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Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to obtain complete written Orders for the administration of Propofol in two of two applicable medical records reviewed (MR20, MR21), and failed to ensure that medication was administered only upon written and signed Orders of a practitioner for two of two medical records reviewed. (MR20, MR21)

Findings include:

Review of the facility's "Diprivan (Propofol) Protocol," undated, revealed, "For intubated, mechanically ventilated adult patients, sedation should be initiated slowly With (sic) a continuous infusion in order to titrate to desired clinical effect and minimize hypotension. The standard concentration is: 10 mg/ml. Dosing: (sedation in the critical care setting) In patient's likely to develop hypotension and patients who have residual effects from anesthetic drugs: 5 mcg/kg/min for at least five minutes. In patients whom are unlikely to develop hypotension: 10-20 mg bolus followed by 5 mcg.kg.min. Doses may be titrated in increments of 5-10 mcg/kg.min. Normal maintenance dose for sedation: 5-50 mcg/kg.min ... The Ramsey Sedation Scale. The Ramsey Sedation Scale (RSS) was designed as a test of rousability. When Diprivan is infusing, we utilize the RSS as a guideline for arousability. The RSS scores sedation at six different levels, according to how rousable the patient is. Ramsey Sedation scale 1 Patient is anxious and agitated or restless or both 2 Patient is co-operative, oriented, and tranquil 3 Patient responds to commands only 4 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus 5 Patient exhibits a sluggish response to light glabellar tap orloud (sic) auditory stimulus 6 Patient exhibits no response ... ."

1) Review of MR20, revealed a Physician Order dated March 13, 2014, which stated "Propofol for sedation-start at 10 mcg/kg/min-adjust per sedation protocol."

Review of MR21, revealed a Physician Order dated Februrary 20, 2014, which stated "Propofol 10 ml and infusion ... ."

Continued review of both MR20 and MR21 revealed nursing documentation indicating instances that the Propofol infusions were titrated.

Interview with EMP5, on August 7, 2014, revealed that nursing staff normally titrate Propofol to a Ramsey of 3. Interview with EMP5, also confirmed that MR20 and MR21 do not contain complete written Orders related to Propofol infusion, and confirmed that physician Orders and the Protocol do not contain direction that Propofol infusions are to be titrated to a Ramsey Scale of 3.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to obtain written Physician Orders for completion of Methicillin Resistant Staphylococcus Aureus (MRSA) screening cultures for three of three applicable medical records reviewed. (MR23, MR24, MR25)

Findings include:

Review of the facility's policy entitled "Management/Patient/Multi-Drug Resistant Organism/Colonization, MRSA, ETC.," dated June 2014, "... 5. All nursing home residents, personal care home residents, and high risks (sic) patients will be screened for Methicillin Resistant Staph Aureus (MRSA), if admitted to the hospital ... ."

1) Review of MR23, MR24, and MR25 revealed that MRSA screening cultures were obtained on admission. Continued review of MR23, MR24, and MR25 revealed no written Orders for the MRSA screening cultures.

Interview with EMP1 on August 7, 2014 confirmed the findings.

Based on a review of facility documents, and staff interviews (EMP), it was determined that the facility failed to conduct fire drills at their provider based satellites and failed to ensure that their external Disaster Plan was rehearsed at least twice a year.

Findings include:

Review of the facility's policy entitled "Emergency Preparedness Management Plan," reviewed July 2014, "... The purpose of the Emergency Preparedness Management Plan is to establish and maintain a Plan to ensure an effective response to disasters or emergencies affecting the environment of care ... This Plan ... shall cover all areas owned or leased by the hospital ... ."

Review of the facility's policy entitled "Emergency Preparedness Management Plan," reviewed July 2014, "... 3. The Emergency Preparedness Plan is implemented semi-annually on a facility-wide basis to test and critique our ability to successfully manage an internal or external disaster ... ."

1) Surveyor requested fire drills for the facility's outpatient provider based satellites. Interview with EMP 2 on August 6, 2014, revealed that no drills had been conducted.

Interview with EMP1 on August 7, 2014, also confirmed that no fire drills had been conducted in off site satellites.

2) Documentation provided to surveyor by facility revealed that the last rehearsal of the facility's Disaster Plan occurred in June 2013.

Interview with EMP2 on August 6, 2014, confirmed that the facility has not conducted disaster drills for the last year.

Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to comply with requirements, as outlined in the letter from the Department, granting the Exception related to regulations for control of anesthetic explosion hazards.

Findings Include:

Review of the letter approving the Exception request, dated January 14, 2008, sent to Windber Hospital, revealed, "... The facility shall institute annual mandatory education to all staff, including the physician staff involved in the use of surgical skin preparations that contain combustible agents. ... ."

Review of "Preoperative Skin Preparation of Patients" dated July 2014, revealed no documentation of the educational requirements of surgical skin preparations that contain combustible agents.

1) Review of "Skin-prep education 2013-2014" documentation provided by EMP3 on August 7, 2014, at 9:30 AM, revealed that education was not provided to one contracted physician, three employed physicians and all independent physicians.

Interview with EMP3 on August 7, 2014, at 9:30 AM, confirmed the above documentation.