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Based on the tour of the facility on May 5th, 2014 with Staff E; this surveyor observed that the hospital failed to be constructed, arranged, or maintained the building to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the NFPA 101 Life Safety Code (2000 Edition) was used for this survey.

42 CFR 485.623: Condition of Participation: Physical Plant is NOT MET.

K-tags cited were as follows:
K-11: Door closer not installed within openings of an occupancy separation wall,
K-17: Corridor openings not smoke-tight,
K-25: Smoke barrier wall rating not maintained,
K-29: Hazardous areas wall rating not maintained, and
K-56: Sprinkler system not installed per NFPA 13.

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with Staff E. Please refer to the individual K-tags for the full description of each deficient practice.

Based on observation, P&P review and interview (F) in 1 of 1 areas were biohazard materials are stored the facility failed to ensure biohazard materials are properly secured. This deficient practice has the potential to affect all patients, visitors and staff at this facility.

Findings include:

On 5/5/14 at 11:30 AM reviewed facility P&P titled "Infection waste policy". It states under #7 "Infections waste will be transported from areas where generated to the locked storage area."

During a tour on 5/5/2014 at 11:15 AM noted an unlocked storage room marked with a biohazard sign. This storage area contained biohazard materials inside a walk in cooler also marked with a biohazard sticker.

Per interview with EVS Manager F on 5/5/2014 at 11:30 AM, biohazard materials and sharps are stored in this unlocked area until picked up by the contracted waste company. Per EVS Manager F the facility does not keep the cooler or storage room locked.

Based on the tour of the facility on May 5th, 2014 with Staff E; this surveyor observed that the hospital failed to be constructed, arranged, or maintained the building to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the NFPA 101 Life Safety Code (2000 Edition) was used for this survey.

42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is NOT MET

K-tags cited were as follows:
K-11: Door closer not installed within openings of an occupancy separation wall,
K-17: Corridor openings not smoke-tight,
K-25: Smoke barrier wall rating not maintained,
K-29: Hazardous areas wall rating not maintained, and
K-56: Sprinkler system not installed per NFPA 13.

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with Staff E. Please refer to the individual K-tags for the full description of each deficient practice.

Based on observation, P&P review and staff interviews (A, C, G), in 3 of 8 patient care areas toured, the hospital failed to ensure that all expired drugs and biologicals are removed to ensure the safety of patients and to prevent unauthorized use. This deficient practice has the potential to affects all 4 inpatients served at the facility during this survey.

Findings include:

According to the hospital's policy, reviewed on 5/6/2014, entitled; "Outdated drugs, chemicals, containers with worn label or illegible labels" dated 10/03; "It is the policy of (the hospital) to remove outdated and unusable drugs and chemicals from the Pharmacy, nursing units, and other areas to prevent their distribution or administration."

Per observation, while touring the fluoroscopy room with Diagnostic Director A on 05/06/14 at 10:30 AM, it was noted that expired (11/07) Barium tablets were kept in a wall cabinet. Diagnostics Director A stated at the time of the tour that these tablets should have been removed.

Per observation, while touring with ED manager C on 05/05/14 at 3:15 PM, it was noted that expired eye wash (10/08) and betadine (08/08) were kept as part of an enucleation kit in a cabinet in the clean utility room as well as an expired (01/12) sexual assault evidence collection kit. ED Manager C confirmed these findings at the time of the tour and stated these items should have been discarded.


32670


During a tour of the Therapy department on 5/6/2014 at 12:10 PM accompanied by Therapy Manager G, observed approximately one dozen expired (1/99) Chlorazene packets (solution used to sanitize whirlpool tub) in under-sink cabinet. Per interview with Therapy Manger G at the time of discovery, the packets should have been discarded since they no longer use the whirlpool tub.

Based on observation and interviews with facility staff (A, B, C, G), in 4 of 8 patient care areas toured, the hospital failed to ensure that patient supplies and medications are properly stored in a clean environment, and there is a system in place to prevent potential sources of contamination and infection. This deficiency potentially affects all 4 inpatients served at this facility during this survey.

Findings include:

In the clean utility room in the ED various supplies were stored under a sink including; traction weights and empty sharps containers. This was observed on 05/05/14 at 3:15 PM during a tour with ED Manager C. ED Manager C stated at the time of the tour that supplies should not be stored in this area.

During a tour of the Radiology Department with Diagnostic Director A on 05/06/14 at 10:30 AM it was observed that under-sink cabinets were used for storage. In General Radiology Room #1, cleaning supplies and tissues were stored under the sink. Spill kits, sharps containers and cleaning supplies were stored under a sink in the Control area. In the Ultrasound room the following items were stored under the sink; cleaning supplies, test strips and sterilizing solution. Sand bags (for patient positioning) and cleaning supplies were stored under the sink in the Fluoroscopy room. Diagnostics Director A agreed at the time of the tour that these areas should not be used for storage of patient use items.

In the outpatient blood drawing room of the laboratory, 3 spill kits were found stored under the sink. This was discovered during a tour of the laboratory on 05/06/14 at 10:15 AM with Diagnostic Director A. Diagnostic Director A agreed under sink areas should not be used for storage of patient care items.


32670


During a tour of the Physical Therapy Department on 5/6/14 at 12:10 PM accompanied by Therapy Manager G, observed cabinets under sinks being used for storage in the main gym, treatment room #1, whirlpool room and pediatrics room. Supplies found in the listed areas include: cleaners, sani-wipes, contact cement and other splinting materials used on patients for casting and molding, rubber gloves, patient urinals, baby powder and a sewing machine. Therapy manager G stated some of the discovered items are used for patients and agreed areas under sinks are not considered clean storage areas.

Per interview with Pt Care Services Director B on 5/6/2014, the facility does not have a policy related to under sink storage.

Based on medical record review, P&P review and interviews with facility staff (B), in 9 of 15 medical records requiring a nursing care plan (# 6, 7, 11, 12, 13, 14, 15, 19 and 20) out of a total of 20 MR reviewed, the hospital failed to ensure nursing care plans are developed for each patient are individualized to reflect each Pt's problems, interventions and goals. This deficient practice has the potential to affect all 4 in patients at the facility during this survey.

Findings include:

Per review on 5/6/14 at 9:30 am of facility policy titled Patient Centered Electronic Documentation, dated 8/2010 stated in part under 2. Patients will have a plan of care individualized to meet their needs. a. An individualized plan of care is initiated by the RN within eight hours of admission. c. The plan includes the patient's primary problems or areas of focus, identified outcomes, interventions, and evaluations of progress towards outcomes.

Per review on 5/6/14 at 1:00 PM, of Pt #6's MR, accompanied by Pt Care Services Director B, noted Pt #6 was admitted to the hospital with a UTI (urinary tract infection), weakness, and had a high fall risk score. The careplan did not include problems or interventions for fall risk, weakness, or urinary issues.

Per review on 5/6/14 at 1:15 PM of Pt # 7's MR, accompanied by Pt Care Services Director B, noted Pt #7 was admitted to the hospital with Pneumonia and Chronic Obstructive Pulmonary Disease. Pt #7 was also treated for alcohol withdrawal and had a high fall risk score. The careplan did not include problems or interventions for alcohol withdrawal or fall risk.


29963


Per review on 5/6/14 at 8:15 am of pt. #11's MR revealed the following information. Pt. #11 was admitted to the hospital with the following a secondary diagnosis, alcohol withdrawal syndrome. The careplan did not include problems, outcomes, interventions, or an evaluation of progress related to alcohol withdrawal syndrome.

Per review on 5/6/14 at 9:30 am of pt. #12's MR reveled the following information. Pt. #12 was admitted to the hospital with the following secondary diagnosis, Type 2 Diabetes. The careplan did not include problems, outcomes, interventions, or an evaluation of progress related to diabetes.

Per review on 5/6/14 at 9:50 am of pt. #13's MR revealed the following information. Pt. #13 was identified per nurses assessment on 2/13/14 to be at high risk for falls. The care plan did not include problems, outcomes, or an evaluation of progress related to falls risks.

Per review on 5/6/14 at 10:15 am of pt. #14's MR revealed the following information. Pt. #14 was admitted on 2/19/14 at 3:00 pm and was transferred to another facility on 2/20/14 at 10:55 am. A care plan was not initiated for pt. #14.


20878


Per MR reviews on 05/05/14 through 05/06/14 the nursing care plans found in the MR of patients #15, 19, and 20 did not contain complete documentation reflecting progress towards goals or interventions implemented.

Per interview with Pt. Care Service Director B on 05/06/14 at 1:15 PM nursing care plans are not complete and interventions are to be found in other parts of the chart which are not directly linked to or included in the care plan itself.

Based on observation, P&P review and interview with staff (A), in 1 of 4 areas where medical records are kept, the hospital failed to ensure records are protected from unauthorized access. This deficiency potentially affects all 4 inpatients served at the facility during this survey.

Findings include:

Per review on 5/6/14 at 11:30 AM of hospital policy titled "Security of Medical Records" it states "Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals."

Per tour of the radiological department accompanied by Diagnostic Director A on 05/06/14 at 10:30 AM, patient information is kept in unsecured areas allowing access by unauthorized individuals in the following areas: Order sheets with patient identifying information were kept in an unlocked file drawer, an unlocked wall cabinet contained patient charge sheets with patient identification, and procedures and billing sheets with patient names were kept on an open shelf above a desk. These findings were confirmed with Diagnostic Director A at the time of the tour. Diagnostic Director A stated that the area remains unlocked after hours when staff are not present.