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Based on observation, staff interviews, and review of maintenance records between January 11 and January 13, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies:
K 12: unprotected construction type for the building;
K 17: provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards, and smoke detection in spaces that are open to the corridor.
K 18: corridor doors that did not latch
K 25: maintain the fire-rating and smoke tightness of smoke barrier walls
K 26: smoke compartments of the appropriate size and layout
K 28: provide smoke barrier doors with the required minimal width
K 29: enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone,
K 35: the facility did not provide sufficient exit width
K 38: egress paths at all times with doors that were unlockable in the egress path, egress without passing through intervening hazardous rooms and snow cleared from the egress path
K 39: maintain corridors and aisles at least the minimal clear width required by the code
K 42: patient suites, larger than 1,000 square feet with at least 2 remote exit access doors
K 43: exiting without the use of a key or locked as permitted by the code
K 47: portable fire extinguishers as required by the code: the facility did not provide and maintains with compliant fire extinguishers.
K 51: a fire alarm system that is installed according to NFPA 72 with visual alarm notification
K 52: the fire alarm system according to NFPA 72 requirements with pull stations free of obstructions, and repair of identified problems
K 56: deficiencies in the sprinkler system;
K 62: the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 and the appropriate quantity of spare sprinklers.
K 63: an adequate and reliable water supply that provided reliable and adequate sprinkler water supply
K 64: the facility did not provide and maintain portable fire extinguishers
K 67: the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with compliant fire dampers, hard ducts and neutral airflow between the corridor and rooms
K 69: the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher identification, range hoods cleaned semi-annually.
K 74: sprinkler obstruction with curtains that permit the designed distribution of sprinkler water
K 75: linen/trash collection receptacles in compliance with codes
K 76: the safe storage of medical gases, as required by NFPA 99 with sealed wall penetrations
K 77: provide medical gas piping as required by NFPA 99 with compliant medical gas piping
K 103: interior walls and partitions made of noncombustible or limited-combustible materials
K 130: Various deficiencies in the Medical Office Building
K 147: Deficiencies in the electrical systems

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

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Based on observation and interview the facility failed to ensure all electronic equipment has been approved for use prior to patient use, in 1 of 1 observation (Rehabilitation Department).

Findings include:

Per observation on 1/11/16 between 11:05 AM and 11:45 AM, an electronic Hi-lo table in a private treatment room did not have a biomed sticker indicating the table was approved for use prior to patient use. This is confirmed in interview during observation with Manager D on 1/11/16 at 11:45 AM, stating all equipment needs to be approved prior to use.

Based on observation and staff interviews, the facility did not construct, install and maintain a proper ventilation and temperature control system in the emergency department and the waiting room for radiology. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 2 of the 8 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

Findings include:

1. On 01/12/1/2016 at 1:39 pm, observation revealed on the 1st floor radiology waiting area, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The waiting area did not have the required ventilation. It is required to have 2 air changes, 12 air changes of total exhaust and be negtive to adjacant spaces per Guidelines for Design and Construction of Health Care Facilities The Facility Guidelines Institue 2010 (FGI Guidelines) and American Society of Heating, Refrigerating and Air Conditionaing Engineers (ASHRAE) Standard 170. This observed situation was not compliant with 42 CFR 482.41(c)(4). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

Based on observation, staff interviews, and review of maintenance records between January 11 and January 13, 2016, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings:

The facility was found to contain the following deficiencies.
K 12: unprotected construction type for the building;
K 17: provide and maintain wall construction to protect the corridor from non-corridor spaces with rooms open to the corridor with the required safe-guards, and smoke detection in spaces that are open to the corridor.
K 18: corridor doors that did not latch
K 25: maintain the fire-rating and smoke tightness of smoke barrier walls
K 26: smoke compartments of the appropriate size and layout
K 28: provide smoke barrier doors with the required minimal width
K 29: enclose hazardous rooms with a smoke-tight room enclosure in a sprinkled smoke zone,
K 35: the facility did not provide sufficient exit width
K 38: egress paths at all times with doors that were unlockable in the egress path, egress without passing through intervening hazardous rooms and snow cleared from the egress path
K 39: maintain corridors and aisles at least the minimal clear width required by the code
K 42: patient suites, larger than 1,000 square feet with at least 2 remote exit access doors
K 43: exiting without the use of a key or locked as permitted by the code
K 47: portable fire extinguishers as required by the code: the facility did not provide and maintains with compliant fire extinguishers.
K 51: a fire alarm system that is installed according to NFPA 72 with visual alarm notification
K 52: the fire alarm system according to NFPA 72 requirements with pull stations free of obstructions, and repair of identified problems
K 56: deficiencies in the sprinkler system;
K 62: the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 and the appropriate quantity of spare sprinklers.
K 63: an adequate and reliable water supply that provided reliable and adequate sprinkler water supply
K 64: the facility did not provide and maintain portable fire extinguishers
K 67: the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with compliant fire dampers, hard ducts and neutral airflow between the corridor and rooms
K 69: the facility did not provide a kitchen extinguishing system as required by NFPA 96 with extinguisher identification, range hoods cleaned semi-annually.
K 74: sprinkler obstruction with curtains that permit the designed distribution of sprinkler water
K 75: linen/trash collection receptacles in compliance with codes
K 76: the safe storage of medical gases, as required by NFPA 99 with sealed wall penetrations
K 77: provide medical gas piping as required by NFPA 99 with compliant medical gas piping
K 103: interior walls and partitions made of noncombustible or limited-combustible materials
K 130: Various deficiencies in the Medical Office Building
K 147: Deficiencies in the electrical systems

Refer to the the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, the facility did not provide doors with positive-latching hardware. This deficiency occurred in 1 of the 10 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 01/11/2016 at 3:40 pm, observation revealed on the basement floor in the former operating rooms, that the corridor door would not positively self-latch. When 5 pounds of pressure was applied to the door, without turning the latch, the latch would not hold the door in the latched position. The doors have roller latches on them. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.3.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance mechanic).

Based on observation and interview the facility failed to ensure medication sterility is maintained and medications are administered per policy in a manner to prevent cross contamination in 3 of 5 direct patient care departments observed (Emergency Department, Rehabilitation and Surgery) and 1 of 3 patients observed receiving medications (Patient #4).

Findings include:

Per interview with Manager B on 1/13/16 at 1:41 PM the facility policy titled "Medication Use Policy", revised 9/1/15, includes cleaning the vial septums prior to entry with a needle, but currently does not address the use of spiking devices as an identified task.

On 1/11/16 at 9:45 AM Emergency Treatment Room 1 and 7 were observed each to have one 1-liter bottles sterile saline for irrigation, open in a cupboard. This was confirmed in interview at time of the observation with Emergency Department Manager C who was unaware open sterile bottles could not be saved for later use.

Per observation 1/11/16 at 11:05 AM in the Rehabilitation Department office there is a vial of Dexamethasone (anti-inflammatory) with a "spike" stop cock (to allow access without entering the septum multiple times) through the septum and a syringe attached to the spike. Per interview with Rehabilitation Department Manager D during the observation, who was unaware medications could not be "spiked" and stated the syringe was used for multiple patients.

On 1/12/16 at 9:35 AM Certified Registered Nurse Anesthetist U was observed preparing medications in the Surgery Department for Patient #4's knee surgery. Nurse U removed the caps to the following medications: Midazolam (amnesiac), Propofol (sedative), Dexamethasone, Ketorolac (non-steroidal anti-inflammatory) and Odansetron (anti-emetic). Nurse U proceeded to insert a needle attached to a syringe into the Midazolam with out cleaning the septum. This observation was discussed with Director Q on 1/12/16 at 10:35 PM who acknowledged staff are to clean the vial septums prior to inserting needles.

Based on observation, record review and interview the facility failed to ensure disinfection of equipment between patients to prevent cross contamination in 4 of 5 direct patient care departments observed (Laboratory, Surgery, Rehabilitation, Medical/Surgical); failed to maintain sterile field for 2 of 2 surgical patients observed (Patient #4, Patient #13); failed to evaluate water temperatures and detergents to maximize antimicrobial efficacy in 1 of 1 onsite laundry department; failed to ensure personal protective equipment is worn to prevent contamination or cross contamination in 2 of 5 direct patient care departments observed (Laboratory, Surgery); failed to ensure staff perform hand hygiene per policy while performing direct patient care for 4 of 6 patients observed (Patient #1, Patient #2, Patient #3, Patient #4); and failed to provide a code compliant sanitary environment with clean and dirty airflows in 1 of 5 direct patient care departments observed (Surgery).

Findings include:

1. Laboratory:

Review of facility policy titled Standard Precautions effective 4/1/15 states under F. "...Gowns and other appropriate protective apparel must be worn when there is potential that an exposure (contact with...splashing with blood...) will occur...G.2. "Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during....transport. The container used for this purpose will be labeled biohazard...This facility utilized standard precautions and considers all specimens and containers potentially hazardous."

Per facility provided World Health Organization recommendation titled Best Practices in Phlebotomy it states on page 7 Step 10 "Pack laboratory samples safely in a plastic leak-proof bag...If there are multiple tubes, place them in a rack or padded holder to avoid breakage during transportation."

Per review of Occupational Safety and Health Administration, Laboratory Safety Guidance guidelines 2011 at https://www.osha.gov/Publications/laboratory/OSHA3404laboratory-safety-guidance.pdf it states "Gloves must be worn when hand contact with blood, mucous membranes...or non-intact skin is anticipated, or when handling contaminated items or surfaces, 29 CFR 1910.1030(d)(3)(ix)."

Per review of Center for Disease Control and Prevention at regarding universal precautions, at www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm, it states under Use of Protective Barriers "Protective barriers reduce the risk of exposure of the health-care worker's skin or mucous membranes to potentially infective materials." And under Protective Barriers #4. "Do not wash or disinfect surgical or examination gloves for reuse...Disinfecting agents may cause deterioration."

Review of facility policy titled Venipuncture Collections, effective 1/28/14, states under #14"...Do not touch the area after it has been cleansed, unless you have similarly prepared your gloved finger."

Per observation on 1/11/16 at 2:30 PM Laboratory Tech F was observed performing a blood draw on Patient #1. Tech F donned gloves, palpated the draw site on Patient #1, cleaned the site with alcohol and proceeded to wipe of the index finger of F's own gloved left hand, palpated the site again and inserted the needle to draw blood into four blood tubes. After the draw was completed, F, still wearing gloves, labeled the blood tubes, removed the gloves, performed hand hygiene, lifted the arm rest to allow the patient to stand and leave, picked up the lab tubes with ungloved hands and carried the tubes into the laboratory. Tech F was asked if there was anything else that needed to be done after a lab draw and Tech F said "no". Tech F did not clean the counter, the chair, side table and arm rest in the draw room after Patient #1 left.

When entering the laboratory with Tech F, Manager G and Tech Z was observed not wearing a protective lab coat. Per Manager G in interview on 1/11/16 at 2:45 PM, they have personal protective equipment and lab coats and they are optional.

2. Surgery:

Review of facility policy titled Hand Hygiene, effective 3/1/15, it states Indications for Hand Hygiene include but are not limited to:...#3. After removing gloves."

Review of facility policy titled Perioperative Surgical Attire, effective 12/1/14, states under 1.c. "All nonscrubbed personnel should wear a freshly laundered long-sleeved warm-up jacket snapped closed with the cuffs down to the wrists...4. Persons entering the restricted areas of the surgical suite (even for a brief time) should cover all head and facial hair...10.b. A fresh clean surgical mask should be worn for every procedure..."

Review of facility policy titled Central Sterile Processing, effective 8/1/15, states under Attire (4.5.1) "...All head and facial hair (except eyebrows and eyelashes) should be completely covered with a surgical-type hair covering."

Review of facility policy titled Cleaning of the Surgical Services Department, effective 8/1/15, states under Room Turnover Decontamination 3. "Wash operating table and mattress pads vigorously, (Breakdown of the table is essential to removing all contaminates)."

Per Association of periOpertive Registered Nurses Guidelines, 2015 Edition, under Aseptic Practice Recommendation VI.b. "Items should be delivered to the sterile field in a a manner that prevents unsterile objects or unscrubbed team members from leaning or reaching over the sterile field...VII.a. "Once created, a sterile field should not be left unattended until the operative or other invasive procedure is completed..."

Per interview with Manager B on 1/13/16 at 5:10 PM there is no surgical policy related to the sterile field.

The following was observed in Operating Room 1 on 1/12/16 with Director Q who stated in interview at 9:00 AM, the facility follows Association of periOperative Registered Nurses Guidelines:

At 8:10 AM there are open instruments on the back table ready for Patient #13's Carpal Tunnel surgery, with no staff in the operating room. This was confirmed in interview at 8:10 AM with Surgical Tech T who said it was opened at 8:00 AM, and was unaware the table had to be in view at all times.

At 9:10 AM Certified Registered Nurse Anesthetist U did not have a bonnet on to cover nape hair,ears or sideburns. U did not wash after removing gloves to assist transport of Patient #13 to recovery.

At 9:12 AM Central Services Tech W was observed with no bonnet on in the decontamination room.

At 9:15 AM Registered Nurse R wiped down a padded extension arm then wiped a side table up to where two table clamps were sitting, picked up the clamps in one hand with the extension in the other and laid the extension pad upside down on the table without wiping the area where the clamps were. R proceeded to wipe down the Operating Room table reaching from one side over to the far side missing the far edges of the pads with disinfectant, and did not clean the base of the table. Nurse R did not remove the individual pads to clean the undersurface or the table itself. Nurse R continued cleaning the instrument stands, and side tables only wiping the tope and not the legs or lower portions of the equipment.

Between 9:40 AM and 9:55 AM, Tech W and Nurse R placed sterile items on the back table by opening the packaged and reaching over the table to drop the items onto the table, rather than placing them on the table in a manner to prevent contamination of the sterile field.

At 9:46 AM and 10:06 AM and Tech W turned so W's back was to the sterile table.

At 10:04 AM Nurses R and U brought Patient #4 into the Operating Room and had not changed out their masks, Nurse U had sleeves of surgical jacket pushed up exposing bare forearms.

At 10:10 AM Doctor V entered the Operating Room wearing a bonnet that did not cover ears or sideburns.

At 10:19 AM Nurse R set up sterile gloves and chloraprep on the side table that also held a box of sutures. R donned the gloves and took the prep over to the patient to prep the site rather than setting up a sterile field next to the patient.

At 10:20 AM Doctor V donned sterile gloves, palpated Patient #4's prepped site and injected lidocaine (numbing agent), V removed the gloves and did not perform hand hygiene.

At 10:25 AM Nurse R opened the Chloraprep next to the computer keyboard, and opened the sterile gloves next to the Chloraprep, donned the gloves, performed the second prep, returned to the computer, removed one glove and began documenting on the computer with out performing hand hygiene or removing the remaining glove.

On 01/12/2016 at 4:03 pm, observation revealed on 1st floor floor in the sterile corridor suite, that airflow is from the 'normal' corridor into the sterile corridor. This observed airflow is from dirty to clean. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff AK (VP,CO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

On 01/12/2016 at 4:50 pm, observation revealed on the 1st floor floor in the back of sterilizer room, that air flow was not to the back of the sterilizers from the adjacent rooms. This observed airflow is from dirty to clean. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff AK (VP,CO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

On 01/12/2016 at 4:59 pm, observation revealed on the 1st floor floor in the Endoscopy room, that air flow was from the endoscopy room to the scope cleaning room. However, there is a drying cabinet in between the two rooms. This drying cabinet has glass doors that open up to endoscopy room and to the endoscopy cleaning room. There is an 1/8 inch gap around the the approximate 2' X 4' doors. After a procedure in the endoscopy room, air flow is from dirty procedure room, across the scopes in the storage/drying cabinet and out into the dirty scope cleaning room. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff K (VP,CFO), staff J (Director Support Services), and staff L (Maintenance Mechanic).

3. Rehabilitation Department:

Per observation on 1/11/16 between 11:05 AM and 11:45 AM, Cavi Wipes and Oxiver wipes (antibacterial wipes), were noted on a table by the Mat table in the Rehabilitation gym. Both wipes indicated in instructions they were to be used on non-porous materials. Per interview with Rehabilitation Manager D on 1/11/16 at 11:45 AM, the wipes are used on all the equipment between patients, including the spongy handles on the exercise equipment.

4. Laundry:

Per interview on 1/11/2016 at 10:30 AM with Environmental Services Manager E, they have not been montioring water temperatures when laundering mammogram gowns. Per interview with Infection Prevetionist AA on 1/11/16 at 11:00 AM, the infection control committee has not approved the laundry detergent used for mammogram gowns.


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5. Medical/Surgical:

Facility policy "Hand Hygiene" dated 3/1/2015 states in part: "Indications for hand hygiene include but are not limited to: 1. After contact with patient's skin or environment. 2. After contact with body fluids or excretions, non-intact skin, wounds and/or dressings."

On 1/11/2016 at 11:00 AM, CNA M obtained a blood sample from Patient #2 for blood glucose monitoring. CNA M then entered the result in the computer while wearing the same gloves used to obtain the blood sample.

On 1/11/2016 at 11:10 AM, CNA N obtained a blood sample from Patient #3 for blood glucose monitoring. CNA N proceeded to disinfect the blood glucose monitor with contaminated gloves. The back portion of the blood glucose monitor dislodged from the machine and fell onto the floor in Patient #3's room. CNA N placed the back portion onto the machine and returned the blood glucose monitor to the common area without disinfecting after falling on the floor.


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6. Basement:


On 01/11/2016 at 11:59 pm, observation revealed on the basement level in the soiled med room, that the airflow was from the room to the corridor. The airflow was from dirty to clean. This observed situation was not compliant with maintaining a sanitary environment. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff H (CEO), staff J (Director Support Services) and staff L (Maintenance Mechanic).

Based on observation, record review and interview, dietary staff failed to date and label open foods to ensure proper storage in 1 of 1 dietary department observed (kitchen).

Findings include:

Facility policy "Storage: Food Service" dated 6/1/2014 states: "4. All food items shall be wrapped...appropriately labeled, and dated. ...c. All items that are not in their original container must be labeled with the product name and use by dated."

Facility guidelines "Storage Periods for Retaining Food Quality" dated 9/2015 lists the following: "Rice, white -- 2 years; Rice, brown -- 6 months; Pasta -- 1 year; Potatoes, instant -- 6-12 months; Chocolate -- 1 year; Spices, ground -- 6 months; Herbs -- 6 months; Herb/spice blends -- 12 months (opened)."

The kitchen was observed to contain the following during observation on 1/11/2016 at 12:45 PM: 1 opened, undated bag each of white rice, brown rice and pasta; 1 unlabeled and undated container of chocolate chips; 1 opened and undated box of flaked mashed potatoes; 1 container of rotisserie seasoning labeled with an expiration date of 12/27; and more than 12 opened and undated containers of spices.

Dietary Manager P stated at the time of the observations that opened items expire "with the manufacturer's expiration date" and the spices "are good 1 year from delivery date." Dietary Manager P confirmed that not all items were being labeled and dated per the facility's food storage guidelines.

Based on record review and interview, facility staff failed to provide relevant and accurate discharge instructions to 2 of 6 discharged patients reviewed (Patient #19, Patient #20).

Findings include:

Per medical record review, Patient #19 was discharged to home from inpatient services on 11/9/2015 with a diagnosis of myocardial infarction (heart attack). The physician's discharge instructions include "Diet: Carbohydrate consistent, no added salt, low fat" and "Special Instructions: [Patient] will go home on nocturnal oxygen therapy." Patient #19's After Visit Summary, provided to the patient upon discharge, does not include instructions for diet type or orders for oxygen therapy at home.

Per medical record review, Patient #20 was discharged to home from inpatient services on 11/21/2015 with a diagnosis of anasarca (generalized swelling). The physician's discharge instructions include a diet order of "Consistent Carbohydrate" and "2 gm Sodium." Patient #20's After Visit Summary does not include the patient's diet order.

On 11/13/2016 at 8:40 AM, RN Informatics Specialist Y stated the After Visit Summary should include all of the physician's discharge orders.

Based on record review and interview the facility failed to ensure medical records document organ procurement contacts in 1 of 3 death medical records reviewed (Patient #5), out of a total 21 medical records reviewed.

Findings include:

Patient #5's medical record review revealed Patient #5 died on 2/17/15 following a blood clot in the brain. There is no documentation in the medical record the organ procurement organization was contacted to determine eligibility for a donation, contact name, the reference number and if the patient qualified to donate. This is confirmed in interview with Registered Nurse Y on 1/12/16 at 1:05 PM, who stated the information should be documented on the Tissue/Organ Procurement screen in the electronic medical record.

Based on record review and interview the facility failed to document that alcohol based skin prep is dry prior to draping in 1 of 1 medical records with alcohol based skin prep is used (Patient #4), and failed to ensure immediate use sterilization is used infrequently and not due to lack of clean surgical instruments in 1 of 1 departments using immediate sterilization (Surgery).

Findings include:

Patient #4's medical record review revealed Patient #4 had knee surgery on 1/12/16. The surgical site was prepped using alcohol based skin prep Chloraprep. There is no documentation of the alcohol based skin prep being dry prior to draping in the medical record. This is confirmed during record review and interview with RN Y on 1/13/16 at 3:00 PM, stating only the prep time and drape time is documented.

Examples with immediate use:

Review of facility policy titled Central Sterile Processing, effective 8/1/15, states "Immediate-use Steam Sterilization (IUSS) (8/6/2/1) Do not use Immediate-use steam sterilization for implantable items except in urgent situations in which patient care requirements preclude other sterilization methods (e.g. a critical piece of instrument is dropped and sterilized back-ups are not available). In such situations , use a sterilization time of 10 minutes...*IUSS is intended for use...in emergent situations to handle immediate reprocessing needs...Alternative such as careful case planning and/or an increase of sterile instrument inventory must be explored"

Per interview on 1/12/16 between 8:15 AM and 8:30 AM with Central Sterilization Tech W, when asked how often immediate use was being done for instruments Tech W stated "quite often". Per interview with Director Q on 1/12/16 at 8:30 AM, Q stated the facility had been doing frequent immediate use sterilization due to lack of instruments, specifically eye instruments and ortho instruments. Manager S stated in interview at on 1/12/2016 at 8:40 AM the facility had 3 sets of eye instruments, but now have six, but they only have 2 sets of ortho knee instruments and 3 sets of hand instruments and it depends on the schedule for frequency of immediate use.

Per review of the immediate use records, between 9/9/15 and 1/11/16 there were 46 sets of instruments that were not dropped and were sterilized with a 4 minute cycle and 1 minute dry time. These included hysterocopy instruments, dilatation and curettage instruments, ortho instruments, retractors, cement gun, arthroscopy instruments, vaginal retractor, and eye instruments. These records were provided by Director Q, and confirmed in interview on 1/12/16 at 8:30 AM, they have not analyzed the data to determine a quality plan to reduce the number of instances were immediate use is performed.
The facility failed to ensure the post-anesthetic evaluation is comprehensive including cardiopulmonary status, level of consciousness, follow-up care, observations and complications in 2 of 2 medical records requiring a post-anesthetic evaluation (4 and 12). See tag C322.

The cumulative effect of these deficiencies potentially affect the 28 patients scheduled for surgical procedures during the survey.

Based on record review and interview the facility failed to ensure the post-anesthetic evaluation is comprehensive and includes cardiopulmonary status, level of consciousness, follow-up care, observations and complications in 2 of 2 medical records requiring a post-anesthetic evaluation (Patient #4 and Patient #12).

Findings include:

Per interview with Certified Registered Nurse Anesthetist on 1/13/16 at 2:20 PM, there is no policy for anesthesia documentation, they are to use the template in the electronic medical record, and they do not document the actual values of vital signs in the post op note.

Patient #4's medical record review revealed Patient #4 had knee surgery on 1/12/16 under general anesthesia. The Anesthesia Postop Note states "...Cardiovascular Status: stable...Post Surgical Pain: controlled...Respiratory Status: adequate..." The note does not have measurable values that include blood pressures, pulse, pain level, respiratory rate and oxygen levels to determine recovery from the general anesthetic used. This is confirmed during record review and interview with RN Y on 1/13/16 at 3:00 PM.

Patient #12's medical record review revealed Patient #12 had tonsils and adenoids removed on 12/17/15 under general anesthesia. The Anesthesia Postop Note states "...Cardiovascular Status: stable...Respiratory Status: adequate..." The note does not have measurable values that include blood pressures, pulse, respiratory rate and oxygen levels to determine recovery from the general anesthetic used. This is confirmed during record review and interview with RN Y on 1/13/16 at 3:40 PM.

Based on record review and interview, the facility failed to evaluate the laundry services of 1 of 1 contracted laundry service.

Findings include:

Facility policy "Quality Assurance Plan" dated 4/1/2015 states: "It will be the policy of [facility] to assure that each department or any service offered under contract shall have an established departmental quality plan unique to the care, treatment and services it provides..."

Per interview with Environmental Services Manager E on 1/11/16 at 10:30 AM, the contracted laundry facility has not been toured to ensure compliance with federal conditions of participation.

During an interview on 1/13/2016 at 7:30 AM, Quality Manager B and could not provide data that the contracted laundry services were being monitored as part of the facility's quality program.

Chief Executive Officer H stated on 1/13/2016 at 10:50 AM that the facility contracts for laundry services with an affiliated facility. Per H, the affiliated facility maintains oversight of the contracted laundry services.