HospitalInspections.org

Based on personnel record review, policy review, document review and staff interview, it was determined that the governing body failed to ensure that 1 of 1 (100%) contracted dietary staff in the sample received hospital orientation. Findings include:

The hospital document entitled "Nanticoke Health Services, Inc. Bylaws" stated, "...The administrative powers of the Corporation shall be vested in the Board, which shall have charge, control, and management of the property, affairs and funds of the Corporation; shall set policy for the operation of the Corporation..."

The hospital policy entitled "Contracted Staff" stated, "...Orientation...will be completed...prior to or on the first day of the assignment..."

Review of the personnel file for Food Service Director A revealed no evidence that an orientation was completed. On 3/15/12 at 9:00 AM,
Human Resources Senior Director A confirmed this finding and reported that Food Service Director A was scheduled to attend an orientation on 3/22/12.

Based on observation, policy review, staff interview and review of other hospital documents, it was determined that for 4 of 10 (40%) patient units in the sample, staff failed to ensure confidentiality of patient information for Patient #'s 47, 53, 54, 55, 56 and 57. Findings include:

The hospital policy entitled "Designated Record Set" stated, "...Protected Health Information ("PHI")...identifiable health information that is transmitted by electronic media...or maintained in any other form or medium (including paper...). This information often contains confidential information such as name, geographic residence, dates, employment and other information unique to an individual, collected in many mediums, and used by health care providers when documenting...health care services...Record: Any item, collection or grouping of information that includes PHI..."

The hospital policy entitled "Safeguarding of Data" stated, "...Computer workstations...users are required to log off before leaving a workstation unattended. If leaving for a brief period only, workstations may be locked instead...Paper documents containing sensitive information will not be unattended..."

The hospital document entitled "Patient's Rights and Responsibilities" given to patients in both the inpatient and outpatient units stated, "...While You are a Patient, We Respect Your Right to...Confidentiality of your medical records..."

Survey activities included patient care observations for inpatient and outpatient units, departmental tours and inspections. The following issues related to patient confidentiality were identified during these observational activities:

A. Medical-Surgical Unit (Census 71) - Unattended, unsecured computer screen

3/8/12 at 12:25 PM
Patient #47 - Registered Nurse H failed to secure the computer screen before leaving the computer unmanned in the patient's room (3021 W). Visible information included the patient's name, date of birth and ordered medications.

Medical-Surgical Unit Director A, present at the time of discovery, confirmed this finding.

B. Vascular Lab (outpatient) (Census 1) - Unattended, unsecured medical record

3/9/12 at 1:35 PM
Patient #57 - The patient's medical record which contained both medical and confidential information was observed to be laying on an unmanned desk in the Vascular Center (across from Room 3001).

Compliance and Quality Director A, Quality Manager A and Maintenance Supervisor A, present at the time of discovery, confirmed this finding.

C. Emergency Department (Census 28) - Unattended, unsecured computer screen

3/12/12 at 3:17 PM
Registration Clerk A failed to secure the computer screen before leaving the computer in the main thoroughfare of the ED. Patients' names were visible on the unlocked computer screen which was facing the general public.

Emergency Department Director A, present at the time of discovery, confirmed this finding.

D. Progressive Care Unit (PCU) (Census 56) - Unattended, unsecured pull down storage desks

Storage desks contained clipboards for each patient with a document entitled "Hand Off Communication Tool - PCU". The document contained confidential information, i.e., name, date of birth, diagnosis, history, surgery, physician, current tests, lab results and physical assessment findings. The patient "paper" medical record was also stored in the pull down desk unit. In addition to medical information, the "face sheet" contained confidential information, i.e., name, date of birth, medical record number, social security number, home address, employer name and number, next of kin, insurance provider, chief medical complaint and previous visit time and date.

3/14/12

9:27 AM
Patient #53 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"
- Medical record

Patient #54 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"

Patient Safety Officer A, present at the time of discovery, confirmed these findings. Safety Officer A secured the desk unit.
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9:33 AM
Patient #55 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"
- Medical record

Patient #56 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"
- Medical record

Patient Safety Officer A, present at the time of discovery, confirmed these findings. Safety Officer A secured the desk unit.
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9:39 AM
Patient #53 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"
- Medical record

Patient #54 - Unattended, unsecured desk unit containing:
- "Hand Off Communication Tool - PCU"

Patient Safety Officer A, present at the time of discovery, confirmed these findings. Safety Officer A once again secured the desk unit.

I. Based on observation, medical record review, policy review, job description review and staff interview, it was determined that the registered nurse (RN) failed to ensure that intravenous (IV) fluids were administered as ordered by the physician for 1 of 16 (6%) patients (Patient #14) in the sample receiving IV fluids. Findings include:

The Elkin, Perry and Potter "Nursing Interventions & Clinical Skills" 4th Edition also utilized by the nursing staff to direct care stated, "...Verify physician's orders..."

The hospital's Licensed Practical Nurse (LPN) Job Description stated, "...the nurse...assuring appropriate care...competence in proper handling, delivering, assessing...medications...labeling, including IV therapy..."

The hospital's document entitled "Corporate Education...Basic IV Therapy Course #191" stated, "...IV Therapy...Label all tubing-including secondary lines..."

A. Patient #14 - MSU

Medical record review on 3/8/12 revealed a physician's order dated 3/5/12 at 9:54 PM, for the IV administration of Dextrose 5% with 0.9% normal saline solution (NSS).

During a medication administration pass on 3/8/12 at 11:00 AM with LPN A, Patient #14 was observed to have two (2) IV solutions infusing. One (1) IV bag containing 0.9% NSS was infusing instead of the solution that was ordered (D5 NSS) by the physician. In addition, one (1) IV bag containing a pre-mixed antibiotic was infusing as ordered. In addition, the IV tubing sets, running from the medication bags into the patient's IV site, were not labeled as required.

Review of the patient's medical record and a second observation of Patient #14 with ICU Director A and RN G on 3/8/11 at 11:30 AM confirmed these findings.

II. Based on observation, medical record review, staff interview and review of other hospital documents, it was determined that the RN failed to ensure the correct application of compression dressings for 1 of 1 (100%) patients (Patient #42) in the sample with a physician order for compression dressings. Findings include:

During an interview with Quality Manager A on 3/15/12 at 11:14 AM, Quality Manager A reported that the hospital had adopted Clinical Nursing Skills (Smith, S., Duell, D., & Martin, B. (2008). Clinical nursing skills: Basic to advanced, 7th ed., Pearson Prentice Hall, NJ)." as the accepted standard of practice for all nurses in the hospital. Review of clinical practice standards for the application of a spiral bandage stated,
"...Applying a Spiral Bandage...continue wrapping extremity upward, using a moderate amount of tension to stretch and apply bandage uniformly. Rationale: Unequal pressure can adversely affect circulation...circular turns create a tourniquet effect...Proximal wrapping (meaning towards the trunk of the body) promotes venous return..."

A. Patient #42 - PCU

Medical record review on 3/9/12 revealed a physician's order for foot and leg wound care dated 3/5/12 to apply short stretch compression dressings to the bilateral leg wounds from toes to knees, including heels, in a spiral fashion.

The following was observed during the application of the compression dressings, using a spiral technique, performed by RN E on 3/9/12 at 11:00 AM in PCU:

1. Left foot/leg
- Completed wound care as ordered
- Applied short stretch compression dressing to left foot and leg, upward in a spiral fashion from toes to knee
- When knee reached, RN E continued to wrap remaining dressing material going downward, approximately 1/3 of the length of left calf

2. Right leg
- Completed wound care as ordered
- Applied short stretch compression dressing to right foot and leg, upward in a spiral fashion from toes to knee.
- When knee reached, RN E continued to wrap remaining dressing material going downward, approximately 1/3 of the length of right calf

RN F and ICU Director A, present during the observation, confirmed these findings. RN F reported that RN E should not have continued wrapping the compression dressings in a downward spiral fashion after reaching the patient's knee.

III. Based on medical record review, policy review and staff interview, it was determined that for 2 of 41 (5%) patients in the sample (Patient #'s 12 and 14), nursing staff failed to monitor the effectiveness of medication. Findings include:

The hospital policy entitled "Nursing Assessment" stated, "...Each patient is reassessed at intervals so that further data may be collected to revise the plan of care...reassessment...guides the continuing plan of care and reassignment of priorities...Any change in a patient's condition...results in a reassessment..."

The hospital policy entitled "Documentation, General Guidelines" stated, "...When medication is given, reassessment of the efficacy of the intervention will be completed within one hour from the time of administration..."

A. Patient #12
Review of the medication administration record (MAR) revealed a physician's order to administer IV hydralazine (lowers blood pressure) every 6 hours as needed for a systolic blood pressure of greater than 170.

Review of the 3/4/12 MAR revealed:
- 7:03 AM: systolic blood pressure of 195
- 7:08 AM: IV hydralazine administered

Review of the MAR and other medical record documentation failed to provide evidence that nursing staff re-assessed Patient #12's blood pressure within one hour of medication administration to determine the effectiveness of the hydralazine. The next recorded blood pressure was documented at 10:00 AM as 139/102, approximately 3 hours after the administration of medication.

On 3/13/12 at 8:10 AM, ICU Director A reviewed Patient #12's medical record and confirmed this finding.
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B. Patient #14
Review of the MAR revealed a physician's order dated 3/6/12 at 1:13 AM for "IV Push" lorazepam (decreases anxiety) every 8 hours as needed for anxiety.

Review of the 3/6/12 MAR revealed:
- 1:37 AM: IV lorazepam administered

Review of the MAR and other medical record documentation failed to provide evidence that nursing staff re-assessed Patient #14's restlessness within one hour of medication administration to determine the effectiveness of the lorazepam. The next recorded patient assessment was at 5:00 AM (3 hours and 23 minutes later).

On 3/13/12 at 11:55 AM, ICU Director A and RN G confirmed this finding. ICU Director A reported that the nurse did not follow hospital policy and that the expectation was that the nurse would have entered a note within 1 hour of the administration of lorazepam.

Based on medical record review, policy review and staff interview, it was determined that for 3 of 41 (7%) patients in the sample (Patient #'s 12, 14 and 49), staff failed to develop and/or revise the plan of care to reflect current patient needs. Findings include:

The hospital policy entitled "Plan of Care" stated, "...plan is formulated after the assessment...and problems, whether actual or potential are identified. Interventions are then developed and implemented with goals and/or expected outcomes identified...plan of care will be individualized and reviewed every twelve (12) hours by an RN/LPN with review and validation by the RN every twenty-four (24) hours..."

A. Patient #12 - Intensive Care Unit (ICU)
Review of the hospital document entitled "Nanticoke Memorial Hospital Standing Orders" for Pneumococcal and Influenza Vaccines, revealed that the nurse assessed Patient #12 for the appropriateness of administering the two identified vaccines on 3/7/12 at 10:00 PM. The nurse determined at the time of the initial assessment that the vaccines were contraindicated secondary to "Acute febrile illness present (re-evaluate prior to discharge)".

The "Interdisciplinary Adult Plan of Care (IPOC) Guidelines" for Patient #12 included a section to develop a plan of care for "Vaccination Status". Patient #12's IPOC revealed that nursing staff failed to revise the plan of care when it was determined that Patient #12's vaccination status was an active problem and would require re-evaluation.

ICU Director A reviewed the medical record on 3/13/12 at 8:10 AM and confirmed this finding. ICU Director A reported that a plan of care for Patient #12's vaccination status should have been developed on or before 3/7/12.

B. Patient #14 - Medical Surgical Unit (MSU)
Review of the 3/5/12 "History and Physical" dictated by the physician at 9:18 PM, revealed a current medication list that included a duragesic patch (administered for the relief of chronic pain) applied every 72 hours (last applied on 3/5/12). The physician documented that a pharmacy consult was requested to assist with conversion to a different pain management protocol.

Review of the medication administration record (MAR) included physician's orders dated 3/6/12 at 4:04 PM and 3/8/12 at 10:00 AM, for the application of a duragesic patch every 3 days beginning on 3/8/12 at 10:00 AM.

Review of Patient #14's IPOC, initiated on 3/6/12, included a section to develop a plan of care for "Pain Management". However, nursing staff failed to implement a plan of care for pain management when it was determined through medication reconciliation, past history and active physician's orders for pain medication and management, that pain was an active problem for Patient #14.

On 3/8/12 at 11:55 AM, registered nurse (RN) G reviewed Patient #14's IPOC and confirmed that nursing staff failed to initiate a pain management plan of care.

C. Patient #49 (MSU)
Review of "Wound Care Documentation" entered by RN F on 3/6/12 at 11:16 AM revealed that she had obtained a physician's order for wound VAC therapy (V.A.C. - vacuum assisted closure).

Review of Patient #49's IPOC revealed an active problem and approaches for skin integrity related to sacral decubitus (pressure ulcer). The plan of care included turning and repositioning every two hours and keeping the patient's skin clean, dry and well hydrated. Nursing staff failed to revise the plan of care to reflect sacral wound treatment interventions and goals.

On 3/14/12 at 1:35 PM, MSU Director A reviewed Patient #49's IPOC and confirmed that Patient #49's care plan had not been updated to reflect Patient #49's current wound care.

Based on medical record review, policy review and staff interview, it was determined that for 5 of 41 (12%) patients in the sample (Patient #'s 12, 14, 15, 16 and 49), the medical record entries failed to be complete. Findings include:

The hospital policy entitled "Documentation, General Guidelines" stated, "...Documentation in the patient's medical record must be accurate, complete and concise...medical record is a reflection of the patient's care and response to all interventions...All documentation must be completed in military time...the nurse has to document how the order was received...A clinical note is required...with the administration of prn medications, excluding pain medications since this documentation has to be entered on the pain assessment/re-assessment form...When a medication is given, reassessment of the efficacy of the intervention will be completed within one hour from the time of administration..."

The hospital's "Rules and Regulations" stated, "...All entries in the medical record must be associated with a date and time to indicate when the entry was made..."

The hospital policy entitled "Extended Care Information & Documentation" stated, "...After the assessment is completed, the Extended Care Form will be completed for those identified needs...rehabilitation...the patient/family is given Extended Care Information Form and choice of provider will be documented into the Case Management Note..."

A. Patient #12
1. Review of the medication administration record (MAR) revealed a physician's order to administer IV hydralazine (lowers blood pressure) every 6 hours as needed for a systolic blood pressure of greater than 170.

Review of the 3/4/12 MAR revealed:
- 7:03 AM: systolic blood pressure of 195
- 7:08 AM: IV hydralazine administered

Review of the MAR and other medical record documentation failed to provide evidence that nursing staff re-assessed Patient #12's blood pressure within one hour of medication administration to determine the effectiveness of the hydralazine. The next recorded blood pressure was documented at 10:00 AM as 139/102, approximately 3 hours after the administration of medication.

On 3/13/12 at 8:10 AM, Intensive Care Unit (ICU) Director A reviewed Patient #12's medical record and confirmed this finding.

2. The nurse assessed Patient #12 for the appropriateness of administering the pneumococcal and influenza vaccines on 3/7/12 at 10:00 PM. The nurse determined at the time of the initial assessment that the vaccines were contraindicated secondary to "Acute febrile illness present (re-evaluate prior to discharge)".

The nurse that performed the initial assessment then signed and dated the "Vaccination Decision". At that time point, a final decision had not been determined. The "Vaccination Decision" should not have been signed off until Patient #12 was reassessed prior to discharge.

ICU Director A reviewed the form on 3/13/12 at 8:10 AM and confirmed that the nurse failed to accurately document the patient's vaccination decisions for pneumonia and influenza vaccines.

B. Patient #14
Review of the MAR revealed a physician's order dated 3/6/12 at 1:13 AM for "IV Push" lorazepam (decreases anxiety) every 8 hours as needed for anxiety.

Review of the 3/6/12 MAR revealed:
- 1:37 AM: IV lorazepam administered

Review of the MAR and other medical record documentation failed to provide evidence that nursing staff re-assessed Patient #14's restlessness within one hour of medication administration to determine the effectiveness of the lorazepam. The next recorded patient assessment was at 5:00 AM (3 hours and 23 minutes later).

On 3/13/12 at 11:55 AM, ICU Director A and registered nurse (RN) G confirmed this finding. ICU Director A reported that the nurse did not follow hospital policy and that the expectation was that the nurse would have entered a note within 1 hour of the administration of lorazepam.

C. Patient #15
3/6/12
1. "MAR Summary" - The nurse documented on the MAR that amlodipine (administered for the treatment of high blood pressure) and cilostazol (administered to improve circulation) were held at 10:00 AM as ordered by the physician.

Review of "Orders" revealed no physician's order to hold the two identified medications.

2. "Interagency Transfer Form" - The physician completed the form on 3/8/12, but failed to document the time of signature entry.

3. "Certification Statement for Ambulance Transfer" - The Case Manager failed to document the time of signature entry.

4. "Extended Care Information" form - During an interview on 3/8/12 at 2:20 PM, Patient #15, a Medicare recipient, reported that he was being discharged "today" to a rehabilitation facility chosen by the family. When asked, Patient #15 reported that he had not received a list of Medicare approved providers.

Review of the medical record revealed no "Extended Care Information" document in the medical record to support that the patient and/or family had been given the "Extended Care Information" choice form.

Interview with ICU Director A on 3/8/12 at 3:55 PM confirmed these findings.

D. Patient #16
1. "Progress Notes" - The physician failed to document the time of record entry on 3/8/12 and 3/12/12.

2. The nurse failed to document an assessment of Patient #16's pain or medication effectiveness, within an hour after administering the pain medication Fentanyl, on 3/11/12 at 1:34 PM.

Interview with ICU Director A on 3/13/12 at 10:10 AM confirmed these findings.

E. Patient #49
"Wound Care Documentation" - RN F documented on 3/6/12 at 11:16 AM, that a physician's order had been obtained for wound VAC (V.A.C. - vacuum assisted closure) therapy to be applied to a sacral wound with visible bone at a pressure setting of 125.

Review of the medical record revealed no physician's order for wound V.A.C. therapy.

On 3/14/12 at 3:40 PM, Medical-Surgical Unit Director A reviewed the medical record and confirmed that there was no physician's order for wound V.A.C. therapy.

Based on observation and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure the safety for 61 of 61 (100%) inpatients and for 3 of 3 (100%) off-campus designated provider-based entities. The hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code (LSC) of the National Fire Protection Association (see the attached CMS-2567s referencing LSC deficiencies).

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness and integrity in a manner to assure patient safety in 14 of 32 (44%) patient care/support areas toured. Findings include:

The hospital policy entitled "Scope of Services" stated, "...the maintenance department is responsible for operation, preventive maintenance; break down maintenance; and troubleshooting of all real property and infrastructure systems. Maintenance duties include but are not limited to, the following...Patching and painting of all damaged areas, Repairing of plumbing...Replacement of any damaged floor and ceiling tiles..."

The hospital policy entitled "Cleaning Non-Patient/Non-Resident Rooms in
Clinical Areas" stated, "To maintain cleanliness throughout the corporation, the following areas require daily cleaning: Treatment Center, Pharmacy, Laboratory, workstations, waiting areas, exam rooms, clean utility rooms, soiled utility rooms, pantries, dictation areas, lounges, printer rooms, consult rooms, and locker rooms..."

The hospital policy entitled "Housekeeping" stated, "...Floors, walls and tabletops are kept visibly clean on a regular basis..."

Hospital staff accompanied the surveyor during environmental tours at the Hospital, the Mears Campus and the Cancer Care Center. The following was observed and confirmed at the time of discovery:

I. Main Hospital Campus on 3/8/12

A. 5th Floor -- Specialty Surgical Unit, beginning at 10:55 AM and ending at 11:45 AM
- 2 taped signs in doctors' dictation area
- computer server desk serving rooms 5001 and 5002 (damaged laminate)
- sign taped to door of room 5003
- wall desk at room 5004, taped signs and stickers
- clean linen closet, excessive build up of dust balls on floor
- wall desk at room 5008, tape and stickers
- medication room, 22 taped signs on cabinet, refrigerator and medication
storage unit; excessive dust on top of medication storage unit and refrigerator
- rehabilitation services, signs taped to windows
- sign taped to orthopedic training door

These findings were confirmed at the time of observation by Quality Manager A.

B. 4th Floor -- Obstetrics and Nursery, beginning at 11:55 AM and ending at 12:30 PM
- shower room - toilet paper dispenser covered with fabric tape, taped sign, sticky floor

These findings were confirmed at the time of observation by Quality Manager A and Compliance and Quality Director A.

C. 2nd Floor -- Intensive Care Unit, beginning at 12:35 PM and ending at 1:05 PM

- equipment room - tape on blanket warmer
- medication room - signs taped to medication refrigerator and to door

These findings were confirmed at the time of observation by Quality Manager A and Compliance and Quality Director A.

D. 3rd Floor -- Medical/Surgical Unit, beginning at 2:20 PM and ending at 2:55 PM
- nourishment room - dusty ceiling vent, signs taped to surfaces
- medication room - 7 signs taped to cabinets and surfaces

These findings were confirmed at the time of observation by Maintenance Supervisor A.

E. 2nd Floor -- Progressive Care Unit, beginning at 3:05 PM and ending at 3:45 PM
- nourishment - 2 signs taped to painted wall
- dialysis room - 4 signs taped to door
- room 2025/2026 - 8 feet of ceiling tile grid rusted

These findings were confirmed at the time of observation by Maintenance Supervisor A.

II. Main Hospital Campus on 3/9/12

A. 1st Floor -- Clinical Decision Unit (CDU), beginning at 8:45 AM and ending at 8:50 AM
- nourishment area - sign taped to refrigerator

B. 1st Floor -- Pediatrics, beginning at 8:59 AM and ending at 9:10 AM
- medication room - tape on refrigerator; air conditioner piping, where it met the ceiling, was covered with tape

Findings were confirmed at the time of observation by Quality Manager A.

C. 1st Floor -- Emergency Department, beginning at 9:25 AM and ending at 10:34 AM
- taped signs in Exam Room 1
- Pediatric Exam Room - signs identifying the bed numbers are paper and taped to the wall; treatment table with stickers and adhesive residue
- Exam Room 14 - adhesive residue, taped signs on cabinets
- Trauma Room B - adhesive tape and residue on the boom supporting the light, monitor, supports and handle

Findings were confirmed at the time of observation by Quality Manager A and Compliance and Quality Director A.

D. 1st Floor -- Radiology/Nuclear Medicine, beginning at 10:55 AM and ending at 11:28 AM
- X-ray Room 1 - two doorways with a hole in drywall created by doorknobs

These findings were confirmed at the time of observation by Maintenance Supervisor A.

E. 1st Floor -- Cardiac Catheterization Suite, observation made at 11:35 AM
- soiled utility closet - adhesive tape closing off the opening to the flushing hopper, when tape was removed, there was no water remaining in the hopper and dead bugs were present

This finding was confirmed at the time of discovery by Maintenance Supervisor A.

III. Main Hospital Campus on 3/12/12

A. 1st Floor -- Pharmacy, observation made at 11:55 AM
- multiple taped signs on glass doors and windows

This finding was confirmed at the time of discovery by Quality Manager A.

B. 1st Floor -- Operating Room (OR) Suite, beginning at 1:43 PM and ending at 3:00 PM
- OR #2 - seamless flooring cracked along cove base
- OR #3 - flooring cracked along cove base
- OR #4 - hole in drywall

These findings were confirmed at the time of discovery by Compliance and Quality Director A.

IV. Mears Campus tour on 3/13/12 beginning at 8:55 AM and ending at 11:10 AM:

A. Outpatient Imaging and Laboratory Services
- phlebotomy 1 area - damaged drywall

B. Orthopedic & Rehabilitation Services
- physical therapy gym - cove base missing

Findings at the Mears Campus were confirmed on discovery by Quality Manager A and Compliance and Quality Director A.

V. Cancer Care Center tour on 3/13/12 beginning at 11:15 AM and ending at 11:45 AM.

- patient changing area - taped sign

Findings at the Cancer Care Center were confirmed on discovery by Quality Manager A and Compliance and Quality Director A.

Based on facility policy, document review and staff interview, it was determined that for 61 of 61 (100%) inpatients, the hospital failed to assure that a bulk water supply would be available in the event of a disruption in water supply or in the event of an emergency. Findings include:

The hospital policy entitled "Domestic Water Failure" stated, "...Non Potable Water will be supplied by the Facility Department through an outside contractor. It will be distributed to each floor that serves patients to provide water for flushing commodes..."

Review of outside contracts on 3/14/12 revealed there was no arrangement or agreement for the provision of bulk water.

During an interview with Facilities Management Director A on 3/14/12 at 10:15 AM, it was confirmed that the vendor supplying water in event of an emergency had discontinued the agreement for the provision of bulk water.

Based on observation and staff interview, it was determined that for 61 of 61 (100%) inpatients and for 3 of 3 (100%) off-campus designated provider-based entities, the hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (see the attached CMS-2567s referencing Life Safety Code deficiencies).

Based on observation, staff interview and policy review, it was determined that the hospital failed to ensure an acceptable level of safety, quality,
cleanliness and condition of patient care equipment and supplies in 11 of 32 (34%) patient care/support areas. Findings include:

The hospital policy entitled "Housekeeping" stated, "...Manufacturer's instructions are followed for cleaning medical equipment..."

The anesthesiology policy entitled "Infection Control Procedures During Anesthesia" stated, "...anesthesia machines will be wiped with hospital approved germicide at the beginning of the day. The machines will be surface cleaned with germicide solution between each patient (case)..."

The hospital policy entitled "Environmental Cleaning in the Surgical Practice Setting" stated, "...Wheels and casters of furniture and equipment must be cleaned and kept free of debris..."

Hospital staff accompanied the surveyor during environmental tours at the Hospital, the Mears Campus and the Cancer Care Center. The following was observed and confirmed at the time of discovery:

I. Main Hospital Campus on 3/8/12

A. 5th Floor -- Specialty Surgical Unit, beginning at 10:55 AM and ending at 11:45 AM
- code cart, top of the cart and defibrillator dusty
- family waiting area, 13 uncleanable fabric-upholstered chairs
- nourishment area, dirty and excessively frosted refrigerator/freezer, sign taped on ice machine
- clean utility room - clean and sterile packaged supply storage commingled with equipment
- dirty utility table, dirty scale and 2 commodes
- sign taped to orthopedic training door
- uncleanable fabric-upholstered furniture (3 chairs, 1 sofa)

These findings were confirmed at the time of observation by Quality Manager A.

B. 2nd Floor -- Intensive Care Unit, beginning at 12:35 PM and ending at 1:05 PM
- 2 dusty crash carts, dusty suction and defibrillator units
- equipment room - tape on blanket warmer
- medication room - signs taped to medication refrigerator and to door
- near respiratory room - electrocardiogram (ECG) machine covered with tape, screen with tape on surface

These findings were confirmed at the time of observation by Quality Manager A and Compliance and Quality Director A.

C. 3rd Floor -- Medical/Surgical Unit, beginning at 2:20 PM and ending at 2:55 PM
- ECG machine with tape covering moderate amount of surface area, dusty

This finding was confirmed at the time of observation by Maintenance Supervisor A.

D. 2nd Floor -- Progressive Care Unit, beginning at 3:05 PM and ending at 3:45 PM
- code cart, suction canister and defibrillator dusty
- central line cart - signs taped to cart, sticker residue on cart
- clean utility room - 8 corrugated cardboard boxes (containing paper isolation gowns)
- equipment room - equipment stored in room with clean supplies

These findings were confirmed at the time of observation by Maintenance Supervisor A.

II. Main Hospital Campus on 3/9/12

A. 1st Floor -- Clinical Decision Unit (CDU), beginning at 8:45 AM and ending at 8:50 AM
- equipment room - vinyl cover on clean linen cart was damaged and cannot be cleaned or disinfected
- tape residue on defibrillator

These findings were confirmed at the time of observation by Quality Manager A.

B. 1st Floor -- Pediatrics, beginning at 8:59 AM and ending at 9:10 AM
- exam room - uncleanable damaged vinyl covers on 2 bassinet mattresses

These findings were confirmed at the time of observation by Quality Manager A.

C. 1st Floor -- Emergency Department, beginning at 9:25 AM and ending at 10:34 AM
- soiled fabric chair seat in physician/patient conference room
- dusty stretcher base in Exam Room 6
- 4 computers-on-wheels (COW) desktop surfaces were soiled
- defibrillator on code cart in minor care area with sticker and residue
- clean supply - commode with non-cleanable lid stored with packaged clean supplies
- Exam Room 9 - latex sensitivity cart with adhesive residue

These findings were confirmed at the time of observation by Compliance and Quality Director A.

D. 1st Floor -- Radiology/Nuclear Medicine, beginning at 10:55 AM and ending at 11:28 AM
- supply room - vinyl cover on linen cart was damaged and uncleanable
- nuclear medicine room 2 - chair with uncleanable damaged vinyl
- nuclear medicine room 1 - large quantity of adhesive tape wrapped around IV (intravenous) pole extension

These findings were confirmed at the time of observation by Maintenance Supervisor A.

III. Main Hospital Campus on 3/12/12

A. 1st Floor -- Operating Room (OR) Suite, beginning at 1:43 PM and ending at 3:00 PM
- OR #2 - adhesive residue on electro-cautery machine; adhesive residue on the anesthesia cart; rusty casters on ring stand and rolling table
- OR #5 - cracked, damaged vinyl cover for linen cart, ring stand with rusty casters, bases of rolling equipment dusty
- restricted corridor - 2 OR tables with damaged vinyl-covered mattresses
- equipment room - damaged vinyl covers on orthopedic surgery equipment and urology procedure table
- OR #4 - end of cystoscopy bed has damaged laminate and adhesive residue
- OR #3 - signs taped on infant warmer, 2 ring stands with rusty casters, rolling IV pole with rusted casters

These findings were confirmed at the time of discovery by Compliance and Quality Director A.

IV. Mears Campus on 3/13/12

A. Outpatient Imaging and Laboratory Services, beginning at 8:55 AM and ending at 9:20 AM
- 5 uncleanable fabric upholstered chairs and 1 settee
- uncleanable fabric seat pads in the 4 changing rooms
- torn vinyl armrest on phlebotomy (blood drawing) chair

B. Orthopedic & Rehabilitation Services, beginning at 9:25 AM and ending at 11:10 AM
- 19 soiled fabric-upholstered chairs in waiting area
- occupational therapy room - treatment tables with dusty bases
- physical therapy evaluation rooms - foam wedges stored on floor
- physical therapy gym - foam therapy equipment stored on the floor

Findings at the Mears Campus were confirmed on discovery by Quality Manager A and Compliance and Quality Director A.

I. Based on observation, policy review, job description review and staff interview, it was determined that for 9 of 23 (39%) patient observations, (Patient #'s 14, 16, 17, 18, 19, 27, 42, 45 and 61) staff failed to follow the hospital's policy for infection control. Findings include:

The hospital job description entitled "Infection Preventionist" stated, "...Responsible for developing and implementing a comprehensive infection prevention, surveillance, and control program...ensures regulatory compliance...and practice standards..."

The hospital's policy entitled "Hand Hygiene" stated, "...staff will follow the recommendations for practicing hand hygiene from the Centers for Disease Control (CDC) and Prevention...All healthcare workers are required to practice hand hygiene...Before and after touching patients. Before and after wearing gloves. After contact with items in the immediate vicinity of the patient. When moving from a contaminated body site to a clean body site during patient care..."

The hospital's registered nurse (RN) job description stated, "...The registered nurse...assures...adherence to infection control standards..."

The hospital's licensed practical nurse (LPN) job description stated, "...the nurse...assures...adherence to infection control standards..."

A. Patient #14 - Medication administration

The following was observed during a medication administration pass by LPN A on 3/8/12 from 11:00 AM - 11:10 AM in the Medical Surgical Unit (MSU):

- Washed hands
- Donned gloves
- With gloved hands:

- Retrieved bandage scissors from inside uniform pocket
- Picked up medication packet containing medication Patch #1 from top of nurse's rolling cart
- Using scissors, opened and removed medication Patch #1
- Touched patient's skin and bed side rail
- Touched nurse's uniform pocket and bed side rail
- Applied medication Patch #1 to patient's skin
- Removed a second medication packet containing medication Patch #2 from the top of the nurse's rolling cart
- Using scissors, opened and removed medication Patch #2
- Applied medication Patch #2 to patient's skin
- Computer hand held "mouse" fell off top of nurse's rolling cart onto the floor by the patient's bed
- LPN A picked up the computer mouse from the floor and placed it back on the top of the rolling cart
- Opened packaging containing antibiotic to be delivered intravenously (IV)
- Removed the IV tubing from a completed/empty IV bag connected to patient's IV machine and then to the patient
- Spiked (pierced) the IV antibiotic medication bag with the IV tubing
- Started the antibiotic infusion
- Removed gloves
- Performed hand hygiene

LPN A failed to perform hand hygiene:
- Before touching the patient
- After touching inanimate objects
- Before spiking the patient's IV medication

Intensive Care Unit (ICU) Director A, present during the observation, confirmed these findings. The medication administration observation was discussed with Infection Preventionist A during an interview on 3/14/12 at 10:03 AM. Infection Preventionist A reported that LPN A failed to follow the hospital's hand hygiene policy and CDC guidelines for infection prevention.
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B. Patient #16 - Wound care: Right Achilles tendon (back of heel); In isolation for MRSA (methicillin-resistant Staphylococcus aureus - bacterial infection)

The following was observed during wound care and dressing change provided by LPN B on 3/13/12 from 10:20 AM - 10:55 AM, in the Surgical Specialty Unit (SSU):

- Performed hand hygiene
- Donned gloves
- With gloved hands:

- Cleansed wound with spray wound cleanser
- Retrieved Silvasorb (anti-infective medication) ointment/gel tube from tray table top, opened tube, applied gel to top-most 4x4 gauze pad in sterile gauze container
- Recapped tube, placed tube on tray table
- Retrieved medicated 4x4 gauze pad from sterile gauze container
- Applied medicated gauze to wound, completed dressing change
- Removed gloves, performed hand hygiene

LPN B failed to perform hand hygiene and/or change gloves:
- After touching an inanimate object and prior to touching the patient

ICU Director A, present during the observation, confirmed these findings. ICU Director A reported that LPN B failed to comply with the hospital's infection control procedures or hand hygiene policy. The wound care observation was discussed with Infection Preventionist A during an interview 3/14/12 at 10:03 AM. Infection Preventionist A reported that nurses were expected to follow hospital policy and CDC guidelines for hand hygiene.
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C. Patient #17 - Wound care: Sacrum (lower back)

The following was observed during wound care and dressing change provided by registered nurse (RN) F on 3/9/12 at 8:45 AM, in MSU:

- Performed hand hygiene
- Donned gloves
- With gloved hands:

- Removed and disposed of old sacral dressing
- Retrieved spray cleanser bottle and cleansed wound
- Applied dressing to sacrum, completed dressing change
- Removed gloves, performed hand hygiene

RN F failed to perform hand hygiene and/or change gloves:
- After touching an inanimate object and prior to touching the patient

Interview with RN F on 3/9/12 at 11:40 AM confirmed that she had failed to comply with the hospital's infection control policy while performing wound care.
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D. Patient #18 - Medication administration

The following was observed during the medication administration pass performed by RN A on 3/8/12 from 11:05 AM - 11:15 AM in MSU:

- Touched IV pump and computer
- Washed hands
- Donned gloves
- With gloved hands:

- Retrieved alcohol pad from pants pocket
- Touched computer
- Opened alcohol pad
- Cleansed patient's abdominal site with alcohol pad
- Injected medication
- Discarded supplies
- Removed gloves
- Touched computer
- Disinfected hands

RN A failed to perform hand hygiene and/or change gloves:
- After touching the computer and before administering medication
- After removing gloves

MSU Director A, present during the observation, confirmed these findings.
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E. Patient #19 - Medication administration

The following was observed during the medication administration pass performed by RN B on 3/8/12 from 2:30 PM - 2:40 PM in the Progressive Care Unit (PCU):

- Washed hands
- Touched Omnicell (medication dispensing unit) screen and drawers
- Disinfected hands
- Touched computer
- Reached into pocket
- Donned gloves
- Opened alcohol pad
- Cleansed patient's abdominal area with alcohol pad
- Injected medication
- Removed gloves
- Plugged computer on wheels into an electrical outlet
- Washed hands

RN B failed to perform hand hygiene:
- Before donning gloves
- Immediately after removing gloves

The Medical-Surgical Unit Director A, present during the observation, confirmed these findings.
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F. Patient #27 - Respiratory therapy treatment

The following was observed during the respiratory treatment administered by respiratory therapist (RT) A on 3/12/12 between 2:00 and 2:15 PM in the Medical-Surgical Unit:

- Donned gloves
- Touched patient wrist to verify identity
- Retrieved nebulizer mask and tubing from a bag (previously used by patient)
- Retrieved a pulse oximeter from pants pocket
- Auscultated (listened to) patient's lungs with stethoscope
- Opened nebulizer medication chamber, filled with medication and closed chamber
- Turned flow meter on
- Placed nebulizer mask on patient's face
- Removed mask after the treatment was completed
- Placed nebulizer and tubing in a bag
- Removed gloves
- Disinfected hands with foam sanitizer

RT A failed to perform hand hygiene and change gloves:
- After touching the previously used nebulizer mask and tubing
- Before and after touching the patient

Medical-Surgical Unit Director A, present during the observation, confirmed these findings.
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G. Patient #42 - Wound care: Left foot

The following was observed during wound care provided by RN E on 3/9/12 from 11:00 AM - 11:40 AM in PCU:

- Washed hands; Donned gloves; Set-up equipment and supplies on tray table top
- Disinfected hands; Donned gloves
- Removed and discarded soiled left leg/foot dressings
- Disinfected hands
- Donned gloves
- With gloved hands:

- Retrieved spray cleanser from tray table top; cleansed wound
- Applied Mepilex dressing (absorbs wound debris and maintains a moist environment) to left foot
- Applied gauze dressing
- Applied short stretch compression dressing to left foot and leg

RN E failed to perform hand hygiene and/or change gloves:
- After touching an inanimate object and before touching the patient

ICU Director A and RN F, present during the observation, confirmed these findings.
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H. Patient #45 - Wound care: Chest (2 wounds)

The following was observed during wound care and dressing change provided by RN D on 3/12/12 from 10:35 AM - 10:55 AM in the SSU:

- Performed hand hygiene; Donned gloves
- Removed and discarded soiled dressing from top of patient's wounds
- Removed packing from Wound #1
- Disinfected hands; Donned gloves
- With gloved hands:

- Opened sterile saline-filled syringe, removed from packaging and placed syringes on tray table top
- Opened 4x4 gauze packet; Placed packet on tray table top
- Picked up sterile saline-filled syringe and 4x4 gauze pads from sterile packet
- Irrigated wound with sterile saline-filled syringe
- Wiped the patient's wound with 4x4 gauze
- Disinfected hands
- Donned gloves
- With gloved hands:

- Retrieved roll of tape from inside RN D's pocket
- Took pieces of tape off tape roll, attached tape strips to side of tray
- Disinfected hands
- Donned sterile gloves
- With gloved hands:

- Packed Wound #1 with gauze
- Used tape strips to secure 4x4 gauze to Wound #1
- Applied 4x4 gauze to chest Wound #2
- Secured dressing with tape
- Removed gloves
- Disinfected hands
- Placed tape roll back in left pocket and retrieved pen from same pocket
- Wrote on tape strip and attached tape to patient's dressing

RN D failed to perform hand hygiene and/or change gloves:
- After touching inanimate objects and prior to touching the patient

ICU Director A, present during the observation, confirmed these findings. ICU Director A reported that RN D failed to follow the hospital's hand hygiene policy during wound care.
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I. Patient #61 - Respiratory therapy treatment

The following was observed during the respiratory treatment administered by RT A on 3/13/12 between 2:05 and 2:28 PM in the Progressive Care Unit:

- Retrieved medication from Omnicell (medication dispensing unit)
- Touched computer
- Donned gloves
- Closed privacy curtain for patient
- Touched computer
- Touched privacy curtain
- Opened privacy curtain
- Auscultated patient's lungs
- Retrieved pulse oximeter from pants pocket
- Retrieved phone from shirt pocket and spoke on phone
- Retrieved hand held nebulizer and tubing from a bag (previously used by the patient)
- Touched patient's left arm to assist him to move up in bed
- Opened nebulizer medication chamber, filled with medication and closed chamber
- Turned flow meter on
- Handed the hand held nebulizer to the patient
- Removed gloves
- Touched computer
- Donned gloves
- Touched nebulizer to check medication level
- After treatment was completed, placed hand held nebulizer and tubing in a bag
- Auscultated patient's lungs
- Removed gloves
- Touched computer
- Disinfected hands with foam sanitizer

RT A failed to perform hand hygiene and/or change gloves:
- Before donning gloves
- After patient contact
- After removing gloves
- After contact with inanimate objects

Medical-Surgical Unit Director A, present during the observation, confirmed these findings.

I. Based on closed medical record review, policy and contract review and staff interview, it was determined that for 4 of 9 (44%) patients (Patient #'s 9, 10, 11 and 32) in the sample that had expired in the hospital, staff failed to notify the Organ Procurement Organization (OPO). Findings include:

The hospital policy entitled "Organ and Tissue Donation" stated, "...organ procurement organization will be contacted for all deaths or pending deaths for the determination of suitability for organ and tissue donation...This policy assures that all potential organ, tissue and eye donors are identified, and that all potential donor families are provided the option of donation...Certificate of Referral/Request for Anatomical Donations is completed by the Charge Nurse or designee and placed in the patient's medical record..."

The hospital had a contract with the Gift of Life Donor Program. Review of the contract entitled "Donor Institution Memorandum of Agreement" stated, "...Donor Institution shall...implement and maintain current policies and procedures to provide for organ and tissue referral...establish a procedure for notification to Gift of Life at or near time of death of every patient at Donor Institution..."

1. Patient #9
Review of the "Discharge Summary" dated 1/1/12 at 11:44 AM revealed that Patient #9 was pronounced dead at 1:00 AM on 12/27/11.

Review of the medical record revealed no "Certificate of Referral/Request for Anatomical Donations" documentation or medical record entries to support that hospital staff had notified the Gift of Life Donor Program of the death of Patient #9.

2. Patient #10
Review of the 12/22/11"ED (Emergency Department) Physician Documentation" entries and additional ED medical record documentation revealed that attempts to resuscitate Patient #10 were unsuccessful and Patient #10 was pronounced dead at 10:14 AM on 12/22/11.

Review of the ED medical record revealed no "Certificate of Referral/Request for Anatomical Donations" documentation or medical record entries to support that hospital staff had notified the Gift of Life Donor Program of the death of Patient #10.

3. Patient #11
Review of the "Discharge Summary" dated 12/31/11 at 12:11 PM revealed that Patient #11 was pronounced dead at 2:00 PM on 12/30/11.

Review of the medical record revealed no "Certificate of Referral/Request for Anatomical Donations" documentation or medical record entries to support that hospital staff had notified the Gift of Life Donor Program of the death of Patient #11.

4. Patient #32
Review of the 12/26/11 "ED Physician Documentation" entries revealed that Patient #32 arrived in the ED without pulses, respirations or reflexes and was pronounced dead upon arrival at 5:53 PM on 12/26/11.

Review of the ED medical record revealed no "Certificate of Referral/Request for Anatomical Donations" documentation or medical record entries to support that hospital staff had notified the Gift of Life Donor Program of the death of Patient #32.

Interview with Program Development Coordinator A on 3/13/12 at 10:36 AM confirmed these findings. Program Development Coordinator A reported that all deaths in the hospital were to be reported to the Gift of Life Donor Program regardless of their disposition, including the deaths of patients that had donated their bodies to science (Patient #'s 9 and 11).

II. Based on contract review and staff interview, it was determined that the OPO contract with the Gift of Life Donor Program failed to address all of the required criteria in the agreement. Findings include:

Review of the OPO document entitled "Donor Institution Memorandum of Agreement" revealed that the Agreement failed to define "imminent death" and "timely notification".

Program Development Coordinator A reviewed the Agreement on 3/13/12 at 10:36 AM and confirmed these findings.

Based on medical record review, policy and document review and staff interview, it was determined that for 3 of 12 (25%) outpatients in the sample that received general, regional or monitored anesthesia (Patient #'s 29, 30 and 31), post-anesthesia evaluations were not completed and documented by an individual qualified to administer anesthesia. Findings include:

The policy entitled "Postoperative Anesthesia Care" stated, "...The patient will be transferred from the operating room...to the PACU...A licensed independent practitioner will document...the discharge of the patient from PACU, when the patient's condition is stable and...meets the PACU discharge criteria..."

Medical record review revealed a lack of documentation of a post-anesthesia evaluation prior to discharge for Patient #'s 29, 30 and 31. These findings were confirmed with Clinical Director of Anesthesia Services A on 3/12/12 at 3:30 PM.

Based on review of the organizational chart and staff interview, it was determined that for all patients receiving outpatient services since 11/9/11, the overall operation for outpatient services was not under the direction of a single individual. Findings include:

Review of the hospital's organizational chart dated 11/9/11 revealed that outpatient services at all locations were under the direction of three (3) individuals - Chief Nursing Officer A, Senior Vice President A and Clinical Operations Vice President A.

Interview with Chief Nursing Officer A on 3/14/12 at 1:54 PM confirmed that there was not one (1) identified person over outpatient services. Chief Nursing Officer A reported that the following operational structure for outpatient services was currently in use:

- Chief Nursing Officer A: Outpatient laboratories and cardiac rehabilitation
- Senior Vice President A: Outpatient radiology
- Clinical Operations Vice President A: Outpatient surgery and rehabilitation services

Chief Nursing Officer A reported that Senior Leaders were in the process of identifying the "right organizational structure" for the Outpatient Services Director.

Based on observation, policy review and staff interview, it was determined that for 2 of 4 (50%) observed respiratory treatments (Patient #'s 27 and 61), the respiratory therapists (RT) failed to follow the hospital policy approved by the medical staff. Findings include:

The hospital policy entitled "Handheld Nebulizer Administration" stated, "...Assess breath sounds, heart rate, cough, sputum production, and position...Assemble nebulizer...treatments usually last 12-15 minutes...When medication nebulizer is complete, turn off the gas flow. Open the nebulizer to tap excess liquid out against a clean, dry towel...Reassess patient..."

A. Patient #61
During an observation of a respiratory treatment for Patient #61 on 3/13/12 between 2:05 and 2:28 PM on the Progressive Care Unit, it was noted that RT A failed to open the nebulizer to tap excess liquid out against a clean, dry towel after the treatment was completed.

Medical Surgical Unit Director A was present at the time of the observation. On 3/13/12 at 4:00 PM, Medical Surgical Unit Director A confirmed that RT A failed to open the nebulizer to tap excess liquid out against a clean, dry towel after the treatment was completed as per the hospital policy.

B. Patient #27
During an observation of a respiratory treatment on 3/14/12 between 8:28 and 8:50 AM on the Medical Surgical Unit, it was noted that RT B failed to assess the patient before starting the nebulizer treatment and after the treatment was completed.

Medical Surgical Unit Director A was present at the time of the observation and confirmed these findings. On 3/14/12 at 9:30 AM, Senior Director of Therapy Services and Wellness A confirmed that RT B failed to perform respiratory assessments before the start of the nebulizer treatment and after the nebulizer treatment was discontinued as per the hospital policy.