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Based on review of facility documents, and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to adopt Medical Staff Rules and Regulations requiring the timing of progress notes and failed to ensure that progress notes were timed in 19 of 36 medical records reviewed. (MR2, MR3, MR4, MR5, MR7, MR8, MR17, MR19, MR21, MR22, MR25, MR26, MR27, MR28, MR29, MR30, MR33, MR35, MR36)

Findings include:

Review of the ACMH Hospital Medical Staff Rules and Regulations, dated June 2009, revealed "... Article 3 Medical Records 3.1 General Rules: ... (e) ... (3) Progress notes shall be written at least daily for all patients who have been admitted to the hospital ... 3.2 Authentication: All entries in the record shall be dated and authenticated by the person making the entry ... 3.5 Progress Notes: (a) Progress notes shall provide a pertinent chronological report of the patient's course of care in the hospital ... All such progress notes shall be legible, shall document the date of observation ... ."

2) Review of MR2, MR3, MR4, MR5, MR7, MR8, MR17, MR19, MR21, MR22, MR25, MR26, MR27, MR28, MR29, MR30, MR33, MR35, and MR36 revealed the records contained progress notes that were not timed.

3) Interview with EMP5 on June 24, 2010, confirmed that progress notes are to be timed.

Based on review of facility documents, and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to adopt Medical Staff Rules and Regulations requiring the timing of written orders and failed to ensure that written orders were timed in 22 of 36 medical records reviewed. (MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR14, MR16, MR17, MR19, MR20, MR21, MR24, MR26, MR27, MR28, MR29, MR30, MR31, MR33, MR34)

Findings include:

Review of ACMH Hospital Medical Staff Rules and Regulations, dated June 2009, revealed "... Article 2 Medical Orders ... 2.2 Who may write Orders: ...(b) All orders must be entered in the patient's record, dated and signed by the responsible appointee ... ."

1) Review of MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR14, MR16, MR17, MR19, MR20, MR21, MR24, MR26, MR27, MR28, MR29, MR30, MR31, MR33, and MR34 revealed all contained written orders that were not timed.

2) Interview with EMP5 on June 24, 2010, confirmed that orders are to be timed.

Based on review of facility documents, and medical records (MR), and staff interview (EMP), it was determined the facility failed to follow adopted Medical Staff and Rules and Regulations by failing to ensure that verbal orders were countersigned with the date and/or time for eight of 36 medical records reviewed. (MR2, MR3, MR6, MR8, MR17, MR20, MR21, MR22)

Findings include:

Review of ACMH Hospital Medical Staff Rules and Regulations, dated June 2009, revealed "... Article 2 Medical Orders ... 2.3 Verbal Orders: ... (c) A verbal order shall include the date, time, and full signature of the person to whom the verbal order has been given; it shall be countersigned dated and timed within twenty-four (24) hours by the ordering physician or the physician responsible for the patient's care ... ."

1) A review of MR2, MR3, MR6, MR8, MR17, MR20, MR21, and MR22 revealed that all contained verbal orders which were not countersigned with the date and/or time.

2) Interview with EMP5 on June 24, 2010, confirmed that verbal orders are to be countersigned with the date and time.

Based on review of facility documents, tour of the microbiology laboratory, and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to assuring that all aspects of construction and renovation were known to Infection Control.

Findings include:

Review of the Plant Engineering/Maintenance policy entitled "Construction/Renovation Projects", dated April 9, 2009, revealed "Policy: The purpose of this policy is to control construction-related air pollution during construction, renovation and/or clean-up projects. These guidelines should create a barrier for dust and debris that may carry pathogenic fungi from construction areas to patients ... Construction Management Director: Prior to construction: Develop restricted traffic flow plan and inspect sites for proper construction control measures ... Assure that all aspects of construction and renovation are known to Infection Control as are areas of potential changes ... ."

1) During a tour of the Microbiology Laboratory on June 23, 2010, a piece of cardboard with duct tape was noted to be covering one of the outside windows. Interview with EMP1 revealed that a contractor was in the process of installing an air conditioning unit to the area.

2) Interview with EMP2, on June 23, 2010, revealed "[The contractor] was installing the unit ... They thought they were going to need two windows and they only needed one. That's why the other window is covered with the cardboard ... ."

3) Interview with EMP3, on June 24, 2010, at approximately 9:10 AM, confirmed that Infection Control was not aware of this project and stated that Infection Control should have been involved in the renovations in the Microbiology Laboratory.

Based on review of facility documents, tour of the cardiopulmonary department, and staff interviews (EMP), it was determined that facility staff failed to ensure the removal of outdated supplies when inspecting storage areas.

Findings include:

Review of the Cardiopulmonary Department's policy entitled "Personnel Policies", dated January 21, 2010, revealed "... Purpose: A brief outline of shift duties to be used as a guideline only. Procedure: ... Night Shift: ... 7. Check and stock machines, carts, and cupboards ... Therapist-in-Charge ... 6. Inspect storage areas ... ."

1) During a tour of a supply storage room in the Cardiopulmonary Department, on June 23, 2010, with EMP4, outdated thoracentesis kits, pneumothorax sets, and sterile gloves were noted on the shelves.

2) Interview with EMP4 on June 23, 2010 confirmed the findings.