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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 20, 2010, the surveyors find 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 C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on January 20, 2010, the surveyors find 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 January 20, 2010.

A. Based on Facility policy and staff interview, it was determined the Facility failed to ensure all blood administration techniques were followed as required. This was evident in 3 ( Pt. #s 14,20,21) of 5 records reviewed with blood administration.

Findings include:

1. Facility policy indicates that when initiating a blood transfusion, page 2, 10.) "assure the patient has an intravenous line and the line should be at least a 20 gauge with no signs of infiltration at the site."

2. In 3 of 5 clinical records reviewed with blood administration, it was documented that the intravenous sites were started with 22 gauge needles.

3. The above findings were verified with the DON on 01/20/10 at 10:00 am.

A. Based on a review of the Medical Record Statistics Form, interview with Hospital staff and a written statement of the Hospital's delinquent medical record rate, it was determined that the Hospital failed to ensure all medical records were completed in a prompt manner.

Findings include:

1. The Medical Record Statistics Form was presented on survey date 01/21/10. It indicated that all records must be completed within thirty days post discharge.

2. On 01/21/10 the Medical Records Director presented a written statement indicating that as of this date, there were 14 delinquent medical records.

3. The above findings were verified with the Chief Nursing Officer on 01/21/10 at 10:00 am.