HospitalInspections.org

Based on review of a letter of attestation, and staff interview, it was determined that the Hospital failed to ensure all records were completed within 30 days following discharge.

Findings include:

1. A letter of attestation presented by the Director of Health Information Management (HIM), on 8/22/12, at approximately 10:30 AM, indicated that as of 8/22/12 there were 188 medical records incomplete 30 days after discharge.

3. The above finding was confirmed with the Director of HIM during an interview on 8/22/12, at approximately 10:00 AM.

A. Based on review of Hospital policy, Dish Machine Temperature Sheet Log, and staff interview, it was determined that for 1 of 1 Dish Machine Temperature log the Hospital failed to ensure all dishwasher temperatures were obtained and documented as required by policy. This potentially affects all patients on census.

Findings include:

1. Hospital policy titled, "Monitoring Dish Machine Temperature" reviewed on 8/21/12, required, "Purpose: To keep the temperature of the dish machine at correct degrees in final rinse...The temperature of the dish machine must always have a final rinse of 180 degrees. Under 160 is not acceptable for sanitizing. Procedure: Seven days a week: Position 13 is responsible for breakfast and lunch recording of the temperature...."

2. The Dish Machine Temperature log sheet for August 1-20, 2012 was reviewed on 8/21/12. Four of 19 days lacked documentation of the wash, rinse and final rinse temperatures during the lunch period.

3. The Assistant to the Director of Dietary Services was interviewed on 8/21/12. The Assistant confirmed the above findings and stated that Machine temperature should be taken for each meal service period.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Non-Accredited Hospital Federal Re-Certification Survey conducted on August 21 22, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Non-Accredited Hospital Federal Re-Certification Survey conducted on August 21 - 22, 2012, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 22, 2012.

Based on observation, interview and stated practice, it was determined that for 1 of 1 Physician (E #1), the Hospital failed to ensure intravenous access ports were disinfected prior to accessing, according to stated practice.

Findings include:

1. During the observational tour of OR room 4 on 8/22/12 between approximately 7:30 AM and 8:20 AM, E #1 (Anesthesiologist) accessed an intravenous port and administered 3 medications without disinfecting the port.

2. The Director of Surgical Services was interviewed on 8/22/12 at approximately 8:30 AM. The Director stated that it is Hospital practice that all intravenous ports are disinfected prior to accessing for medication administration.

Based on review of Hospital policy, observation and staff interview, it was determined that for 2 of 2 physicians (E #1 & 2) the Hospital failed to ensure staff adhere to appropriate surgical attire as required by policy.

Finding include:

1. The Hospital policy titled, "Dress Code for Surgical Suite" (revised 07/2009), reviewed on 8/22/12, required, "Proper surgical attire will be worn in all areas of the department... A clean mask is worn to cover nose and mouth when entering the sterile operating room."

2. During an observational tour of OR 4 on 8/22/12 between 7:35 AM to 8:30 AM the following was observed:

*At 7:54 AM the Anesthesiologist (E #1) entered the room with open surgical instruments, with the mask bottom ties unsecured, leaving the mask dangling over his nose and his mouth not covered.

* At 8:24 AM the Surgeon (E #2) entered the room with open surgical instruments with his mask unsecured, leaving his nose and mouth not fully covered.

3. The Director of Surgical Services was interviewed on 8/21/12 at approximately 8:30 AM and stated that masks should be secured to cover the nose and mouth.

Based on review of a letter of attestation, and staff interview, it was determined that the Hospital failed to ensure all records were completed within 30 days following discharge.

Findings include:

1. A letter of attestation presented by the Director of Health Information Management (HIM), on 8/22/12, at approximately 10:30 AM, indicated that as of 8/22/12 there were 188 medical records incomplete 30 days after discharge.

3. The above finding was confirmed with the Director of HIM during an interview on 8/22/12, at approximately 10:00 AM.

A. Based on review of Hospital policy, Dish Machine Temperature Sheet Log, and staff interview, it was determined that for 1 of 1 Dish Machine Temperature log the Hospital failed to ensure all dishwasher temperatures were obtained and documented as required by policy. This potentially affects all patients on census.

Findings include:

1. Hospital policy titled, "Monitoring Dish Machine Temperature" reviewed on 8/21/12, required, "Purpose: To keep the temperature of the dish machine at correct degrees in final rinse...The temperature of the dish machine must always have a final rinse of 180 degrees. Under 160 is not acceptable for sanitizing. Procedure: Seven days a week: Position 13 is responsible for breakfast and lunch recording of the temperature...."

2. The Dish Machine Temperature log sheet for August 1-20, 2012 was reviewed on 8/21/12. Four of 19 days lacked documentation of the wash, rinse and final rinse temperatures during the lunch period.

3. The Assistant to the Director of Dietary Services was interviewed on 8/21/12. The Assistant confirmed the above findings and stated that Machine temperature should be taken for each meal service period.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Non-Accredited Hospital Federal Re-Certification Survey conducted on August 21 22, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Non-Accredited Hospital Federal Re-Certification Survey conducted on August 21 - 22, 2012, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 22, 2012.

Based on observation, interview and stated practice, it was determined that for 1 of 1 Physician (E #1), the Hospital failed to ensure intravenous access ports were disinfected prior to accessing, according to stated practice.

Findings include:

1. During the observational tour of OR room 4 on 8/22/12 between approximately 7:30 AM and 8:20 AM, E #1 (Anesthesiologist) accessed an intravenous port and administered 3 medications without disinfecting the port.

2. The Director of Surgical Services was interviewed on 8/22/12 at approximately 8:30 AM. The Director stated that it is Hospital practice that all intravenous ports are disinfected prior to accessing for medication administration.

Based on review of Hospital policy, observation and staff interview, it was determined that for 2 of 2 physicians (E #1 & 2) the Hospital failed to ensure staff adhere to appropriate surgical attire as required by policy.

Finding include:

1. The Hospital policy titled, "Dress Code for Surgical Suite" (revised 07/2009), reviewed on 8/22/12, required, "Proper surgical attire will be worn in all areas of the department... A clean mask is worn to cover nose and mouth when entering the sterile operating room."

2. During an observational tour of OR 4 on 8/22/12 between 7:35 AM to 8:30 AM the following was observed:

*At 7:54 AM the Anesthesiologist (E #1) entered the room with open surgical instruments, with the mask bottom ties unsecured, leaving the mask dangling over his nose and his mouth not covered.

* At 8:24 AM the Surgeon (E #2) entered the room with open surgical instruments with his mask unsecured, leaving his nose and mouth not fully covered.

3. The Director of Surgical Services was interviewed on 8/21/12 at approximately 8:30 AM and stated that masks should be secured to cover the nose and mouth.