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Based on interview and document review and policy review, the facility failed to ensure that all medical records are completed within 30 days after discharge. Findings include:

During interview with the Director of Health Information Management on 01/07/2011 at 1000, he revealed that the facility had 526 records requiring physician's signature that were 30 or more days post discharge.
Document titled Marquette General Hospital Deficiency Chart Total by Physician revealed that there were 169 records 30+ days, 33 records 60+ days, 34 records 90+ days and 286 records 120+ days that still required a physician's signature to close the chart.
Review of policy no: 8960-002 revision date 06/23/2006 titled Medical Record Guideline For Physician, General Guidelines "Records shall be completed and authenticated within thirty (30) days following patient discharge. In no event shall the completion of a chart exceed 30 days following patient discharge.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors, the facility does not comply with the applicable provisions of the Life Safety Code.

See the K-tags on the CMS-2567 dated January 6, 2011 for Life Safety Code.

Based on observation and interview the facility failed to ensure supplies are kept at an acceptable level of safety and quality.

Findings include:

During the initial facility tour of 3 North, Rehabilitation on 1-5-11 at approximately 0915 it was observed that the following items were expired on top of and within the crash cart in the medication room:

1. Two packages of electrodes had an expiration date of 07/10
2. Two 14 gauge intravenous catheters had an expiration date of 11/10
3. One #11 scalpel with an expiration date of 12/10
4. One percutaneous entry needle with an expiration date of 08/10

These findings were confirmed by the 3 North Clinical Director.

During the initial facility tour of 7 West, Cardiac Unit on 1-5-11 at approximately 1130 it was observed that the following items were expired in Respiratory Care Boxes throughout the unit:

1. Two Respiratory care boxes above the unit crash cart had CO2 (Carbon Dioxide) detectors that had an expiration date of 09/10
2. One Respiratory care box in the medication room had a "poke kit" that had an expiration date of 08/10 and an ABG (Arterial Blood Gas) kit that had an expiration date of 09/10
3. One Respiratory care box within the hall corridor had a "poke kit" that had an expiration date of 08/10 and a CO2 detector that had an expiration date of 09/10

These findings were confirmed by the 7 West, Cardiac Unit Clinical Director and the Director of Respiratory Care.

Based on record review of the Operating Rooms Log, the facility failed to provided adequate humidity in 2 of the 10 Operating Rooms. Findings Included:

During the tour of the operating suite on January 11, 2011 at approximately 11:00 AM the temperature and humidity logs were reviewed. OR #9 and #10 had low humidity which was at about 20% for at least two weeks. Humidity levels should be between 30% and 60%. Interview with OR staff revealed that it was unclear what adequate humidity parameters as they were not outlined on Operating Room temperature and humidity log sheet.

Based on observation, the facility failed to provide a safe and sanitary environment. Findings include:

During the emergency department tour on January 11, 2011 at approximately 9:00 AM to 9:30 AM, it was discovered that the seat back covers on all of the staff chairs in the patient exam rooms in the Emergency Department were ripped and the padding and wood backing was exposed. This presents and area that can not easily be cleaned. A clean linen cart was observed uncovered in at the ambulance drop off and the emergency department clean linen room door was held open with a magnetic hold open device and all the clean linen on the carts were not covered.

At approximately 9:30 to 10:30 AM on January 11, 2011 when touring the 1981 patient tower, it was noticed that a majority of the doors to patient rooms had large gouges in them. This presents an area that can not easily be cleaned. The splinters in the gouges could cut patients and staff.

At approximately 11:30 AM on January 11, 2011 while touring the pharmacy, a donut box, soda cups and other food containers were observed in the trash can in the pharmacy.