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A. Based on review of the Hospital's dialysis contractor's memo, clinical record review, and staff interview, it was determined that for 1 of 1 patient (Pt. #5) undergoing dialysis on the Cardiovascular Telemetry Unit (CVTU), the Hospital failed to ensure that dialysis orders for calcium were written.

Findings include:

1. On 9/29/09 at 9:50 AM, a memo dated 9/29/09 at 8:01 AM, from the Hospital's dialysis contractor was reviewed. The memo included: "...Unlike an outpatient dialysis clinic we do not have a standard sodium or calcium for all patients. In the acute setting the physician has the option to order dialysate solution specific to the patients needs. The physician has about 10 different concentrations to choose from..."

2. On 9/28/09 at 10:45 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was an 88 year old female, admitted on 9/15/09, with diagnoses of End Stage Renal Disease, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Decubitus, and Sepsis. Seven physician orders for hemodialysis treatment were written for Pt. #5, however, six of the orders written (9/15/09 to 9/27/09) for Pt. #5 lacked the amount of Calcium (CA) required in the dialysate. The hemodialysis treatment sheets from 9/15/09 to 9/27/09, indicated that the hospital used the standard 2.5 CA in the dialysate for each dialysis treatment because there was no written physician order for Pt. #5.

3. The above findings were confirmed with the Clinical Manager during an interview on 9/28/09 at 1:30 PM. The Clinical Manager stated that there were two CA solutions (2.5 and 3.0) in stock for 2.0 Potasium dialysate and additional solutions could be ordered.

A. Based on observation and staff interview, it was determined that for 50 of 50 individually packaged Verapamil medications in the Pharmacy, the Hospital failed to ensure expired medications were not available for use.

Findings include:

1. On 9/30/09 from approximately 10:30 A.M.-12:00 P.M., a tour of the Pharmacy Department was conducted. There were 50 individually packaged Verapamil 300 mg tablets with an expiration date of 8/31/09, that were available for use.

2. The above finding was confirmed with the Director of Pharmacy on 9/30/09 at approximately 12:00 P.M. during an interview.

A. Based on Hospital policy review, review of Deli Station Quality Control Temperature Maintenance :Lunch Logs, and staff interview, it was determined that in 7 of 9 days of temperature logs reviewed, the Hospital failed to ensure that all cold food temperatures were monitored and documented.

Findings include:

1. Hospital policy entitled, "Hazard Analysis Critical Control Point," reviewed on survey date 10/1/09 at 9:45 AM required, "Procedure:..f. Holding - check temperatures each hour..."

2. The Hospital's Quality Control Temperature Maintenance :Lunch Logs (Deli Station), reviewed on 10/1/09 at 9:00 AM indicated that for 7 of 9 days (9/1, 9/2, 9/3, 9/4, 9/11, 9/15, and 9/17/09), the logs lacked documentation of hourly temperature checks for cold food items on the Deli Station, as required.

3. The findings were confirmed with the Director of Nutrition and Food during an interview on survey date 10/1/09 at 9:00 AM.

B. Based on Hospital policy review, review of Deli Station Quality Control Temperature Maintenance :Lunch Logs and staff interview, it was determined that in 2 of 9 days of temperature logs reviewed, the Hospital failed to ensure that all cold food temperatures were maintained as required per hospital policy.

Findings include:

1. Hospital policy entitled, "Hazard Analysis Critical Control Point," reviewed on survey date 10/1/09 at 9:45 AM required, "Procedure:...d. Holding- Cold foods at 40 degrees or less..."

2. The Hospital's Quality Control Temperature Maintenance :Lunch Logs (Deli Station), reviewed on 10/1/09 at 9:00 AM indicated that for 2 of 9 days (9/21 and 9/23/09) the logs lacked documentation that temperatures for cold food items on the Deli Station were at less then 40 degrees.

3. The findings were confirmed with the Director of Nutrition and Food during an interview on survey date 10/1/09 at 9:00 AM.

C. Based on Hospital policy review, review of Quality Control Temperature Maintenance Logs Breakfast, and staff interview, it was determined that in 9 of 9 days temperature logs reviewed, the Hospital failed to ensure that all hot food temperatures were at or above the required temperature or removed per hospital policy.

Findings include:

1. Hospital policy entitled, "Hazard Analysis Critical Control Point," reviewed on survey date 10/1/09 at 9:45 AM required, "Procedure:...e. Holding-Hot foods at 140 degrees or more..."

2. The Hospital's Quality Control Temperature Maintenance Log : Breakfast, reviewed on survey date 10/1/09 at 9:00 AM required, "Instructions: Record temperature at start of Station and every two hours. If temperature is not above 165 F remove food item and record corrective action at bottom of sheet".

3. The Hospital's Quality Control Temperature Maintenance Logs : Breakfast for 9 of 9 days (9/18/09, 9/21/09, 9/22/09, 9/23/09, 9/24/09, 9/25/09, 9/28/09, 9/29/09, and 9/30/09) were reviewed on 10/1/09 at 9:30 AM. All hot food items were not at or above the required 165 F temperature were not removed, as required by the Hospital's Log.

4. The findings were confirmed with the Director of Nutrition and Food during an interview on survey date 10/1/09 at 9:00 AM.

D. Based on Hospital policy review, observation and staff interview, it was determined that in 4 of 5 (#2, 3, 4, and 5) walk-in Freezers/Coolers, the Hospital failed to ensure that all food items were properly labeled and/or stored.

Findings include:

1. Hospital policy entitled, "Hazard Analysis Critical Control Point," reviewed on survey date 10/1/09 at 9:45 AM required, "Procedure:..II. Storage:..d. All items are to be placed on shelving units, at least 6 inches off the floor...f. No items on the top shelves are to be above the fire line located 18 inches from the ceiling"

2. Hospital policy entitled, "Food and Food Item Storage," reviewed on survey date 10/1/09 at 9:45 AM required, "Procedure:..7. All foods that have been taken out of their original wrap or are in another form after processing are to be covered, labeled and dated (3- Days) prior to storage."

3. On survey date 10/1/09 at 8:30 AM the Food and Nutrition Department was toured. The following were observed: Cooler #2, a cart of meat products was opened and not dated; Freezer #3, food products were stored on the floor; Freezer #4, food products were stored on the floor, food items were stored less than 18 inches from ceiling and tray of prepared was food not dated; Freezer #5, food items stored less than 18 inches from ceiling.

4. The findings were confirmed with the Director of Nutrition and Food during an interview on survey date 10/1/09 at 9:00 AM.

A. Based on review of Hospital policy, observation, and staff interview, it was determined that for 1 of 2 Dialysis treatment rooms (453), the Hospital failed to ensure that the room was cleaned per Hospital policy.

Findings include:

1. On 9/29/09 at 1:15 PM, the policy titled: "Environmental Services Standard Cleaning Procedure" was reviewed. The policy included: "Policy: To provide a clean sanitary environment that helps to minimize the risk of nonsocial infection... 2. High dust... dusting everything at shoulder height... 3. Dust mop hard surface floor..."

2. On 9/28/09 between 1:30 PM and 2:30 PM, a tour was conducted in the dialysis treatment rooms (453 & 526). A thick layer of dust was found on the light cover above the first dialysis chair in room 453. Used dialysis testing strips were seen on the floor behind the dialysis chairs in room 453.

3. These findings were confirmed with the Dialysis Clinical Manager during an interview on 9/28/09 at 1:50 PM.

B. Based on observation and staff interview, it was determined that for 1 of 1 water tank in dialysis treatment room #526, the Hospital failed to ensure that the water supply tank was properly cleaned.

Findings include:

1. On 9/28/09 between 1:30 PM and 2:30 PM, a tour was conducted in the dialysis treatment rooms (453 & 526). A water supply tank in room 526 lacked a cover. The inside of the tank was rust colored and contained rust colored precipitate at the bottom of the tank. The red float bulb on the top of the water contained a layer of black substance.

2. These findings were confirmed with the Dialysis Clinical Manager during the interview on 9/28/09 at 1:50 PM.

A. Based on policy review observation, and staff interview, it was determined that for 3 of 3 staff members (E #s 1, 2, and 3) on the Medical Intensive Care Unit, the hospital failed to ensure that staff adhered to isolation precautions.

Findings include:

1. Hospital policy # 01-004 and titled "Isolation Precaution" was reviewed on 9/28/09 at approximately 2:00 PM. The policy included, "Contact Precautions...personal protective equipment:..gowns shall be removed and hand hygiene performed before leaving the patient care environment...17. All hospital personnel including Medical Staff are to observe isolation/precautions at all times... if common use of equipment for multiple patients is unavoidable, equipment shall be cleaned and disinfected prior to use on another patient."

2. On 9/28/09 at approximately 10:00 AM the Medical Intensive Care unit was toured. The unit census was 7 with 2 patients on contact precautions. A doctor (E#1) was observed on 9/28/09 at 10:10 AM in isolation room #9 examining a patient. The signage on the door read, "Contact Precaution." E# 1 failed to remove his gown and gloves and sanitize his hands prior to exiting the room. The Nurse Manager, who was present, immediately instructed E#1 to comply with Hospital policy regarding isolation precautions, and E#1 stated, "I do this all the time."

3. The findings was confirmed with the Nurse Manager on 9/28/09 at 10:15 AM during an interview.

4. On 9/29/09 at 11:05 AM, a physical therapy student (E#3) placed an oxygen tank inside the doorway of contact isolation room Intensive Care Unit (ICU) #9 and within a few minutes the tank was removed, but failed to disinfect after removal from the isolation room.

5. On 9/28/09 at approximately 11:10 AM a doctor (E # 2) entered ICU 3, a contact precaution room with his gown partially tied and examined a patient with his stethoscope. The signage on the door read," Contact Precaution." E#2 removed his gown and gloves, did not perform hand hygiene or disinfect his stethoscope, exited the room and proceeded to examine another patient in room # 8.

6. E#2 was observed a second time, at 11:20 AM on 9/28/09, exiting isolation room #9 still wearing his isolation gown and gloves. E#2 proceeded to an unoccupied patient's room and disposed of his gown and gloves, sanitized his hands and then went to examine a patient in room #4.

7. The above findings were discussed with the Nurse Manager during an interview on 9/28/09 at approximately 11:30 AM.

B. Based on Hospital policy/guidelines review, observation and staff interview, it was determined that for 2 of 16 rooms ( room #s 510-2 and 515-2) inspected on 5 North, the hospital failed to ensure bloody items were disposed of in accordance with hospital policy.

Findings include:

1. On 9/28/09 at approximately 3:00 PM policy #01-005 and titled, "Isolation Precautions" included, "Articles soiled with blood...are to be placed in the Red Hazardous Waste Container"

2. On 9/28/09 at approximately 2:00 PM unit 5 North was toured with the Nurse Manager. The bedside tables in room 510-2 and 515-2 contained small gauze pads soiled with bright red blood.

3. The above findings were confirmed with the Nurse Manager during an interview on 9/28/09 at approximately 3:00 PM.

A. Based on clinical record review and staff interview, it was determined that for 1 of 2 (Pt. #17) clinical records reviewed on the 3 South Unit, the Hospital failed to ensure insulin sliding scale coverage was administered as ordered.

Findings include:

1. On 9/28/09 at approximately 1:38 P.M. the clinical record for Pt. #17 was reviewed. This was a 79-year-old male, admitted 9/21/09 with a diagnosis of Failure to Thrive. The record included a physician's order dated 9/22/09 at 6:00 A.M. for "...moderate dose sliding scale regular Novolin R insulin for the following: 151-200 (2 units); 201-250..." Documentation in the clinical record indicated that Pt. #17 had the following blood glucose results: 9/25/09 at 3 P.M. (162); 9/25/09 at 9 P.M. (179); and 9/28/09 at 10:30 A.M. (190). The record lacked documentation that the patient received sliding scale insulin coverage as ordered for the elevated blood glucose results.

2. The above findings were confirmed with the VP of Clinical Operations and the Critical Care Manager during a simultaneous interview on 9/30/09 at approximately 1:00 P.M.


B. Based on clinical record review and staff interview, it was determined that for 1 of 1, (Pt. #17) clinical record reviewed on the 3 South Unit for a patient with Diabetes, the Hospital failed to ensure blood glucose monitoring was implemented as ordered.

Findings include:

1. On 9/28/09 at approximately 1:38 P.M. the clinical record for Pt. #17 was reviewed. This was a 79-year-old male, admitted 9/21/09 with a diagnosis of Failure to Thrive. The record included a physician's order dated 9/23/09 at 2:00 P.M. for accucheck (blood glucose monitoring) every 4 hours. The record lacked documentation that the accucheck were implemented on the following dates and times as required: 9/24/09 at 9:00 P.M., 9/25/09 at 1:00 P.M., 9/25/09 at 7:00 P.M., and 9/26/09 at 1:00 A.M.

2. The above findings were confirmed with E#7 (Charge Nurse of the 3 South Unit) during an interview on 9/28/09 at approximately 1:45 P.M.