HospitalInspections.org

Based on hospital policy reviews, "Reverse Osmosis (RO) Performance" log review, hemodialysis patient log review, personnel file reviews, grievance file reviews, staff interviews, and observations during tours as referenced in the Life Safety Report of Survey, the hospital failed to have an effective Governing Body to ensure: the promotion of patient's rights and to ensure a safe physical environment for patients, staff, and visitors.

The finding include:

1. The hospital failed to protect and promote patients' rights to ensure a safe setting by failing to provide hemodialysis treatment for dialysis patients in a safe environment by failing to perform water testing of chlorine and chloramine levels before initiating hemodialysis treatments to hemodialysis patients; failing to ensure documentation of water testing for chlorine and chloramine levels in hemodialysis treatments were performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift; failing to ensure that hemodialysis staff performing water testing of chlorine and chloramine levels were color tested to determine if they were able to discern colors in colormetric tests used at the hospital in 2 of 6 sampled staff members that performed water testing at the hospital (Hemodialysis nurse #2, #3); and failing to provide a timely written notice of its' decision and results of the grievance process for 2 of 4 grievance files reviewed (#22, #24).

~cross refer to 482.13 Patients' Rights - Condition Tag A0115.

2. The hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

~cross refer to 482.41 Physical Environment Condition: Tag A0700.

Based on hospital policy review, the hospital's "Reverse Osmosis (RO) Performance" log review, the hospital's hemodialysis patient log review, personnel file review, grievance review, and staff interview, the hospital failed to protect and promote patients' rights to ensure a safe setting by failing to provide hemodialysis treatment for dialysis patients in a safe environment by failing to perform water testing of chlorine and chloramine levels before initiating hemodialysis treatments to hemodialysis patients; failing to ensure documentation of water testing for chlorine and chloramine levels in hemodialysis treatments were performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift; failing to ensure that hemodialysis staff performing water testing of chlorine and chloramine levels were color tested to determine if they were able to discern colors in colormetric tests used at the hospital in 2 of 6 sampled staff members that performed water testing at the hospital (Hemodialysis nurse #2, #3); and failing to provide a timely written notice of its' decision and results of the grievance process for 2 of 4 grievance files reviewed (#22, #24).

The findings include:

1. The hospital failed to provide hemodialysis treatment for dialysis patients in a safe environment by failing to perform water testing of chlorine and chloramine levels before initiating hemodialysis treatments to hemodialysis patients.

~Cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144.

2. The hospital failed to ensure documentation of water testing for chlorine and chloramine levels in hemodialysis treatments were performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift.

~Cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144.

3. The hospital failed to ensure that hemodialysis staff performing water testing of chlorine and chloramine levels were color tested to determine if they were able to discern colors in colormetric tests used at the hospital in 2 of 6 sampled staff members that performed water testing at the hospital (Hemodialysis nurse #2, #3).

~Cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144.

4. The hospital failed to provide a timely written notice of its decision and results of the grievance process for 2 of 4 grievance files reviewed.

~Cross refer to 482.13(a)(2)(iii) Patient Rights Standard: Tag A0123.

Based on review of hospital policies and procedures, grievance reviews and staff interviews hospital staff failed to provide a timely written notice of its' decision and results of the grievance process for 2 of 4 grievance files reviewed (#22, #24).

The findings include:

Review on 03/13/2012 of hospital policy "Complaint and Grievance Resolution" dated 02/2012 revealed "Procedure:...E. If a concern is considered to be a grievance...2. The resolution to most grievances should be reached within 7 days as practicable, and a written response is generated to the patient or patient's personal representative. If the issue has not been resolved within 7 days, the patient/personal representative will be notified in writing that the hospital is still working to resolve the grievance and the anticipated timeframe in which the patient/personal representative can expect a written response...5. A written response should be provided to each grievance, and includes the following information...b. The steps taken to investigate the grievance; c. The results of the grievance process..."

1. Review on 03/13/2012 of a grievance file for Patient #22 revealed the grievance was received on 01/16/2012. Review revealed an acknowledgement letter was sent to the complainant 01/19//2012 (three (3) days after grievance receipt). Review revealed another letter was sent to the complainant by the Director of Surgical Services on 02/17/2012 (32 days after grievance receipt). Review of the 02/17/2012 letter revealed "...Please be advised we are continuing to investigate your complaint and should have a final response to you very soon." Review failed to reveal any specific timeframe of completion. Review of the grievance file on 03/13/2012 failed to reveal any final resolution sent to the complainant (57 days after original date of receipt).

Interview with the hospital's Risk Manager on 03/14/2012 at 1600 revealed there was no final resolution letter sent to the complainant as of 03/14/2012. Interview revealed the letter sent out 02/17/2012 should have indicated a timeframe that follow-up would have occurred between the hospital and the complainant. Interview revealed facility staff failed to follow policy regarding grievance resolution with Patient #22 by failing to provide a follow-up timeframe and by failing to ensure a follow-up resolution letter was sent regarding the findings of the investigation and final determination regarding the grievance.

2. Review on 03/13/2012 of a grievance file for Patient #24 revealed the grievance was received on 02/03/2012. Review revealed a final resolution letter was sent to the complainant dated 02/15/2012. Review of the letter revealed "In reviewing the concerns you and your wife (name of spouse), shared with us at our meeting on February 1, 2012, we understand those to be as follows:...You had concerns regarding the care provided by (Dr. A)...You expressed concerns regarding the care provided to you by (Dr. B)...". Further review revealed "We completed the investigation on February 10, 2012...We have determined as follows:...Please allow me to reiterate from our initial letter that (Dr. A) is employed by (name of practice). We encourage you to discuss any concerns with the care she provided either with her directly or with (name of practice staff)...Please allow me to share with you that (Dr. B) is employed by (name of practice). We encourage you to discuss any concerns with the care he provided by contacting their office..."

Interview with the hospital's Risk Manager on 03/14/2012 at 1600 revealed the letter dated 02/15/2012 was the final resolution letter related to the grievance filed 02/03/2012 regarding Patient #24. Interview revealed the facility had investigated the issues regarding the physicians in the complaint, however had not included the information in the final letter. Interview failed to reveal any evidence the facility had communicated the investigative findings regarding the physicians to the complainant. Interview revealed staff failed to follow facility policy by failing to ensure written communication of investigative findings and final resolution to the complainant.

Based on hospital policy review, the hospital's "Reverse Osmosis (RO) Performance" log review, the hospital's hemodialysis patient log review, personnel file review, and staff interview, the hospital failed to provide hemodialysis treatment for dialysis patients in a safe environment by failing to perform water testing of chlorine and chloramine levels before initiating hemodialysis treatments to hemodialysis patients; ensure documentation of water testing for chlorine and chloramine levels in hemodialysis treatments were performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift; and ensure that hemodialysis staff performing water testing of chlorine and chloramine levels were color tested to determine if they were able to discern colors in colormetric tests used at the hospital in 2 of 6 sampled staff members that performed water testing at the hospital (Hemodialysis nurse #2, #3).

The findings include:

1. A review of the hospital's policy and procedure "Chlorine/Chloramine" (revised 01/2008) revealed "Purpose: To ensure that water used to prepare dialysate is free of chlorine and chloramines. Standard based on AAMI RD 62. Rational: Chlorine and Chloramine will damage the reverse osmosis membranes. RED BLOOD CELLS EXPOSED TO CHLORINE/CHLORAMINE WILL BE DESTROYED!! Procedure: 3...At the beginning of each day prior to starting hemodialysis treatments and after the RO has been running for several minutes, a water sample is tested for chlorine/chloramines. 11...If Chlorine/Chloramine result is positive after repeating testing notify Dialysis Medical Director and DO NOT start hemodialysis treatments."

A review on 03/12/2012 of the hospital's "Reverse Osmosis (RO) Performance" log from 03/2011 through 03/13/2012 (total of one year) revealed that on 10/20/2011 no documentation was found where any water testing for chlorine/chloramines was performed. The review of the hospital's RO performance log revealed that the log had a section labeled as "Chloramines Test (maximum 0.1ppm)". The review of the log revealed that the entire section of the RO Performance log on 10/20/2011 for the chloramines was left blank and not completed.

A review on 03/12/2012 of the hospital's hemodialysis patient log and census for 10/20/2011 revealed that a total of six (6) patients received hemodialysis. The hospital log did not reveal the complete names of the patient's receiving hemodialysis on 10/20/2011.

An interview on 03/12/2012 at 1430 with the hospital's Hemodialysis Director revealed that no chlorine/chloramine level for the dialysate water was complete on 10//20/2012. "We did not do it and I do not know reason why it was not done on the 20th. I usually catch that in the log reviews.. There was a schedule for 6 patients that received dialysis that day."

2. A review of the hospital's policy and procedure "Chlorine/Chloramine" (revised 01/2008) revealed "Purpose: To ensure that water used to prepare dialysate is free of chlorine and chloramines. Standard based on AAMI RD 62. Rational: Chlorine and Chloramine will damage the reverse osmosis membranes. RED BLOOD CELLS EXPOSED TO CHLORINE/CHLORAMINE WILL BE DESTROYED!! Procedure: 3...At the beginning of each day prior to starting hemodialysis treatments and after the RO has been running for several minutes, a water sample is tested for chlorine/chloramines. 11...If Chlorine/Chloramine result is positive after repeating testing notify Dialysis Medical Director and DO NOT start hemodialysis treatments."

A review on 03/12/2012 of the hospital's "Reverse Osmosis (RO) Performance" log from 03/2011 through 03/13/2012 (total of one year) revealed no documented times found anywhere on the log to indicate when the dialysis staff tested the hemodialysis water for levels of chlorine/chloramines. The review revealed no evidence or documentation that that water testing of chlorine/chloramine was performed prior to patient's beginning their hemodialysis treatments.

An interview on 03/12/2012 at 1430 with the hospital's Hemodialysis Director revealed that no times were on the "Reverse Osmosis (RO) Performance" log to be able to tell when the dialysis water testing for chlorine/chloramines was completed. "There is no space on that log for times to be put in. I never thought of that when doing the testing. We are doing the tests prior to patients starting dialysis, but there is not documentation to show that."

3. A review of the hospital's policy and procedure "Chlorine/Chloramine" (revised 01/2008) revealed "Purpose: To ensure that water used to prepare dialysate is free of chlorine and chloramines. Standard based on AAMI RD 62. Rational: Chlorine and Chloramine will damage the reverse osmosis membranes. RED BLOOD CELLS EXPOSED TO CHLORINE/CHLORAMINE WILL BE DESTROYED!! Procedure: 3...At the beginning of each day prior to starting hemodialysis treatments and after the RO has been running for several minutes, a water sample is tested for chlorine/chloramines. 4. A water sample 5-10mls (milliliters), is collected from the test port after the 1st carbon tank. 5. Use a "WaterCheck 2" (colormetric test) test strip. 6. Compare color of test strip to color boxes on test strip bottle. 8. Any change in color is a POSITIVE result and retesting if required prior to starting hemodialysis treatments."

a. A review on 03/13/2012 of the hospital's personnel files for hemodialysis nurse #2 revealed that the nurse was hired at the hospital on 06/07/1983. The review revealed that the nurse performs water testing for chlorine/chloramine levels used to make dialysate for hemodialysis patients. The review further revealed that the nurse did not receive any color blindness testing until the survey date of 03/13/2012.

b. A review on 03/13/2012 of the hospital's personnel files for hemodialysis nurse #3 (Hemodialysis Director) revealed that the nurse was hired at the hospital on 04/13/1987. The review revealed that the nurse (Hemodialysis Director) performs water testing for chlorine/chloramine levels used to make dialysate for hemodialysis patients. The review further revealed that the nurse did not receive any color blindness testing until the survey date of 03/13/2012.

An interview on 03/12/2012 at 1430 with the hospital's Hemodialysis Director revealed that he and nurse #2 did not have any color blindness testing until 03/13/2012. The interview revealed no reason why the nurses did not receive any color blindness testing before 03/13/2012 since they were able to perform chlorine/chloramine testing. The interview also revealed that color blindness testing is needed since the strips used for water testing is requires the ability to read different colors.

Based on hospital policy review, medical record reviews, and nursing management staff interview, the emergency department's (ED) nursing staff failed to ensure the initial assessment of a patient's pain level upon admission (triage) to the ED for 7 of 15 records reviewed (#40, #32, #10, #7, #5, #4, #3) and failed to reassess a patient's response to pain interventions for 2 of 15 records reviewed (#40, #32).

The findings include:

Review of current hospital policy "Pain Management" revised July, 2011, revealed "...II Assessment A. In any area where a nursing assessment is performed, patients will be screened for pain as a part of the admission/pre-procedure assessment. If pain is identified during the initial assessment, the location, scale, characteristics, frequency and duration of the patient will be assessed. ...E. Not all patients are able to describe pain....Pain assessment for these patients should be based upon behavior, facial expression and the appropriate pain scale applied. ...Plan of Management A. ...When analgesia is administered in response to the patient's complaints of pain, the nurse will assess the effectiveness of the medication within one hour, or sooner, as appropriate to the condition of the patient and the route of administration. ..."

1. Closed record review on 03/13/2012 for Patient #40 revealed a 46 year old male admitted to the hospital's emergency department (ED) on 03/10/2012 at 1711. Review revealed the patient was triaged at 1715 by a registered nurse (RN). Review revealed a chief complaint of back pain. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Review of nursing documentation revealed the patient was administered Demerol (narcotic pain medication) 100 milligrams intramuscular per physician's order by a RN at 2030. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level (within one hour or sooner) in response to the administration of the Demerol at 2030, prior to the patient's discharge at 2210.

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Further interview revealed "pain will be reassessed after pain medications are administered, usually within one hour." Interview confirmed no documented evidence of an initial pain assessment upon admission to the emergency department nor any reassessments of the patient's pain level within one hour or sooner in response to the administration of the Demerol at 2030, prior to Patient #40's discharge at 2210. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

2. Closed record review on 03/13/2012 for Patient #32 revealed a 82 year old male admitted to the hospital's emergency department (ED) on 03/06/2012 at 1135. Review revealed the patient was triaged at 1135 by a registered nurse (RN). Review revealed a chief complaint of shortness of breath. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Review of nursing documentation revealed the patient was administered Dilaudid (narcotic pain medication) 1 milligram intravenous per physician's order by a RN at 1255. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level (within one hour or sooner) in response to the administration of the Dilaudid at 1255, prior to the patient's admission to an inpatient unit at 1540.

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Further interview revealed "pain will be reassessed after pain medications are administered, usually within one hour." Interview confirmed no documented evidence of an initial pain assessment screening upon admission to the emergency department nor any reassessments of the patient's pain level within one hour or sooner in response to the administration of the Dilaudid at 1255, prior to the Patient #32's admission to an inpatient unit at 1540. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

3. Closed record review on 03/13/2012 for Patient #10 revealed a 38 year old male admitted to the hospital's emergency department (ED) on 03/08/2012 at 1153. Review revealed the patient was triaged at 1156 by a registered nurse (RN). Review revealed a chief complaint of right middle finger partial tip amputation. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level prior to the patient leaving before receiving treatment (LBRT) at 1245.

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Interview confirmed no documented evidence of an initial pain assessment upon admission to the emergency department nor any reassessments of the patient's pain level prior to Patient #10 leaving before receiving treatment at 1245. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

4. Closed record review on 03/13/2012 for Patient #7 revealed a 9 year old male admitted to the hospital's emergency department (ED) on 01/01/2012 at 0116. Review revealed the patient was triaged at 0135 by a registered nurse (RN). Review revealed a chief complaint of wheezing. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level prior to the patient being discharged at (no time documented).

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Interview confirmed no documented evidence of an initial pain assessment upon admission to the emergency department nor any reassessments of the patient's pain level prior to the Patient #7's discharge. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

5. Closed record review on 03/13/2012 for Patient #5 revealed a 45 year old female admitted to the hospital's emergency department (ED) on 12/04/2011 at 1157. Review revealed the patient was triaged at 1200 by a registered nurse (RN). Review revealed a chief complaint of vomiting and generalized body aches. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level prior to the patient's admission to an in-patient unit at (no time documented).

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Interview confirmed no documented evidence of an initial pain assessment upon admission to the emergency department nor any reassessments of the patient's pain level prior to Patient #5's admission to an in-patient unit. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

6. Closed record review on 03/13/2012 for Patient #4 revealed a 89 year old female admitted to the hospital's emergency department (ED) on 11/10/2011 at 0950. Review revealed the patient was triaged at 0950 by a registered nurse (RN). Review revealed a chief complaint of a fall with right leg pain. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED.

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Interview confirmed no documented evidence of an initial pain assessment upon Patient #4's admission to the emergency department at 0950. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

7. Closed record review on 03/13/2012 for Patient #3 revealed a 45 year old male admitted to the hospital's emergency department (ED) on 11/06/2011 at 1321. Review revealed the patient was triaged at 1325 by a registered nurse (RN). Review revealed a chief complaint of toothache for two days. Review of the ED nursing record revealed a section for the RN to document the patient's initial pain assessment screening upon triage. Review revealed the following "PAIN LEVEL pain level _[left blank]_/10 locations_[left blank]_ characteristics__[left blank]_ onset_[left blank]_ frequency_[left blank]_ A=Aching B=Brusing C=Cramping P=Pressure T=Throbbing S=Sharp" preprinted on the ED nursing record. Further record review failed to reveal documented evidence of an initial pain assessment screening upon admission to the ED nor any reassessments of the patient's pain level prior to the patient's discharge at (no time documented).

Interview on 03/13/2012 at 1330 with the ED Nurse Manager revealed "pain is to be assessed on presentation, especially if injuries are present." Interview confirmed no documented evidence of an initial pain assessment upon admission to the emergency department nor any reassessments of Patient #3's pain level prior to the patient's discharge. Interview confirmed the nursing staff failed to follow hospital policy for pain management.

Based on hospital policy review, observations during tour, Grandmaster Key Permanent Issue List review, and staff interview, the hospital failed to ensure patient records were kept secured and accessible only by those persons having a part in the patient's care or a need to know by failing to limit access to the Medical Record Department by non-medical record department personnel who were issued a master facility key.

The findings include:

Review of hospital policy "Security of the Medical Record Department" revised 01/2010, revealed "Policy: 1. During evening (6pm-11pm) and night (11pm-7pm) hours all doors in the Medical Record Department shall be closed and locked...."

Review of hospital policy "Confidentiality and Security of Protected Health Information" revised 03/2012 revealed "...Other hospital employees that have a key to the Medical Record Department are listed on the Grand Master Key List...maintained by Engineering Director. (attached) Positions included CEO, Vice Presidents, Engineering, Housekeeping Director, Housekeeping Supervisor, Nursing Supervisor, Information Systems Director and Security Supervisor. ..."

Interview on 03/14/2012 at 1000 with the Medical Records Director revealed the hospital's Medical Record Department is located in (4) locations within the hospital. Interview revealed three of the four locations store medical records. Interview revealed the main file room is staffed 24 hours per day, 7 days per week, 365 days per year with a minimum of 1 (on nights) medical records staff member available within the hospital. Interview revealed pagers are available for staff members to carry when not in the file room, for emergencies.

Observation during tour on 03/14/2012 at 1025 of the Medical Record Department's main file room (located on the 1st floor of the hospital), revealed the file room had two entry doors, each secured with a single key lock. Observation revealed medical records containing confidential health information in line-of-sight upon entry from the two doors. Observation revealed medical records staff present. Interview during tour with the Medical Records Director revealed the main file room is where the public presents for copies of medical records between 0900 and 1600. Interview revealed after 1800 the main file room doors are locked for security. Interview revealed each medical records staff member is issued a key that fits all four department locations. Interview revealed keys are also issued to non-medical records staff. Interview revealed (1) key is issued to each nursing supervisor and (1) key is issued to each administrator on-call. Interview revealed the Director did not know the exact number of keys issued. Interview revealed housekeeping staff are only allowed to perform housekeeping duties when department staff are present.

Continued observation during tour on 03/14/2012 at 1030 of the Medical Record Department's coding room (located on the 2nd floor of the hospital), revealed the coding room had one entry door secured with a single key lock. Observation revealed medical records containing confidential health information in line-of-sight upon entry from the door.
Observation revealed staff present. Interview during tour with the Medical Records Director revealed the coding room is only staffed during business hours (~0700 - 1600). Interview revealed records are not stored in the coding room after hours of operation.

Continued observation during tour on 03/14/2012 at 1035 of the Medical Record Department's transcription analyst room (located on the 2nd floor of the hospital) revealed the transcription room had two entry doors, both secured with one single key lock. Observation revealed medical records containing confidential health information in line-of-sight upon entry from both doors. Observation revealed staff present. Interview during tour with the Medical Records Director revealed the transcription analyst room is only staffed during business hours (~0700 - 1600). Interview revealed records are stored in the transcription analyst room after normal business hours.

Continued observation during tour on 03/14/2012 at 1040 of the Medical Record Department's physician's chart room (located on the 1st floor of the hospital) revealed the physician's chart room had two entry doors, both secured with one single key lock. Observation revealed medical records containing confidential health information in line-of sight upon entry from both doors. Interview during tour with the Medical Records Director revealed the physician's chart room is only staffed during business hours (~0730 - 1900). Interview revealed records are stored in the physician's chart room after hours of operation. Interview revealed the medical staff members are not issued a key to the physician's chart room. Interview revealed if a medical staff member needs to get into the physician chart room after normal hours business hours, he or she must go to the main file room or page the on-duty medical records file clerk.

Review on 03/15/2012 of a "GRANDMASTER KEY PERMANENT ISSUE LIST" revised 12/10/2011 and maintained by the engineering department revealed twenty-three (23) master keys issued to non-medical records department personnel in the following departments: Chief Executive Officer (1) ;Vice-President Ancillary & Support (1); Vice-President of Professional Services & Facility Planning (1); Vice-President of Nursing/Patient Care (1); Vice-President Business & Network Development (1); Engineering, Assistant Director (1); Engineering, Biomedical (4); Engineering , Director (1); Engineering, Electrician (2); Engineering, HVAC (2); Engineering, Plumber (2); Engineering, Supervisor (1); Housekeeping (2); Information Systems, Director (1); Nursing Supervisors (1); and Security, Supervisor (1).

Follow-up interview on 03/15/2012 at 1020 with the Medical Records Director revealed the key that fits the locks to all Medical Record Department's areas is a "facility master key." Interview revealed the key is issued by engineering. Upon review of the Grandmaster Key Permanent Issue List maintained by the engineering department, the Director was aware of only 12 keys issued to non-medical record department staff out of 23 listed. Further interview revealed the Director was aware of at least two (2) keys maintained by the Nursing Supervisors, due to overlapping shifts, not just the one (1) as indicated on the list. Interview revealed the list may not be accurate. Interview revealed the Director was aware certain staff had access to the department but was unaware of them being issued keys. Interview revealed there is not a system in place to track unauthorized access to the Medical Record Department by non-medical records staff who are issued master keys. Interview revealed there are no secondary locking mechanisms on the entry doors to the four (4) Medical Record Department areas to prevent unauthorized access after normal hours of operation when department staff are not present. Interview confirmed the Medical Record Department is staffed 24 hours per day, 7 days per week, 365 days per year. Interview confirmed when the the department staff member on-duty is out of the department, the staff member can be reached by pager. Interview revealed the Director was unable to provide a rationale for non-medical record department staff having a key to the department when medical records staff are present in the hospital 24 hours per day.

Based on hospital policy review, medical record review, and staff interview, the hospital's pharmacy failed to ensure that resume previous medication orders were prohibited and not used in 1 of 3 sampled hemodialysis patients (Hemodialysis patient #33).

The findings include:

A review of the hospital's policy and procedure "Standards For Medication Ordering, Transcription, and Administration" (revised 01/20110 revealed "VII. Blanket reinstatement of previous orders for medications is not acceptable. Orders such as "resume pre-op meds" and "continue same meds" are considered blanket orders and not acceptable."

An open medical record review on 03/13/2012 of patient #33 revealed that the patient was admitted to the hospital on 12/16/2011. The review of the patient's physician orders revealed on 02/22/2012 at 1644 a telephone order from a registered nurse was written as "Resume all medications as previously ordered- TO (telephone order) Dr.__ (physician name)/___RN (Nurses name)." The review of the physician orders further revealed that no documentation was found where the nurse wrote and completed the actual medications of the patient that referred to the "Resume previous medication orders".

An interview on 03/14/2012 at 1400 with the hospital's Director of Pharmacy revealed that no "resume previous medication orders" should be written and accepted. The interview further revealed "Our policy does state that we do not accept blanket orders for medications. They should not document any of those types of orders."

Based on review of hospital policy and procedures, observations during tour, and staff interviews, the hospital failed to ensure unauthorized staff did not have access to locked medication rooms without direct supervision by authorized staff in order to perform work duties for 1 of 7 in-patient nursing units toured.

The findings include:

Review of current hospital policy "MEDICATION SECURITY," Policy# 05-30, revised 02/2012, revealed "....Medication Storage Areas (outside of pharmacy) ...Access to locked medication rooms is limited to pharmacy staff and persons authorized to handle and administer the medications contained in these areas (nurses, respiratory therapists, and nursing messengers). Other staff may be granted access to the medication room in conjunction with their duties and while under direct supervision of authorized staff. ..."

Observations during tour on 03/14/2012 at 1355 of the 4 North in-patient nursing unit revealed a locked medication room with one entry door. Observation revealed the door was secured by a keyless "push-button" mechanical locking mechanism. Observation revealed nursing staff had to enter a numbered code into the locking mechanism to gain access to the medication room. Observation within the medication room revealed a stainless steel refrigerator stored beneath a counter. Observation revealed the refrigerator door was unsecured and easily opened by the surveyor. Observation of the contents of the refrigerator revealed prescription intravenous (IV) antibiotic medications (Rocephin, Zosyn, Vancomycin) and oral antibiotic medications (Duke's Magic Mouthwash) being stored. Further observation revealed a plastic bin stored ontop of the counter. Observation of the contents of the bin revealed prescription IV antibiotics (Cipro, Maxipime), antifungals (Diflucan), and IV potassium solutions being stored. Further observations during tour revealed two (2) housekeeping staff (assigned to the floor) on-duty. Observation revealed when requested by the surveyor both of the housekeeping staff, individually, were able to gain access to the locked medication room by entering a numerical code into the locking device on the medication room door. Interview during tour with the two housekeeping staff revealed they were given the access code to enter the locked medication room by other housekeeping staff. Interview revealed nursing staff members are not needed to enter the access code. Interview revealed when inside the locked medication room their duties include cleaning the sink and countertops, emptying the trash, hi-lo dusting, wiping down surfaces, and mopping the floor. Interview revealed nursing staff enter and exit the locked medication room when the housekeepers are in the room performing their duties. Interview revealed the nursing staff nor any other staff are required to stay inside the locked medication room to provide direct supervision to housekeeping staff. Interview during tour with floor nursing staff revealed nurses do not let the housekeeping staff into the locked medication room because the housekeepers have the code. Interview revealed the nursing staff enter and exit the locked medication room while the housekeeping staff are performing their duties, but do not stay and provide direct supervision.

Interview on 03/14/2012 at 1530 with administrative nursing management staff confirmed per policy, housekeeping staff are not authorized to have unsupervised access to locked medication rooms when performing their duties. Interview revealed unauthorized staff must have direct supervision. Interview confirmed the hospital staff failed to follow the hospital's policy.

Based on observations as referenced in the Life Safety Report of Survey completed 03/15/2012, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

~cross-refer to 482.41(b) Physical Environment: Life Safety from Fire - Standard Tag A0709.

Based on observations as referenced in the Life Safety report of survey completed March 15, 2012, the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association to assure the safety and well being of patients, staff, and visitors.

The findings include:

1. Building #1, 2nd floor, mechanical room at respiratory classroom corridor - There are unsealed penetrations in the 1 hour rated assembly above the duct work just above the entry doors.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

2. Building #1, 2nd floor, transformer room at the respiratory classroom corridor - There are unsealed penetrations in the 1 hour rated assembly above the door.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

3. Building #1, 2nd floor middle area across from room 273 - The one hour rated wall above the soiled utility room has an unsealed penetration from a pipe penetrating the wall just above the door frame on the corridor side.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0012.

4. Building #1, 1st Floor, Suite area in front of Doctor's charting area:
a. The corridor wall for the Suite in front of the Doctor's charting are was not constructed smoke tight. The corridor wall was not complete at the deck above;
b. The corridor wall to the Administration suite area was not sealed smoke tight to the deck above.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0017.

5. Building #1, 3rd floor Caesarean Section room, Delivery Room and both observation rooms - There was more than one range of motion on the above mentioned treatment area doors that do not allow single motion opening of the space into an egress corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

6. Building #1, lower level, lab across from the receptionist desk - There are unsealed penetrations in the rated smoke wall above the ceiling at the sprinkler pipe at the door entry area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0025.

7. Building #1, lower level, lab storage room near the house keeping closet - The 1 hour rating for that space is not maintained as the door has only a 20 minute rating.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

8. Building #1, loading dock storage area - The loading dock landing does not have protection from falling at this location as the exit egress from this area lead to the loading dock.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0032.

9. Building #1, 3rd floor next to room M9 - The facility is utilizing delayed egress in its stairwells. These doors are normally in the locked position. These doors had a delay when opening with activation of the fire alarm system when tested.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

10. Building #1, Tower birthing wing. 3rd floor - This area utilizes North Carolina special locking systems for the baby alert system and delayed egress. The North Carolina special locking system has a master lock release switch at the nurse's station that is greater tan 48 inches off the finished floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

11. Building #1, several egress paths - The exit egress path can be blocked as there was a floor slide bolt "shooter blocks" that can be deployed to prevent a cross corridor door from being opened at the following locations:
a. 3rd floor on the entrance hall;
b. 2nd floor entrance to "2 middle" corridor entrance;
c. 1st floor lobby to the administration area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

12. Building #1, 3rd floor, waiting room that housed stairwell "E" - There was not sufficient exit directional signage leading from this waiting room to the nurses station where other exit directional signs could lead you to a path of egress.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0047.

13. Building #1, Ground floor near the surgical waiting room - During the testing of the Fire Alarm Control panel and its components the cross corridor smoke doors did not release with activation a smoke detector within that particular smoke area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0051.

14. Building #1, the facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have sprinkler coverage or smoke detection in the following areas:
a. 3rd floor bath rooms in the Observation rooms 10 and 11;
b. 1st floor Lab, and X-ray area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

15. Building #1, Ground floor, near cardiac catheterization - The facility is utilizing special locking systems and is not fully sprinklered as required. The facility does not have proper sprinkler coverage in the following area: there were two sprinkler heads on the same side of the room leaving the opposite side without coverage in an area greater than 500 square feet.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

16. Building #1, 1st Floor, Stairwell E-2 - Facility at the time of the inspection could not verify the installation of sprinkler heads at the top portion of the vertical shaft accessible from stairwell E-2.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

17. Building #1, Document Review Sprinkler System certification noted the following outstanding items that had no resolution at the date of the survey: stated the following items were non-compliant:
a. MRI preaction: water flow device does not report to main FACP;
b. Sprinkler systems are due for its five (5) year system checks;
c. Dry sprinkler system drops in the kitchen are over 10 years old.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.

18. Building #1, Document Review Fire Pump certification noted the following outstanding item that had no resolution at the date of the survey:
a. Underground piping leading to the fire pump leaks.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.

19. Building #1, Document Review - There were several outstanding items noted from the 12/10 "fire damper inspection and testing log" that were not resolved during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0067.

20. Building # 1, oxygen farm:
a. The oxygen farm has cylinders that are not individually chained;
b. The oxygen farm does not have the cylinder valves protected from extremes of weather;
c. The oxygen farm does not have its cylinders protected from rusting as they are touching the concrete slab that they rest on.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0076.

21. Building #2, Ground floor, between PACU and OR - The corridor walls above the ceiling outside PACU and OR suites were not sealed in order to maintain the required rating of the area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0017.

22. Building #1, Ground Floor, ICC & CCU corridor - The corridor door at the entrance to the ICC & CCU suites did not close smoke tight as there was a gab greater than 1/8th of an inch during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0018.

23. Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms - There are two sets of oxygen storage room doors on that corridor.
a. one set has one of its double doors that does not latch;
b. both sets have gaps grater than 1/8th of in inch not keeping the rating of the doors at that location.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

24. Building #2, Ground Floor, PACU - The soiled linen room door at PACU did not close, latch, and seal when tested during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

25. Building #2, Ground Floor, Outpatient Surgery area
a. The cross corridor doors leading from outpatient surgery area to the corridor in front of operating rooms is equipped with an incomplete North Carolina Special Locking system. There was no simple on or off door release mechanism/switch in the vicinity of the door. There was no simple on or off door release mechanism/switch at a regularly manned station that serves that area;
b. The door release mechanism that was in the vicinity of the door was a momentary switch that would reengage the locking mechanism attached to the door after it was released;
c. Door did not release with activation of the fire alarm system when tested.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0038.

26. Building #2, Ground Floor Cold Room - The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The entrance to the cold room has incomplete sprinkler coverage.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

27. Building #2, Ground Floor, PACU - The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The PACU does not have 100% sprinkler coverage, and the bathroom in PACU did not have sprinkler coverage or protected with smoke detector.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

28. Building #2, Ground Floor, Operating Rooms - The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 tower in the following areas:
a. The facility operating rooms 1 trough 7 do not have sprinkler coverage.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

29. The facility is utilizing special locking systems and is not fully sprinklered as required. The facility doses not have a complete sprinkler system in the 1986 bed tower in the following areas:
a. Bathrooms in the 1986 Tower;
b. staff lounge bathrooms near the elevator lobby areas in 1986 tower;
c. men and women's bathrooms on the 2nd floor near the assistant housekeeping managers office in the 1986 tower.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0056.

30. Building #2, Ground Floor, Operating Rooms - The equipment storage room between operating room 1 & 2 has a defective sprinkler head where the colored fluid in the glass capsule is missing and appeared clear during the survey.

NOTE: this specific deficiency was corrected before the survey was finished.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0062.

31. Building #2, Tower, 5th floor - The clean linen closet double doors open into the corridor 180 degrees but the left leaf of the doors protrudes into the corridor leading to the "H" stairwell.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

32. Building #2, 1st floor, clean linen closet - The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

33. Building #2, 2nd floor - The clean linen closet double doors do not open 180 degrees into the corridor and are not equipped with door closers to keep the doors closed after being opened.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

34. Building #2, Ground Floor, Outpatient Surgery area - The corridor doors to the CO2 storage room located between outpatient surgery and operating room did not open 180 degrees or equipped with self-closing device to prevent the door from being left open into the egress corridor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

35. Building #2, Ground floor, Operating Rooms - There are items (equipment) in the exit egress corridor in front of the operating room #8, this area is not included in the operating room suite.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0072.

36. Building #2, Ground Floor, exit corridor located in front of cross corridor doors leading to the operating rooms. The oxygen storage room located on that corridor did not have oxygen storage signage on it during the survey.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0141.

37. Wound Care, soiled linen room - The hospital based provider space does not have a one hour rated enclosure for the soiled linen room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

38. Wound Care, treatment room - The hospital based provider space does not have a one hour rated enclosure for the treatment room which houses two hyperbaric chambers.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

39. Wound Care Services, Exit egress corridors - The hospital based provider space does not currently have emergency egress lighting.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0045.

40. MOB Rehab Services, Transformer room - The hospital based provider space does not have a one hour rated enclosure for the transformer/electrical room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0029.

41. MOB Rehab Services, Exit egress corridor and stairwell - The hospital based provider space does not have complete emergency lighting for the exit egress stairwell leading to the ground floor of the building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0045.

42. MOB Rehab Services - The Medical Office Building which houses the hospital based provider is grater than 3 stories. This space is in a sub-leased area on the third floor, and does not have a remote annunciator for the Fire Alarm Control Panel (FACP) in an area where it is likely to be heard.

NOTE: The facility does have a remote FACP annunciator panel in the main entry lobby of the building.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0051.

Based on hospital policy review, medical record review, observation, and staff interview, the hospital's Infection Control Officer failed to ensure the control of infections by failing to ensure isolation precautions were initiated per hospital policy for 1 of 4 sampled patients with a history of infectious/communicable disease (#19) and failing to ensure the prevention of cross-contamination in the hemodialysis unit by failing to ensure staff appropriately utilized personal protective equipment (PPE) (Nurse #1, #4, and Patient #33).

The findings include:

1. Review of current hospital policy entitled "Infection Control Guidelines for Multi-Drug Resistant Organisms" dated 02/2012 revealed, "...Contact precautions are used for a variety of infectious diseases including Methicillin resistant Staph aureus referred to as 'MRSA'....The nursing unit will institute 'Contact 'Precautions' (on) patients infected or colonized with a multi-resistant organism...."

Review of current hospital policy entitled "Isolation Precautions" dated 08/2010 revealed, "...Appropriate infection control measures must be expedited in a timely manner to prevent the spread of infection to patients, visitors, and health care workers....Discontinuing Contact Precautions for patients with multi-resistant organisms - MRSA - A patient with MRSA may be taken off Contact Precautions after two cultures taken 24 hours apart are found to be negative for MRSA...."

Open medical record review for Patient #19 revealed a 62 year-old male that was admitted on 03/08/2012 with diverticulitis and a colostomy. Review of "Nursing Adult Admission Assessment and History" dated 03/08/2012 at 0900 revealed, "...Chronic Infection: (checked) MRSA...." Record review revealed on 03/08/2012 at 1129 the patient underwent a surgical colostomy takedown. Record review revealed the patient was transferred to the Intensive Care Unit (ICU) at 1540, following surgery. Review of "Nursing Adult Admission Assessment and History" documented by ICU nursing staff and dated 03/08/2012 at 1540 revealed, "...Chronic Infection: (not checked) MRSA...." Review of ICU nurses' notes revealed no documentation the patient was placed on Contact Precautions. Further record review revealed on 03/09/2012 at 0925 the patient was transferred to Unit 5-North (post-operative care unit). Review of "In-House Transfer Record" dated 03/09/2012 at 0910 revealed, "...Isolation - Type (initialed) NA (not applicable)...." Review of 5-North nurses' notes revealed the first documentation the patient was placed on Contact Precautions on 03/10/2012 at 0800 (2 days after the admission nurse noted the patient had a history of MRSA).

Interview on 03/13/2012 at 1500 with the Assistant Nursing Director of 5-North revealed the patient's wife told the first admission nurse the patient had a history of MRSA, but after surgery the patient denied ever having MRSA. Interview revealed, "I talked to Infection Control this morning and she checked in the (computer) system and said the patient was positive for MRSA here in 2009." Interview revealed a nasal swab for MRSA had been sent to the lab on the morning of 03/13/2012 and results were not yet available. Interview confirmed there was no available documentation Contact Precautions were implemented prior to 03/10/2012 at 0800 (2 days after the admission nurse noted the patient had a history of MRSA).

Interview on 03/15/2012 at 1030 with the Infection Control Practitioner revealed, "All patients with a history of MRSA should be placed on contact isolation until they are found to have negative cultures. This patient should have been placed on Contact Isolation upon admission."



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2. Observation on 03/13/2012 at 0922 in the hospital's hemodialysis unit revealed a hemodialysis nurse (#1) with contaminated gloves (PPE) handle a designated clean patient medical record chart. The observation revealed the nurse handling the chart with the dirty gloves and at the same time, a rounding physician was touching the same patient medical record chart with his bare hands. The observation revealed that the nurse was showing the physician parts of the medical record with the contaminated gloves on both hands and the physician holding the same chart with his bare hands. Further observation revealed that no disinfectant was used on the patient's medical record chart after the contamination by the nurse with the dirty gloves.

An interview on 03/13/2012 at 0940 with the hospital's hemodialysis nurse #1 revealed that the patient's hemodialysis machines are considered contaminated and dirty when the patient is receiving hemodialysis treatment. The interview revealed that gloves are used when touching a machine and should be removed before touching a patient medical record chart. The patient chart is considered clean and does stay in the nursing station area. No reason was given for the nurse wearing her gloves while touching a patient's medical record chart.

3. Observation on 03/13/2012 at 0956 in the hospital's hemodialysis unit revealed a hemodialysis nurse #4 disconnecting a patient's (#33) internal jugular catheter (hemodialysis access site) from her hemodialysis treatment following her treatment completion. The observation revealed that the patient did have a mask on her face, the nurse had a face shield, gloves, gown and a face mask on during the disconnection. The observation did reveal the nurse did not have her mask covering her nose. The observation revealed the nurse with her nose over the top of her mask. The observation revealed that the nurse's mask (PPE) was not worn properly to prevent potential cross-contamination to the patient's internal jugular catheter.

An interview on 03/13/2012 at 1010 with hemodialysis nurse #4 revealed that PPE should always be worn correctly during patient care. The interview also revealed that the mask should be work correctly and should always cover a staff members nose.

Based on hospital policy review, medical record review and staff and physician interviews, the hospital failed to ensure a post-anesthesia evaluation was completed and documented within 48 hours after surgery or following a change in patient condition during the immediate post-anesthesia recovery period for 3 of 7 sampled surgical patients (#14, #11 and #18).

The findings include:

Review of current hospital policy entitled "Discharge Criteria for Patients in Post Anesthesia Care Unit (PACU)" dated 04/2010 revealed, "...Inpatients do not have to be seen by the Anesthesiologist prior to discharge from PACU. the patients will be seen by Anesthesia staff the following day during post-op(erative) rounds...."

1. Closed medical record review for Patient #14 revealed a 75 Year-old female that was admitted on 02/10/2012 for recto-colon cancer. Record review revealed on 02/10/2012 the patient underwent a surgical abdominal resection with permanent colostomy with general anesthesia. Record review revealed an anesthesia start time of 1350 and end time of 1537. Record review revealed no documentation that a post-anesthesia evaluation was completed within 48 hours after surgery. Record review revealed the patient was discharged on 02/17/2012. Further record review revealed documentation of a "Post Anesthesia Note" signed by Anesthesiologist #1 and dated 03/02/2012 at 1035 (21 days after surgery and 14 days after discharge). Review of the post anesthesia note revealed, "Cardiopulmonary status within acceptable limits? (checked) Yes....LOC (level of consciousness) within acceptable limits: (checked) Yes....Complications: (checked) No....chart reviewed."

Interview on 03/14/2012 at 1440 with the Chief CRNA (certified registered nurse anesthetist) revealed usually the anesthesiologist sees the patient in PACU and does the post anesthesia evaluation there, after the patient is awake, stable, and can respond to questions. Interview revealed anesthesia providers also make daily post operative rounds, at which time they complete any post anesthesia evaluations that were not done in PACU. Interview revealed Patient #14 went to ICU after surgery, so the post anesthesia evaluation was probably missed because they were waiting for the patient to return more to her pre-operative baseline. Interview revealed, "They probably had her on the list to be done the day after the procedure, then put it off until the second day, but forgot to add her to the list that day." Interview confirmed there was no available documentation that a post-anesthesia evaluation was completed within 48 hours after surgery. Further interview revealed, "Medical record picked up on the missing documentation and referred it to (Anesthesiologist #1 - the Chair of the Anesthesia Department). He reviewed the record then."

2. Closed medical record review for Patient #11 revealed an 84 year-old female that was admitted on 03/05/2012 for a fractured right hip. Record review revealed on 03/06/2012 the patient underwent a surgical right hip hemiarthroplasty (hip replacement) with spinal anesthesia. Record review revealed an anesthesia start time of 1316 and end time of 1554. Record review revealed the patient was in the operating room until 1555, at which time she was transferred to PACU. Record review revealed documentation by Anesthesiologist #2 of a "Post Anesthesia Note" dated 03/06/2012 at 1520, when the patient was still in the operating room and prior to the anesthesia end time. Review of the PACU nurse's notes revealed the first documentation the spinal anesthesia level was receding at 1615 and the first documentation the patient could move her legs at 1625 (55 minutes and 65 minutes, respectively, after the anesthesiologist's documented Post Anesthesia Note). Further record review revealed no documentation that a post-anesthesia evaluation was completed within 48 hours after surgery.

Interview on 03/13/2012 at 1350 with Anesthesiologist #2 confirmed the note was timed at 1520, when the patient was still in surgery. Interview revealed, "I must have accidentally documented 1520. I saw the patient at 1620 in PACU. The case was still going on at 1520. I never do post anesthesia evaluations in the OR (operating room). I usually do post anesthesia evaluations in PACU after the patient is awake, can move extremities, and answer my questions."

3. Closed medical record review for Patient #18 revealed a 71 year-old female that was admitted on 01/27/2012 for a fractured left hip. Record review revealed on 01/28/2012 the patient underwent a surgical left hip hemiarthroplasty (hip replacement) with spinal anesthesia. Record review revealed an anesthesia start time of 1030 and end time of 1225. Record review revealed at 1230 the patient was transferred to PACU, at which time the nurse noted the patient to be sleepy, arousable on calling, and with a spinal anesthesia level of T-6 (6th thoracic vertebrae). Review of PACU nurse's notes timed 30 minutes after admission to PACU (1300) revealed, "L.O.C....Arousable on calling...." Record review revealed the first available documentation the spinal anesthesia level was receding at 1330, when the nurse noted the level to be T-8. Record review revealed at 1250 the nurse initiated a blood transfusion. Record review revealed documentation by Anesthesiologist #3 of a "Post Anesthesia Note" dated 01/28/2012 at 1256. Review of the Post Anesthesia note revealed, "Cardiopulmonary status within acceptable limits? (checked) Yes....LOC (level of consciousness) within acceptable limits: (checked) Yes....Complications: (checked) No." Further review of PACU nurse's notes revealed, "1320 Patient has (decreased) LOC. Resp(eratory rate) (decreased) to 6-8/min(ute). (Anesthesiologist #3) paged. Pt (patient) sats (oxygen saturation level) 74%. Pt. bagged (oxygen administered via bag and mask). 1321 (Anesthesiologist #3) and ICU RN (registered nurse) at bedside. 1322 Blood turned off. 1322 Pt breathing on own. Not answering questions. Sat 96%. VSS (vital signs stable)....1335 (Anesthesiologist #3) at bedside. 1340 VSS. Pt answering questions. (Anesthesiologist #3) restarted blood. 1345 Pt has (decreased) LOC. Breathing on own. Blood off and disconnected. 1350 LOC, Pt awake. VSS. C/O (complains of) 'chest pain'. (Late entry for 1330 - 1335 EKG [electrocardiogram] obtained)." Review of PACU nurse's notes revealed the patient's vital signs remained stable for the remainder of her stay in PACU. Review of PACU nurse's notes revealed the patient remained sleepy until 1520, at which time the nurse noted "Awake + alert. VSS. Remembers incident. States 'I could hear you but I couldn't talk.'" Record review revealed at 1530 the patient was fully awake and talking with a spinal anesthesia level of T-10 (further receded). Record review revealed at 1530 the patient was transferred to an inpatient unit. Record review revealed no documentation of a post-anesthesia evaluation following the change in the patient's condition while she was in PACU.

Interview on 03/14/2012 at 0945 with Anesthesiologist #3 revealed post-anesthesia evaluations included assessment of cardiac and pulmonary functioning, mental status, pain, nausea, and hydration status. Interview revealed, "Anything out of the ordinary is noted on the post anesthesia note also." Interview revealed the anesthesiologist did the post-anesthesia evaluation for Patient #18 on 01/28/2012 at 1256. Interview revealed, "The spinal level had not worn off, but she had good level of consciousness, heartrate, respirations, and (oxygen) sats." Further interview revealed at 1320 the patient had decreased LOC and respiratory rate and had to be bagged. Interview revealed it was unlikely, but possible, that the change in the patient's condition was a complication of the spinal anesthesia. Interview revealed, "The concern was whether or not she was having a reaction to the blood....It seemed sudden in onset, so I don't think it was an anesthesia complication....It was hard to figure out what was going on. We had stopped the blood. We were trying to figure out what was going on. At the time I thought it was not necessarily a reaction to the blood, so I turned it back on. after a few minutes, we turned it off again.....I was present and taking care of it. I was present the whole time. By the time she was leaving my care at 1530, she was fine. I didn't do another note....We (anesthesia) didn't see her the next day because her issue was resolved when she left PACU." Further interview revealed each day an anesthesia provider makes rounds on all first day post-operative patients. Interview revealed, "First I check the chart. If there is a post-anesthesia note in the chart, I don't see the patient again....We used to do post anesthesia notes on all patients the day after surgery. We changed because of regulatory requirements. We occasionally missed some. We now do the post-anesthesia evaluation in PACU after the patient is back to baseline level of consciousness. It may be soon after the patient is in PACU, or later in the PACU stay....The patient may not be fully recovered from the spinal....What I tell the PACU nurses is they can discharge them from PACU when the spinal anesthesia level is receding."

Based on review of hospital policies and procedures, medical records and staff interviews respiratory therapy (RT) staff failed to ensure reassessment of patients on mechanical ventilation according to hospital policy for 2 of 2 records reviewed of mechanical ventilator patients (#43, #31).

The findings include:

Review on 03/14/2012 of hospital policy "Mechanical Ventilator Monitoring" dated 03/2012 revealed "Policy - Respiratory Care will monitor and record settings for Mechanical Ventilators initially and every two hours to insure accuracy of set ventilator parameters."

1. Open record review on 03/14/2012 for Patient #43 revealed a 50 year old admitted 03/12/2012 for overdose and mechanical ventilation. Review revealed the patient was on the mechanical ventilator from 03/12/2012 at 0930 until 03/13/2012 at 1013. Review revealed Respiratory Care staff failed to document ventilator checks every two hours on 03/12/2012 from 1155-1444 (two hours and 49 minutes), 1741-2100 (three hours and 19 minutes), 2100-0015 (three hours and 15 minutes), and on 03/13/2012 from 0345-0625 (two hours and 45 minutes).

Interview on 03/14/2012 at 1530 with Respiratory Therapist staff revealed mechanical ventilator checks should occur every two hours. Interview revealed the ventilator checks for Patient #43 on 03/12/2012 and 03/13/2012 were not monitored per facility policy and were monitored from 45 minutes to one hour and 19 minutes past the required timeframe. Interview failed to reveal any further evidence the ventilator checks were performed within the two hour timeframe as required by facility policy.

2. Closed record review on 03/14/2012 for Patient #31 revealed a 94 year old admitted 03/01/2012 for sepsis and mechanical ventilation. Review revealed the patient was on the mechanical ventilator from 03/01/2012 at 1655 until 03/02/2012 at 1430 when Respiratory Care staff realized the patient had removed the endotracheal tube (artificial breathing tube hooked to mechanical ventilator). Review revealed Respiratory Care staff failed to document ventilator checks every two hours on 03/02/2012 from 0200-0445 (two hours and 45 minutes), 0445-0900 (four hours and 15 minutes) and 0900-1130 (two hours and 30 minutes). Review revealed the patient was re-intubated (artificial airway was reinserted for mechanical ventilation) on 03/03/2012 at 1530 and on mechanical ventilation until 03/05/2012 at 0435, when the patient expired. Review revealed Respiratory Care staff failed to document ventilator checks every two hours on 03/03/2012 from 1835-2135 (three hours), 2135-0050 (three hours and 15 minutes), on 03/04/2012 from 0050-0355 (three hours and 5 minutes), 0545-0931 (three hours and 14 minutes), 0931-1220 (two hours and 49 minutes), 1220-1455 (two hours and 35 minutes), 1735-2225 (four hours and 50 minutes), 2225-0058 (two hours and 33 minutes), and on 03/05/2012 from 0058-0410 (three hours and 12 minutes).

Interview on 03/14/2012 at 1530 with Respiratory Therapist staff revealed mechanical ventilator checks should occur every two hours. Interview revealed the ventilator checks for Patient #31 on 03/02/2012, 03/03/2012, 03/04/2012 and 03/05/2012 were not monitored per facility policy and were monitored from 30 minutes to 2 hours and 50 minutes past the required timeframe. Interview failed to reveal any further evidence the ventilator checks were performed within the two hour timeframe as required by facility policy.

NC00079241