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Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a sample validation survey conducted on March 16-18, 2015 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated March 18, 2015.

A. Based on observation document review and staff interview, it was determined in 2 of 2 mechanical weight scales, (1) in the cardio/pulmonary rehabilitation unit and (1) in the rehabilitation unit the Hospital failed to ensure the scales were calibrated to ensure accurate weights were being taken, potentially affecting all patients utilizing services in those departments.

Findings include:

1. On 3/16/15 at 10:00 AM, a tour of the rehabilitation unit was conducted. During the tour it was observed that one, mechanical weight scale was being utilized for patient care. There was no documentation on the scale or in the unit to indicate the scale had been calibrated to ensure accurate readings.

2. On 3/18/15 at 11:00 AM a review of Hospital policy "Medical Equipment Management Plan", revised April 2014, was conducted. Under "SCOPE", third paragraph it reads "Clinical Engineering Service schedules and performs corrective maintenance, preventive maintenance and safety inspections........on all inventoried managed clinical equipment." Under "preventive maintenance 1)" it reads "such as cleaning, lubricating, adjusting, calibrating...... ."

3. On 3/16/15 at 10:10 AM, an interview with the Rehabilitation Unit Manager (E #7) was conducted. E #7 verbalized the scale was utilized for patient care and there was no documentation to indicate the scale had ever been calibrated for accuracy.

4. On 3/17/15 at 11:00 AM, a tour of the cardio/pulmonary rehabilitation unit was conducted. During the tour it was observed that one, mechanical weight scale was being utilized for patient care. There was no documentation on the scale or in the unit to indicate the scale had been calibrated to ensure accurate readings.

5. On 3/17/15 at 11:00 AM, an interview with the cardio/pulmonary Nurse (E #9) was conducted. E #9 verbalized the scale was utilized for patient care and there was no documentation to indicate the scale had ever been calibrated for accurate readings.

B. Based on document review, observation, and staff interview, it was determined in 1 of 2 crash carts in the emergency department, the hospital failed to ensure emergency equipment was checked for safety and reliability.

Findings include:

1. On 3/16/15 at 11:00 AM, a tour of the emergency department was conducted while being escorted with the Director of Nursing, Emergency Services (E#10). During the tour it was observed that documentation on the "Emergency/Crash Cart Checklist" for the month of February 2015 was incomplete. There was no initials on the 25th of February and incomplete checks for February 26th.

2. On 3/18/15 at 11:30 AM, a review of Hospital policy "Crash Cart Policy" revised 6/18/13, was conducted. Under "1." it reads "The Crash Cart Checklist must be checked at least once a day by a designated staff member.........Document inspection of the cart by initialing the checklist."

3. On 3/16/15 at 11:00 AM, an interview with E #10 was conducted. E #10 verbalized the emergency/crash cart checklist contained improper documentation and should have been initialed on the 25th of February and check marks should have been put in every box on the 26th of February.

A. Based on document review, observation, and interview it was determined the Hospital failed to ensure adherence to infection control processes for Nutritional Services. This has the potential to affect all patients, staff and visitors utilizing the Nutritional Services Department.

Findings include:

1. The container "QAC QR Test Strips" expiration date: September 2016, was reviewed on 3/17/15 at 9:30 AM. The container reads "NOTE: Sample must be at room temperature (above 75 degrees)."

2. A tour of the Nutritional Services Department was conducted on 3/17/15 at 9:30 AM while being escorted by the Director of Nutritional Services (E #6). During the tour it was observed in one of six sinks, the water temperature was not being monitored to ensure the QAC QR test strips were being utilized according to manufacturers guidelines. During the tour the water temperature in the sink being utilized for sanitization was checked and registered 60.4 degrees (outside the range for use of the QAC QR Test Strips). This process is a critical process to ensure proper sanitization of Nutritional Services equipment.

3. An interview with the Director of Nutritional Services was conducted on 3/17/15 at 9:30 AM and again at 3/18/15 at 9:00 AM. E #6 verbalized the Nutritional Services Department utilizes six sinks for sanitization and the staff do not monitor the water temperature prior to utilizing the QAC QR Test Strips. E #6 stated "the water temperature is automatically warmed to the proper temperature when it comes out of the "ECOLAB" sanitizer machine." E #6 verbalized there was no log book to indicate water temperatures were being monitored prior to using QAC QR Test Strips. On 3/18/15 at 9:00 AM, E #6 verbalized the water temperatures of the six sinks in the Nutritional Services Department were checked immediately after the water came out of the "ECOLAB" sanitizer machine. The tests indicated three of the six sinks failed to have proper water temperature according to manufactures guidelines for QAC QR Test Strips.

B. Based on document review, observation, and interview it was determined in 1 of 4 patients (Pt #31) observed on isolation precautions, medical surgical floor (4th floor) the Hospital failed to ensure visitors wore proper isolation personal protective equipment prior to entering patient rooms.

1. On 3/18/15 at 2:30 PM, the medical record of Pt #31 was reviewed. Pt #31 was admitted on 3/15/15 at 8:15 PM with a diagnosis of respiratory syncytial virus bronchitis and was placed on isolation precautions in room 4210 (4th floor). The patient's diagnosis required all staff and visitors to maintain droplet precautions (wear a mask).

2. On 3/18/15 at 2:15 PM, a tour of the medical surgical unit (4th floor) was conducted while being escorted by the Infection Control Nurse (E #14). During the tour it was observed in Room 4210, (Pt #31's room) a visitor sitting in the patients room without a mask on.

3. On 3/18/15 at 2:20 PM, an interview with the medical surgical floor nurse (E #15) was conducted. E #15 verbalized that the visitor must have slipped by the nursing staff and entered the patient's room." E #15 also verbalized the visitor should have put on a mask prior to entering the patient's room.