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A. Based on a review of contractual services and a request for Governing Body meeting minutes and staff interview, it was determined that the Hospital failed to ensure all services performed under contract were provided in an effective manner and evaluated for quality issues.

Findings include:

1. There was no documentation presented to indicate the Governing Body had evaluated and monitored the contractual services to ensure effectiveness of services. One of 12 contractual services listed, (Food and Nutrition), indicated that an audit by the contracted food company was performed by a subcontractor on 08/05/09. The audit indicated that there were no pertinent dietary issues. During a tour of the dietary department on 08/24/09 there were several issues of concern regarding infection control, quality assurance.

2. The above findings were conveyed to the Director of Performance Improvement on 08/26/09 at 10:00 AM.

A. Based on a review of the contractual list for the Facility and staff interview, it was determined that the Facility failed to include the scope and nature of the services provided for contractual services.

Findings include:

1. The contractual list of services for the Hospital was reviewed on 08/24/09. The list of contractors was presented but documentation failed to include the scope and nature of services provided.

2. The above findings were conveyed to the Director of Performance Improvement and Patient Safety Officer on 08/25/09 at 10:00 AM.

A. Based on a review of the quality assurance, performance improvement data, and staff interview, it was determined that the Facility failed to ensure all hospital services were monitored for quality control.

Findings include:

1. A request for the list of contractual services was made on 08/24/09. A list of twelve contracted management services was presented. There was no documentation to indicate quality assurance monitoring or performance improvement objectives had been initiated and implemented for any of the services.

2. The above findings were confirmed with the Director of Performance Improvement on 08/26/09 at 10:00 AM.

A. Based on a review of Hospital wide quality assurance monitoring and request for Governing Body meeting minutes regarding details, it was determined that the Facility failed to ensure that data collection for quality issues was specific.

Findings include:

1. There was no documented Governing Body minutes that reflected quality assurance data collection. There was no documented frequency and detail of necessary data collection objectives. The Governing Body minutes reviewed failed to specify any details regarding proposed quality monitoring of contractual services or any performance improvement activities associated with contractual services.

2. The above findings were verified with the Director of Performance Improvement and Patient Safety Officer on 08/26/09 10:00 AM.

A. Based on medical record review and staff interview, it was determined in 2 of 33 (Pt #10, #11) medical records reviewed, that the Hospital failed to ensure that a History and Physical (H&P) was completed within 24 hours of admission.

Findings include:

1. The medical record of Pt #10 was reviewed on 8/24/09. Pt #10 was admitted to the Hospital on 8/17/09 with the diagnosis of Bilateral Lower Extremities with Cellulitis. The H&P indicated that it was dictated on 8/22/09, 4 days late.

2. The medical record of Pt #11 was reviewed on 8/24/09. Pt #11 was admitted to the Hospital on 8/21/09 with the diagnosis of Pulmonary Emboli. The H&P indicated that it was dictated on 8/23/09, 1 day late.

3. During a staff interview, conducted with the Patient Safety Officer 8/24/09 at 1:50 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 3 (Pt #1) medical records reviewed in which the patient was administered insulin, the Hospital failed to ensure there was proper documentation.

Findings include:

1. The medical record of Pt #1 was reviewed on 8/24/09. It indicated that Pt #1 was admitted on 8/20/09 with diagnoses of Left Foot Cellulitis, Osteomyelitis, and Hyperglycemia. Pt #1 received insulin on 8/21/09 at 12:32, 18:51, 21:00, and 22:50. The nursing documentation indicated only that the medication was administered "subcutaneous" with no site indicated. On 8/23/09 documentation indicated that Pt #1 was administered insulin at 13:36 and recorded as "4 Units, Subcutaneous, Giv...Inj site: Right Vastus Lateralis (a muscle)..."

2. During an interview with the Patient Safety Officer, conducted on 8/24/09 at 11:45 AM, it was verbalized that nursing staff are to document the site of the injection and that no insulin was to be injected into a muscle. She confirmed the above findings.

A. Based on a review of the medical record delinquency rate and staff interview, it was determined that the Facility failed to ensure all medical records were completed in a timely manner.

Findings include:

1. The Medical records department presented the number of delinquent records on 08/26/09. The delinquent rate was 533.

2. An interview, conducted with the Performance Improvement Coordinator, on survey date 08/26/09 at 2:30 PM, verified the number of delinquent records and it was indicated that Hospital policy states delinquency is determined 28 days after patient discharge.

A. Based on a review of the Hospital's Bylaws, Rules and Regs, medical record review, and staff interview, it was determined that in 1 of 33 (Pt. #17) records reviewed the hospital failed to ensure that a discharge summary was completed.

Findings include:

1. The Hospital's Bylaws, Rules and Regulations was reviewed on 8/26/09. It indicated under, "17. The patient's medical record should be complete at the time of discharge, or no longer than 28 days after discharge, including...discharge summary..."

2. The medical record of Pt. #17 was reviewed on 8/25/09. Pt. #17 was admitted on 7/23/09 with diagnosis of Active Labor and required a C-section with delivery of a single male infant. Pt. #17 was discharged on 7/26/09. There was no discharge summary dictated as of 8/26/09.

3. During a staff interview with the Risk Manager on 8/26/09 at 2:30 PM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Facility failed to ensure all outdated medications were not available for patient use.

Findings include:

1. The Medication Administration policy indicated that all outdated medications would be checked and disposed accordingly.

2. During a tour of the surgical area, 3 - .9% NaCl prefilled 5cc syringes were found in an anesthesia cart in Operating Room #7. The prefilled syringes were expired in Dec. 2007 and May of 2008. In the anesthesia work room, a bottle of Isoflurane, 250ml, liquid for inhalation that expired on 1 Aug 2009.

3. During an interview with the Surgery Director, conducted on 8/26/09 at 11:10 AM, the above findings were confirmed.

B. Based on a review of policy and procedure, observation, and staff interview, it was determined that the hospital failed to ensure that multidose vials were properly annotated according to policy.

Findings include:

1. The policy titled "Multi Dose Vials and Multiple Dose Containers" was reviewed. It indicated under "IV. A., Staff shall place their initials and the date of cap removal/first entry into any multi-dose vial."

2.. During a tour of the Psychiatric Unit on 8/24/09 at 11:00 AM, it was observed that a multi-dose vial of Norepinephrine in the crash cart medication box was opened but not marked with date of opening and initials of staff.

3. During an interview with the Director of Performance Improvement on 8/25/09 at 11:30 AM, the above finding was confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure that the Director of Food Services ensured the food storage policy was followed.

Findings include:

1. The Hospital policy titled "Food Storage" was reviewed on 8/24/09. It indicated "Procedure: 3. Rotate stock so that older items are used first. Date products to ensure the use of "First-In, First-Out"
procedures."

2. During a tour of the Dietary storage area, conducted 8/24/09 at 3:00 PM, the following were observed: In the Food Storage Room - 2 cases Pulmocare expired 10/1/07, 1 case Pulmocare expired 1/1/09, 1 case Pulmocare expired 2/1/09, all large canned items with no dates as to when received, 32 bottles (750 ml) coffee bar syrup all with no dates as to when received, 3 cases Ensure Plus stored with newer items on the top and older items on the bottom, and 3 cases of Glucerna stored with newer items on top and older items on the bottom of the storage shelves.

3. During a staff interview, conducted with Food and Nutrition Director on 8/24/09 at 3:30 PM, the above findings were confirmed.

B. Based on a review of Hospital Dishwashing/Warewashing Machine Temperature Logs from 7/15/09 thru 8/23/09 and staff interview, it was determined that the Hospital failed to ensure that the Director of Food Services ensured that the Dish Machine temperatures were maintained as per dietary logs utilized by the Hospital.

Findings include:

1. The Hospital form titled "Dishwashing/Warewashing Machine Temperature Log" was reviewed on 8/24/09. It indicated "For High Temperature Machine...Temperature Requirements: Wash-150, Rinse-160, and Final Rinse-180. Record temperatures once during each meal period" The Dishwashing Machine Logs from 7/15/09 thru 8/23/09 (a total of 120 meals) were reviewed on 8/25/09. There was no documentation of dishwasher machine temperatures being taken during 59 out of 120 meals. On 8/4/09, the dishwasher rinse temperature was 158 degrees F. There was no documentation that the result was reported. 6 out of the 64 documented Dishwasher Final Rinse temperatures were 100 degrees F to 177 degrees F. There was no documentation that the results were reported, followed up, and corrected.

2. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed.

C. Based on a review of the Hospital's food refrigerator and freezer logs from 7/15/09 thru 8/23/09, and staff interview, it was determined that the Hospital failed to ensure that the Director of Food Services assured the food refrigerator and freezer temperatures were maintained to assure safe food storage.

Findings include:

1. The Hospital food refrigerator and freezer temperature log form was reviewed on 8/24/09. Each indicated that "Temperatures to be recorded twice a day. 1. Record date, time, your signature and corrective action plan to recheck temperature if it is outside of the acceptable range...3. If on second reading, temperature is outside of standard, take refrigerator out of service and report to Engineering." The food refrigerator and freezer logs from 7/15/09 thru 8/23/09 (a total of 80 temperatures per refrigerator or freezer) were reviewed on 8/25/09. The dietary department utilizes a total of 24 refrigerator/freezers, inclusive of 4 Walk-In Refrigerators, 7 Reach-In Refrigerators, 1 Walk-In Freezer, 1 Reach-In Freezer, and 2 Refrigerator Drawers. There were no temperatures documented on any of the refrigerators or freezers on 7 of 40 mornings and 2 of 40 evenings. The logs indicated that the following refrigerators/freezers had deviations above the standard (Note: a total of 73 temperatures were documented): a. Walk-In Refrigerator #1- 1 out of 73 readings; Walk-In Refrigerator #2- 3 out of 73 readings; Walk-In Refrigerator #3- 3 out of 73 readings; Reach-In Refrigerator #1- 8 out of 73 readings; Reach-In Refrigerator #2- 18 out of 73 readings; and Reach-In Refrigerator #5- 20 out of 73 readings. There was no documentation of a second temperature being taken, of the refrigerators being taken out of service, or of Engineering being notified.

2. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed.

D. Based on a review of food temperature logs from 7/15/09 thru 8/23/09, and staff interview, it was determined that the Hospital failed to ensure that the Director of Food Services ensured that food temperatures were maintained to prevent food borne illness.

Findings include:

1. The Hazard Analysis Critial Control Points (HAACP) temperature logs for 7/15/09 thru 8/24/09 were reviewed on 8/25/09 (a total of 120 meals.) There was no documentation of 35 out of 80 internal cooking temperatures. There was no documentation of holding temperatures every 2 hours during serving time in 89 of 120 meals.

2. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed. It was verbalized by the Food and Nutrition Director that the HACCP guidelines are that the Internal Cooking temperature is taken and recorded prior to serving and then the Holding temperatures should be taken and recorded every 2 hours during serving time.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure that food items were stored in a manner to prevent the availability of expired items being utilized for patient meals.

Findings include:

1. The Hospital policy titled "Food Storage" was reviewed on 8/24/09. It indicated "Procedure: 3. Rotate stock so that older items are used first. Date products to ensure the use of "First-In, First-Out"
procedures.

2. During a tour of the Hospital, conducted 8/24/09 at 3:00 PM, the following were observed in the Dietary Storage areas: In the Food Storage Room- 2 cases Pulmocare expired 10/1/07, 1 case Pulmocare expired 1/1/09, 1 case Pulmocare expired 2/1/09, all large canned items with no dates as to when received, 32 bottles (750 ml) coffee bar syrup all with no dates as to when received, 3 cases Ensure Plus stored with newer items on the top and older items on the bottom, and 3 cases of Glucerna stored with newer items on top and older items on the bottom of the storage shelves.

3. During a staff interview, conducted with Food and Nutrition Director on 8/24/09 at 3:30 PM, the above findings were confirmed.

B. Based on a review of Hospital Dishwashing/Warewashing Machine Temperature Log form, a review of temperature logs from 7/15/09 thru 8/23/09, it was determined that the Hospital failed to ensure that the Dish Machine temperatures were maintained to provide a sanitary food preparation environment.

Findings include:

1. The Hospital form titled "Dishwashing/Warewashing Machine Temperature Log" was reviewed on 8/24/09. It indicated "For High Temperature Machine...Temperature Requirements: Wash-150, Rinse-160, and Final Rinse-180. Record temperatures once during each meal period"

2. The Dishwashing Machine Logs from 7/15/09 thru 8/23/09 (a total of 120 meals) were reviewed on 8/25/09. There was no documentation of dishwasher machine temperatures being taken during 59 out of 120 meals. On 8/4/09, the dishwasher rinse temperature was 158 degrees F. There was no documentation that the result was reported. 6 out of the 64 documented Dishwasher Final Rinse temperatures were 100 degrees F to 177 degrees F. There was no documentation that the results were reported, followed up, and corrected.

3. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed.

C. Based on a review of a review of Hospital food refrigerator and freezer temperature log, a review of food refrigerator and freezer logs from 7/15/09 thru 8/23/09, and staff interview, it was determined that the Hospital failed to ensure that food refrigerator and freezer temperatures were maintained to provide a sanitary food preparation environment to prevent food spoilage.

Findings include:

1. The Hospital food refrigerator and freezer temperature log form was reviewed on 8/24/09. Each indicated that "Temperatures to be recorded twice a day. 1. Record date, time, your signature and corrective action plan to recheck temperature if it is outside of the acceptable range...3. If on second reading, temperature is outside of standard, take refrigerator out of service and report to Engineering."

2. The food refrigerator and freezer logs from 7/15/09 thru 8/23/09 (a total of 80 temperatures per refrigerator or freezer) were reviewed on 8/25/09. The dietary department utilizes a total of 24 refrigerator/freezers, inclusive of 4 Walk-In Refrigerators, 7 Reach-In Refrigerators, 1 Walk-In Freezer, 1 Reach-In Freezer, and 2 Refrigerator Drawers. There were no temperatures documented on any of the refrigerators or freezers on 7 of 40 mornings and 2 of 40 evenings. The logs indicated that the following refrigerators/freezers had deviations above the standard (Note: a total of 73 temperatures were documented): a. Walk-In Refrigerator #1- 1 out of 73 readings; Walk-In Refrigerator #2- 3 out of 73 readings; Walk-In Refrigerator #3- 3 out of 73 readings; Reach-In Refrigerator #1- 8 out of 73 readings; Reach-In Refrigerator #2- 18 out of 73 readings; and Reach-In Refrigerator #5- 20 out of 73 readings. There was no documentation of a second temperature being taken, of the refrigerators being taken out of service, or of Engineering being notified.

3. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed.

D. Based on a review of Hazard Analysis Critical Control Points (HACCP) Critical Control Points Daily Temperature Log form, a review of food temperature logs from 7/15/09 thru 8/23/09, and staff interview, it was determined that the Hospital failed to ensure that food temperatures were monitored and maintained to prevent potential food spoilage and infection.

Findings include:

1. The HACCP Critical Control Points Daily Temperature Log form was reviewed on 8/25/09. It was verbalized by the Food and Nutrition Director that the HACCP guidelines are that the Internal Cooking temperature is taken and recorded prior to serving and then the Holding temperatures should be taken and recorded every 2 hours during serving time.

2. The HAACP temperature logs for 7/15/09 thru 8/24/09 were reviewed on 8/25/09 (a total of 120 meals.) There was no documentation of 35 out of 80 internal cooking temperatures. There was no documentation of holding temperatures every 2 hours during serving time in 89 of 120 meals.

3. During a staff interview, conducted with the Food and Nutrition Director on 8/25/09 at 10:00 AM, the above findings were confirmed.


E. A. Based on observation, a review of Hospital policy, and staff interview, it was determined that the Hospital failed to ensure disinfection practices included proper labeling of supplies with expiration dates.


Findings include:

1. The Hospital policy titled "Wet Prep Procedure" was reviewed on 8/26/09. It failed to indicate a process for identifying expiration of the disinfectant solution once it was prepared.

2. During a tour of the Surgical Suite, conducted on 8/26/09 at 10:30 AM, 6 quart bottles of Pro Con System Silver 1 step disinfectant and 3 Pro Con System Silver 1 step gallon containers were observed in the Ambulatory Surgical Center clean utility. There were no manufacturer or expiration dates observed. The Pro Con System Silver 1 step gallon containers were observed hanging from the walls throughout the unit. All were without manufacturer or expiration dates.

3. During a staff interview, conducted with the Director of Environmental Services on 8/26/09 at 3:30 PM, it was verbalized that the Hospital utilizes the Wet Task Procedure and that the manufacturer expiration date is one year after opened. The 1 step quart bottles were prepared by the staff using a concentrate solution and then these bottles are poured over wipes in the 1 step gallon containers and placed in use. The containers are reusable. It was confirmed that the all of the above containers were without dates as to when concentrate was opened, when they were prepared, and/or when they would expire.

A. Based on staff interview, it was determined that the Facility failed to ensure the potential for cross contamination of contagions did not exist.

Findings include:

1. A tour of the Obstetrics (OB) department was conducted on survey date 08/24/09. The Director of OB indicated that maternal and neonatal linens were not separated prior to sending to the laundry, resulting in the potential for cross contamination of potential infection.

2. The above finding was confirmed with the Director of OB on 08/24/09 10:00 AM.

A. Based on a review of the Hospitals's Bylaws, Rules/Regulations, a review of surgical privileges, and staff interview, it was determined that in 2 of 4 (Physicians #1 and #2) surgical privileges reviewed, the Hospital failed to ensure updated and current surgical privileges were maintained in the surgical services.

Findings include:

1. The Hospital's Bylaws, Rules/Regulations were reviewed on 8/26/09. They indicated under, "Duration of Appointment Initial appointments to the medical staff shall be made for a period of not more than twenty-four (24) months and shall extend to the next reappointment cycle...."

2. The surgical privileges of Physician #1 were reviewed on 8/26/09. The surgical privileges of Physician #1 that were in the surgical services were granted in 2006 (requiring re-credentialing in 2008) and the privileges in the computer indicated his privileges were re-credentialed in 7/07 (requiring re-credentialing in 7/09). There was no documentation that the physician had current surgical privileges.

3. The surgical privileges of Physician #2 were reviewed on 8/26/09. The surgical privileges of Physician #2 that were in the surgical services were granted in 2006 (requiring re-credentialing in 2008) and the privileges in the computer indicated his privileges were re-credentialed in 7/07 (requiring re-credentialing in 7/09). There was no documentation that the physician had current surgical privileges.

4. During an interview with the Patient Safety Officer, conducted on 8/26/09, the above findings were confirmed. It was also verbalized that if the physician's surgical privileges were not current in the books in the surgical services area, they would be current in the computer which could be used as a back-up reference.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure jewelry was not worn in the surgical area.

Findings Include:

1. Hospital policy titled "Surgical Services," indicates that jewelry if worn will be contained under caps or jackets.

2. A tour of the surgical area was conducted on 08/26/09. The escorting Surgical Nurse Manager was wearing an exposed watch and ring. It was observed that an individual identified as a staff registered nurse who was assisting with an open case was wearing earrings that were not contained under her cap.

3. The above findings were conveyed to the Interim Director of Surgery on 08/26/09 at 10:30 AM.