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Based on medical record review, observation, staff interview and facility policy review; the facility failed to assure physician orders and infection control measures were followed for one ( Patient # 24) of one dressing change observed. The facility census was 33.

Findings include:

Review of the medical record completed on 11/21/13 revealed a date of admission of 11/18/13 and diagnoses to include osteoarthritis and right knee replacement. Review of the physician order dated 11/18/13 revealed reinforce the dressing as needed, change dressing post op day two and three and apply Mupirocin ointment and did not include the use of soap and water to the wound. Review of the nursing notes failed to reveal evidence that the right knee dressing was changed on post op day two.

An observation on 11/21/13 at 8:30 AM with Staff M and Staff N revealed a dressing change to the right knee incision. Staff M confirmed at the time of the observation that the patient was three days post operative. Staff M was observed wearing non sterile gloves while cleaning the wound with a washcloth taken from a basin of soapy water. The washcloth was used to remove dried blood from the wound and was visibly soiled when Staff M dropped the soiled washcloth into the basin of soapy water and took another washcloth out to continue cleaning the wound. After the wound was cleaned Staff M failed to change from clean gloves to sterile gloves prior to applying Mupirocin ointment and the clean dressing. While applying the ace wrap on top of the clean dressing Staff M reached into his/her uniform pocket to obtain an additional ace wrap while still wearing the gloves used when cleaning dried blood from the incision.

At 8:50 AM on 11/21/13 Staff M confirmed the failure to use hand hygiene after removing gloves during the dressing change, failure to change gloves after cleaning the incision and reaching into her/her pocket while wearing gloves used to clean the incision.

An interview with Staff N on 11/21/13 at 10:30 AM confirmed the dressing removed was the operative dressing and the failure for the dressing to be changed on post op day two as per the physician order. Staff N further confirmed the physician order did not include the use of soap and water.

An interview with Staff C on 11/21/13 at 2:15 PM revealed the expectation for dressing changes according to the agency policy would be to change gloves after cleaning the wound and prior to administration of the treatment or application of a new dressing. Staff should not place a dirty glove into a uniform pocket during a treatment. Staff C confirmed the policy indicated a sterile glove should be used for the clean dressing application.

Review of the Memorial Hospital of Union County Policy for Applying a Dry Sterile Dressing completed on 11/21/13 revealed dressing changes should be done according to physician orders and using procedures outlined in Clinical Nursing Skills and Techniques 7th edition pages 1005-1012. Review of the Procedures in the above reference book on 11/21/13 revealed clean gloves should be used to remove the soiled dressing and for cleaning the wound and sterile gloves for applying the clean dressing.

Review of the Memorial Hospital of Union County Infection Prevention and Control: Hand Hygiene Policy completed on 11/21/13 revealed staff must clean hands with soap and water or alcohol hand sanitizer after removing gloves and when moving from a contaminated body site to a clean body site during patient care.

Based on policy and procedure review, staff interview and observation; the facility failed to ensure all medical records were completed within 30 days from the time of discharge. This deficient practice effected 276 total medical records. The facility also failed to ensure all medical records were protected from fire and water damage. A total of 138,188 medical records were fire protected but not water protected, and a total of 180 unscanned medical records were not fire nor water protected. The patient census was 33.

Findings include:

A tour of the medical records department (Health Information Management) was conducted on 11/19/13 starting at 2:00 PM. During tour of the department, a total of 180 unscanned medical records were found, and the medical records were not protected from fire. This was confirmed by Staff A and Staff B on 11/19/13 at 2:10 PM during the tour.

A tour of a medical record storage room on 11/19/13 at 2:15 PM revealed outpatient medical records from 2009 to 2010 and inpatient medical records from 2004 to 2010 were protected from fire but not from water damage. This was confirmed with Staff A and Staff B during an interview on the tour. On 11/20/13 at 3:30 PM, Staff A confirmed a total of 41,780 outpatient medical records and 18,319 inpatient medical records were unprotected from water damage in this storage room.

A tour of a second medical record storage room on 11/19/13 at 2:20 PM revealed medical records from 1998 to 2001 were protected from fire but not from water damage. This was confirmed with Staff A and Staff B during an interview on the tour. On 11/20/13 at 3:30 PM, Staff A confirmed a total of 78,089 medical records were unprotected from water damage in this storage room.

A request for a total number of delinquent medical records was made on 11/19/13 at 2:45 PM. On 11/20/13 at 3:45 PM, Staff A revealed and confirmed the facility had a total of 276 delinquent medical records at a rate of 7.18%. On 11/21/13 at 2:20 PM, Staff D revealed and confirmed 13 physicians are under disciplinary action for delinquent medical records.

Review of the facility's policy and procedure number 8381-009 for medical record completeness was conducted on 11/21/13 at 1:00 PM, which revealed "all medical records must be completed within thirty (30) days of discharge or outpatient care". "Medical records not completed within thirty (30) days of discharge or outpatient care are deemed delinquent".

Based on observation, staff interview, and policy review; the facility failed to ensure Food and Nutritional Service policy for labeling and dating food items was enforced. This had the potential to affect 15 in-patients on regular or modified diets. The facility census was 33 including 15 patients on regular or modified diets, two patients on clear liquid diets, 11 patients on nothing by mouth (NPO) diets, and five babies.

Findings include:

On 11/20/13 from 11:00 AM to 11:50 AM a tour was conducted of the facility's dietary kitchen. Two coolers and a walk-in freezer had food items that were not labeled or dated. The food items included bagged entrees, box lunches, and individually wrapped cakes and pies. Staff Q was interviewed as to when the food items were prepared and when they would expire. Staff Q indicated he/she did not know when the food items were prepared and therefore did not know when they would expire.

On 11/21/13 the facility's Food and Nutrition Services Department policy, Inspection of Foods for Outdates and Use of Leftovers, document control #8050-1.2, revised on 08/21/13 was reviewed. The policy documented, "all labeling of food items will follow the Ohio Department of Health - Food Code and the Federal Drug Administration Food Code for labeling laws. The items name, preparation date or opened date will be noted and a discard date of five days, including today as day one". The policy also documented dessert items including "cakes and pies will be individually packaged or wrapped with a dating label. All items will be discarded after three days to ensure a fresh product."

Based on observation and interview the facility failed to manage the accessibility of fire extinguishers, failed to maintain the sprinkler system in a reliable operating condition, the integrity of smoke barrier and fire barrier walls, ensure signage on paths of egress, stairways were free of obstructions, and patient sleeping areas were free of portable space heating devices. The cumulative affect of these sytemic practices resulted in the inability to maintain the enviroment safe from fire.This has the potential to affect all patients, staff and visitors to the facility. The facility's census was 33 patients.

Findings include:

See A710

Based on observation, documentaion review and interview the facility failed to maintain the environment in a safe manner. This has the potential to affect all 33 patients in the facility.

Findings include:

Please refer to findings under the life safety code survey.

K11 of the life safety code was not met. Penetrations were observed in 2 hour fire resistive construction separating two buildings.

K20 of the life safety code was not met. A stairway door ' s fire resistive rating could not be determined.

K22 of the life safety code was not met. Not all paths of egress had signage

K25 of the life safety code was not met. Penetrations were observed in the smoke barriers.

K29 of the life safety code was not met. Penetrations were observed in the protective construction surrounding a hazardous area.

K34 of the life safety code was not met. Stairways were not clear of obstructions.

K62 of the life safety code was not met. The sprinkler system was not maintained in a reliable operating condition.

K70 of the life safety code was not met. Space heaters were found in patient sleeping areas.

K72 of the life safety code was not met. Storage was observed in exit access areas.

K45 of the life safety code was not met. Outdoor lighting to exit discharge areas was lacking.

K54 of the life safety code was not met. Smoke detectors were observed too close to airflow devices.

Building #2

Heart and Surgical Pavilion

K64 of the life safety code was not met. Portable fire extinguishers were not readily accessible.

K76 of the life safety code was not met. Medical gas shutoff valves were not readily accessible.

Building #3

Imagining Center/Damascus road location

K130 of the life safety code was not met. Portable fire extinguishers were not readily accessible and maintained, the sprinkler system was not inspected quarterly, and the fire alarms transmission time was not documented.