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Based on review of facility documents and personnel files (PF), as well as employee interviews (EMP), it was determined that the facility failed to ensure compliance with all applicable State regulations.

The facility was found to be non-compliant with the following State regulation:

28 PA Code 109.2(b) The director of nursing services shall be employed on a full-time basis and shall be responsible to the chief executive officer or his designee for developing and implementing policies and procedures of the service.

This is not met as evidenced by:

Based on review of facility documents and personnel files (PF), and employee interviews (EMP), it was determined that the facility failed to ensure that a director of nursing services is employed on a full-time basis.

Findings include:

1. Review of a LECOM Health Memorandum dated August 8, 2016, revealed, "... TO: Board of Trustees All Employees Medical Staff Members Allied Health Professionals FROM: [President/CEO] SUBJECT: Director of Patient Care Services (Formerly DON) Please be advised that effective today, I will be the Acting Director of Patient Care Services. ..."

2. Review of the personnel file for the President/Chief Executive Officer did not reveal a position description for Director of Nursing and/or Director of Patient Care Services.

3. During entrance conference, at approximately 10:53 AM on September 6, 2016, it was relayed that EMP23 was currently on leave for the week. At this time, EMP1 and EMP2 related that EMP23 is currently the CEO and acting DON. EMP1 explained that EMP2 is filling in as CEO while EMP23 is off. When asked who is filling in as DON while EMP23 is off, as EMP2 does not have a nursing background, EMP1 stated, " Maybe [EMP18]. ... Or [EMP22]."

Based on review of facility policies and procedures, observation and staff interview (EMP), it was determined that the facility staff failed to ensure that all essential patient-care equipment is maintained in safe operating condition.

Findings included:

Review of facility policy on September 7, 2016, at approximately 2:30 PM revealed, "Infection Control Policy and Procedure..." dated June 2016 revealed, "...Purpose: To maintain aseptic technique controlling and reducing cross infection of the patient and/or operating room by confining, containing and disposing of pathologic organisms...Procedure: A. Prior to the first schedule of the day: damp dust all horizontal surfaces and overhead lights with 70% isopropyl alcohol...2. Keep room neat and orderly in appearance: Paper products in trash...14. At the end of the day the room is cleaned by Housekeeping Department..."

1. Tour of Operating Room (OR) #2 on September 6, 2016, at approximately 11:40AM revealed an uncovered storage cart located in Operating Room #2, which contained OR supplies such as fluid for Intravenous administration, suction connectors and suction containers. Behind the cart was a vent that contained excessive dust.

During an interview on September 6, 2016, at approximately 11:40AM, when asked if the cart and items in the cart are in the room during surgical procedures EMP5 indicated, "Yes, but the cart should be covered..." EMP5 also confirmed the dust in the vent at this time.

Based on review of facility documentation, credential files (CF), and employee interview (EMP), it was determined that the Governing Board failed to ensure that physicians appointed to the Medical Staff had clinical privileges defined specific to Corry Memorial Hospital, as part of the appointment process, for three of five physicians (CF2, CF4 and CF5).

Findings include:

Review of the Medical Staff Bylaws Of Corry Memorial Hospital, approved October 21, 2015, revealed, "Part II Policy On Medical Staff Appointment, Reappointment And Clinical Privileges ... Article I Appointment To The Medical Staff ... Section 1.03 No Entitlement To Appointment No individual shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges in the hospital merely by virtue of the fact that such individual ... (c) has in the past, or currently has, Medical Staff appointment or privileges at any hospital or health care facility. ... Article III Application For Initial Appointment And Clinical Privileges Section 3.01 Information A. Applications for appointment to the Medical Staff shall be in writing, and shall be submitted on forms approved by the Board upon recommendation of the Executive Committee ... B. The application shall contain a request for specific clinical privileges desired by the applicant and shall require detailed information concerning the applicant's professional qualifications ... Article 6 Clinical Privileges Section 6.01 general A. Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those clinical privileges specifically granted by the Board."

1. Review of CF2 revealed a clinical appointment for Provisional Courtesy Medical Staff in the category of Internal Medicine and Emergency Medicine. Review of CF2 revealed no privileges requested or granted specific to Corry Memorial Hospital. The review revealed an uncompleted Corry Memorial Hospital privilege list. Review of the form revealed a handwritten note stating, "Attached [facility-OTH1's] privilege list." Review of CF2 revealed a delineation of privileges list for [facility-OTH1] for the categories of Internal Medicine and Emergency Medicine. The list from the OTH1 facility did not reflect Corry Memorial Hospital.

2. Review of CF4 revealed a clinical appointment for Provisional Courtesy Medical Staff in the category of Internal Medicine and Geriatrics. Review of CF4 revealed no privileges requested or granted specific to Corry Memorial Hospital. The review revealed an uncompleted Corry Memorial Hospital privilege list. Review of CF4 revealed a delineation of privileges list for [facility-OTH1] for the category of internal medicine. The list from the OTH1 facility did not reflect Corry Memorial Hospital.

3. Review of CF5 revealed a clinical appointment for Provisional Courtesy Medical Staff in the category of General Surgery. Review of CF5 revealed no privileges requested or granted specific to surgical privileges at Corry Memorial Hospital. Review of CF5 revealed a delineation of privileges list for [facility-OTH1] for the category of general surgery. The list from the OTH1 facility did not reflect Corry Memorial Hospital.

4. On September 7, 2016, at approximately 11:20 AM, EMP24 confirmed that CF2, CF4 and CF5 did not have completed and Medical Staff approved delineation of privilege lists specific to Corry Memorial Hospital.

Based on review of facility documents, observation, and staff interview (EMP), it was determined that three pre-filled medication syringes were not disposed of at the end of the day in two of two operating rooms, and the facility staff failed to date open multi-dose vials to ensure safe use as per the regulation that multi-dose vials expire in 28 days after opening or sooner if indicated by the manufacturer.

Findings include:
Review of the Corry Memorial Hospital-Nursing Policy Guidelines-Infection Control Policy Procedure, dated June 2016 revealed "...Procedure:..E. Clean-up following surgical procedure:...6. Sharps and needles are placed in discard-a-pads and placed in plastic lined kick bucket..."

1. On September 6, 2016, at approximately 11:25 AM, revealed a prefilled syringe, labeled Atropine, dated September 1, 2016, in a locked cart in operating room #1, and two prefilled syringes labled Neosynepherine dated August 16, 2016.

During an interview during the time of the operating room tour on September 6, 2016, at 11:30 AM, EMP5 confirmed that the prefilled syringes should not have been left in the carts at the end of the day.

2. Tour of the operating suite on September 6, 2016, at approximately 11:30 AM, revealed an open multi dose bottle of Glycopyrrolate with no open date, and one open vial of Neostigmine with no open date.

During an interview during the time of the operating room tour on September 6, 2016, at 11:30 AM, EMP5 confirmed that the vials could be kept if they contained an open date.

3. On September 6, 2016, at approximately 1:00 PM EMP1 was asked for a policy for for multi-dose vials. EMP1 provided several policies, but none of the policies were specific for expiration dates for open multi-dose vials.


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Based on tour of the operating room suite and facility interview (EMP) it was determined that the facility failed to ensure that syringes were stored in a way to prevent contamination.

Findings include:

1. Tour of operating room #1 on September 6, 2016, at approximately 11:25AM revealed empty syringes that had been removed from the plastic packaging and labeled Robinul, Fentanyl, Toradol, Midazolam and Zofran. The syringes were on the anesthesia cart in a towel.

2. Tour of operating room #2 on September 6, 2016, at approximately 11:30AM revealed empty syringes that had been removed from the plastic packaging and labeled Robinul, Fentanyl, Toradol, Midazolam and Zofran. The syringes were on the anesthesia cart in a towel.

During an interview on September 6, 2016, at approximately 11:45 AM, when asked if the syringes should be out of their package, EMP5 indicated, "they should not be, they should be in the [unopened] package until used."

During an interview on September 7, 2016, at approximately 10:50 AM, EMP12 indicated, "What you found in the OR [syringes out of the package], they should not have been opened." EMP12 further explained that any needle or syringe removed from its sterile wrapper should be used immediately and then discarded. EMP12 explained that the nurse anesthetist removed the syringes from their wrappers and labeled the empty syringes in attempt to save time the following day.