, etc) were properly maintained and routinely inspected.

Findings include:

On September 27, 2011, interview with the department manager (Employee #3) and a review of the department Quality Assurance records showed the last records for the annual safety inspection of the aprons and other shielding equipment was entered on February and March of 2008.

Based on policy review and interview the facility failed to ensure there were written policies and procedures regarding the visitation rights of patients.

Findings include:

Review of the facility's visitation policies revealed two policies for visitation:

"Visiting policy for obstetrical department" with an effective date of 12/10/09; and

"Visitation rights for swing bed residents" with no effective date.

Review of these two policies failed to reveal policies or procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitations that the facility may need to place on the visitation rights.

On 9/28/11, the Director of Quality Assurance (Employee #1) was interviewed and reported there were no other policies regarding visitation rights for hospital patients.

Based on policy and admission packet review and interview the facility failed to inform each patient on admission of his or her visitation rights and the right to receive designated visitors.

Findings include:

Review of the facility's admission packet revealed a sheet with patient rights and responsibilities. The listing of patient rights and responsibilities did not address visitation rights.

Review of the facility policies and procedures revealed visitation policies for obstetrical patients and swing bed residents. The policies did not address visitation for general hospital patients or include informing hospital patients of their visitation rights upon admission.

On 9/28/11, the Director of Quality Assurance (Employee #1) was interviewed and confirmed patients rights were not included in the admission packet or admission forms for patients being admitted to the hospital.

Based on policy review and interview the facility failed to ensure the policies and procedures regarding visitation rights included not restricting or limiting visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

Findings include:

Review of the facility's policies on visitation revealed two policies, one for obstetrical patients and one for swing bed residents. Review of the visitation policies failed to reveal any policy for general hospital patients. The policies did not include procedures regarding not restricting or limiting visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability.

On 9/28/11, the Director of Quality Assurance (Employee #1) was interviewed and reported there were no additional policies regarding visitation.