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A. Based on a review of the Medical/Dental Staff Bylaws, Rules and Regulations, observation and staff interview, it was determined that the Hospital failed to ensure that all staff followed the established bylaws for medical screening examinations.

Findings include:

1. A review of the Medial/Dental Staff Bylaws, Rules and Regulations was conducted on 07/13/10. It indicated under, "5.4 Medical Screening...Obstetrical patients, greater than 20 weeks gestation, presenting in active labor or with obstetrical complaints will be escorted to the Labor and Delivery Unit after being logged in the Emergency Department..."

2. During a tour of the Emergency Department on 07/13/10 at 2:00 PM, it was noted by the Emergency Department Director that obstetrical patients of greater than 20 weeks gestation presenting to the Emergency Department currently are not logged in the Emergency Department.

3. During an interview conducted on 07/14/10 at 9:45 AM with the Director of the Obstetrical Unit, the above finding was confirmed.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 1 of 3 (Pt #6) medical records reviewed, in which the patient received Psychiatric services, that the Hospital failed to ensure that psychotropic medication consents were obtained, as per Hospital policy.

Findings include:

1. The Hospital policy titled "Psychotropic Medication Information" was reviewed on 7/13/10. It indicated "Procedure: 3. If the patient agrees to take medication then... form is signed..."

2. The medical record of Pt #6 was reviewed on 7/13/10. Pt #6 was admitted to the Hospital on 7/10/10 with the diagnosis of Paranoia. On 7/10/10, there was a physician's order for Vistaril as needed for anxiety. There was no Psychotropic Medication Information sheet.

3. During a staff interview, conducted with the Director of Behavioral Center on 7/13/10 at 11:00 AM, the above findings were confirmed.

A. Based on policy, record review and staff interview, it was determined that in 1 of 4 patients with restraint orders, the hospital failed to ensure that orders were followed as written.

Findings include:

1. The hospital policy titled "Restraint Seclusion" page 2, under "Orders for Restraints: Orders for restraint or seclusion are not written as a standing order or on an as needed basis (PRN)."

2. The medical record of Pt. #20 was reviewed on survey date 7/14/10. Pt. #20 was admitted to the hospital on 12/30/09 with diagnoses of Chest Pain with Cardiac Vessel Disease, Coronary Syndrome, Kidney Failure and Obesity. Documentation indicated an order was written by the physician on 1/13/2010 for "Restrain Patient with soft bilateral (restraint)." Documentation indicated "reason for restraint- attempting extubation." There was no documentation that the order for restraint was implemented. There was no documentation to indicate that the order was discontinued or cancelled. There was no documentation to indicate that Pt. #20 exhibited behavior requiring restraint.

3. During an interview with the Chief Nursing Officer on 7/15/10 at 3:00 PM, the above finding was confirmed.

A. Based record review, policy review, observation, and staff interview, it was determined that in 1 of 2 (Pt #12) medical records reviewed in which the patient was on high risk falls protocol, the Hospital failed to ensure all aspects of the protocol were implemented.

Findings include:

1. The medical record of Pt #12 was reviewed on 7/13/10. It indicated Pt #12 was admitted on 7/12/10 with a diagnosis of Cerebral Vascular Accident (CVA). Documentation indicated that the patient was at high risk for falls and was on the SAFE (Staff Against Falls Everywhere) program.

2. The policy titled "SAFE" was reviewed on 7/13/10. It indicated under "Procedure for In-Patients: 2. If the patient is identified at risk for falls.....the SAFE Program is initiated. 2.1 The Orange Safe arm band is placed on the patient."

3. During a tour of the Intermediate Care Unit, conducted on 7/13/10 11:15 AM, it was observed that Pt #12 was on the SAFE program (identified by the signage on the door). However, there was no SAFE orange arm band on the patient's arms or legs.

4. During an interview with the Chief Nurse Officer, conducted on 7/13/10 at 11:45 AM, the above finding was confirmed.

B. Based on medical record review and staff interview, it was determined that Hospital dialysis staff failed to ensure all dialysis treatments were implemented with orders by the physician and that dialysis clinical record flowsheets and treatments were maintained as required with appropriate information.

Findings include:

1. The medical record of patient #10 was reviewed on 07/14/10. Pt. #10 was admitted with colitis and diarrhea on 07/07/10. Documentation indicated Pt #10 had received acute dialysis three times while hospitalized. There was no documented estimated dry weight recorded on any of the treatment sheets reviewed. The weight utilized to determine an appropriate dialysis prescription was an admission weight from the floor. Documentation indicated that the "weights were unable to be determined, unable to stand, no weigh bed." On 07/09/10 the dry weight was "tbo,"or ""uto." (This was verified by CNO as unknown nursing abbreviations that "may mean, to be obtained or unable to be obtained. These are not acceptable abbreviations.") There was no order on the dialysis prescription for a dry weight or how much weight was to be removed. Documentation indicated a blood flow rate of 500 was prescribed on the flowsheet, although all treatment sheets, dated 07/09, 07/12, and 07/14/10 indicated the rate was documented at 390- 400BFR. Pre-weights were documented as "per MAR, (Medication administration record), unable to weigh." A pre- weight of 87 kg was recorded on 07/12/10. The post weight documented indicated a 3kg weight gain at 90 kg standing.

2. During a staff interview, conducted with the CNO on 7/16/10 at 10:00 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 2 (Pt #13) medical records reviewed in which the patient was on the adult locked unit, the Hospital failed to ensure all medications were administered with the proper time frame.

Findings include:

1. The medical record of Pt #13 was reviewed on 7/13/10. It indicated that Pt #13 was admitted to the adult locked unit. Numerous medications were marked as "not performed" with the reason "patient sleeping". An example was with Inderal on 7/8/10 at 8:00 AM and again on 7/11/10 at 7:00 AM and 9:00 AM.

2. During an interview with the Director of Nursing, conducted on 7/13/10 at 2:45 PM, the above finding was confirmed.

B. Based on medical record review, a review of policy and procedure, and staff interview, it was determined that in 1 of 2 (Pt #11) medical records reviewed in which the patient was receiving insulin injections, the Hospital failed to ensure nursing documentation was in accordance with documentation policies.

Findings include:

1. The medical record of Pt #11 was reviewed on 7/14/10. It indicated Pt #11 was admitted on 7/13/10 with diagnoses of ESRD and Acute Renal Failure. Documentation indicated that On 7/14/10 at 8:30 AM, the patient received 5 units of Lispro Insulin. There was no documentation that indicated the site of the injection was documented.

2. The Second Edition of Delmar's Fundamental & Advanced Nursing Skills, used to supplement the Hospital's policy and procedures was reviewed. It indicated in Chapter 5, Page 616, under "Documentation Medication Administration Document the date, time, dose, route, site of injection, and signature or initials."

3. During an interview with the Chief Nursing Officer, conducted on 7/13/10, the above finding was confirmed.

A. Based on policy, record review and staff interview, it was determined that in 1 of 3 patients who received blood transfusions, the hospital failed to ensure that the blood transfusion records were complete.

Findings include:

1. The hospital policy titled " Blood and Blood Products Transfusion Administration" under Procedure: 3. Take temperature, pulse, respiration and blood pressure. Record on Transfusion Record." In the policy under 9. " Blood/ Blood Products Infusion, 9.2 Retake vital signs... Record in the medical record." In the policy under 13. "Record the following on the Chart and Blood Bank copies of the Transfusion Record: 13.2 Amount transfused, 13.3 Adverse Reaction Yes__ NO__ and 13.5 Temperature, pulse... one hour after administration."

2. The medical record of Pt. #20 was reviewed on 7/14/10. Pt. #20 was admitted to the hospital on 12/30/09 with diagnoses of Chest Pain with Cardiac Vessel Disease, Coronary Syndrome, Kidney Failure and Obesity. Documentation on the Transfusion Records failed to include vital signs during the transfusion of 2 units of blood on 01/13/10. A review of the Transfusion Records for 2 units of blood dated 1/09/10 and 2 units of blood dated 1/13/10 failed to include documentation of the "amount transfused" and "adverse reaction Yes___
NO___ "sections.

3. During an interview with the Chief Nursing Officer on 7/15/10 at 2:30 PM, the above findings were confirmed.

A. Based on review of Medical/Dental Staff By-Laws Rules and Regulations, record review, and staff interview it was determined that in 2 of 19 (Pt #18, Pt #23) records reviewed with Emergency Department (ED) visits, the Hospital failed to ensure that resident physicians were countersigned by the attending physician.

Findings include:

1. The Medical/Dental Staff By-Laws Rules and Regulations was reviewed on 7/15/10. The By-Laws under "6.5 a. History and Physical Examination indicates that "Residents...may perform the patient's history and physical...the patient must be examined by the attending physician...countersigned with any changes." "6.6 Progress Notes " indicates "All progress notes written in the medical record by resident physicians must be countersigned...by supervisory or attending Medical Staff members."

2. The medical record of Pt. #18 was reviewed on 7/14/10. Pt. #18 was in the ED on 1/10/10. Documentation indicated that Pt. #18 received a Medical Screening Exam (MSE) on 1/10/10 by a resident physician. The MSE was not countersigned by the attending physician.

3. The medical record of Pt. #23 was reviewed on 7/14/10. Pt.#23 was in the ED on 1/11/10. Documentation indicated that Pt. #23 received a MSE on 1/11/10 by a resident physician. The MSE was not countersigned by the attending physician.

4. During an interview with the Chief Nursing Officer on 7/15/10 at 1:00 PM, the above findings were confirmed.

B. Based on medical record review and staff interview, it was determined that in 1 of 30 (Pt # 19) medical records reviewed, the Hospital failed to ensure all physician orders were completely documented.

Findings include:

1. The medical record of Pt #19 was reviewed on 7/14/10. A pre-printed physician's order, dated 3/19/10, indicated "Notify __________ if pulse oximetry <_____________%. The contact physician's name and the parameter for the pulse ox were not completed.

2. During an interview with the Director of Nursing, conducted on 7/14/10 at 3:10 PM, the above finding was confirmed.

A. Based on record review and staff interview, it was determined that in 6 of 30 (Pt.# 4; #5; #16; #20; #29 and # 30) records reviewed the Hospital failed to ensure that all orders were dated, timed, and authenticated by the ordering physician.

Findings include:

1. The medical record of Pt #4 was reviewed on 7/13/10. Pt #4 was admitted to the Hospital on 7/6/10 with the diagnosis of Severe Right Heart Failure. There was no documentation of times on 6 physician orders between 7/6/10 thru 7/13/10. There was no documentation of time on 3 physician progress notes between 7/7/10 thru 7/13/10.

2. The medical record of Pt #5 was reviewed on 7/14/10. Pt #5 was admitted to the Hospital on 7/11/10 with the diagnosis of Exacerbation of Chronic Obstructive Pulmonary Disease (COPD). There was no documentation of time on 2 physician progress notes.
There was no documentation to indicate the time of the MSÉ

3. The medical record of Pt #16 was reviewed on 7/14/10. Pt. #16 was admitted to the Hospital on 1/12/10 with the diagnoses of Gastrointestinal Bleed and Atrial Fibrillation. Documentation indicated that 2 telephone orders, one written on 1/12/10 and one on 1/28/10 were not timed by the physician.

4. The medical record of Pt. #20 was reviewed on survey date 7/14/10. Pt. #20 was admitted to the Hospital on 12/30/10 with diagnoses of Chest Pain with Cardiac Vessel Disease, Coronary Syndrome, Kidney Failure and Obesity. Documentation in the physician orders indicated multiple telephone and verbal orders dated 12/31/09 through 1/25/10 with no date or time of the physician signature.

5. The medical record of Pt #29 was reviewed on 7/15/10. Pt #29 was admitted to the Hospital on 6/16/10 with the diagnosis of Exacerbation of COPD. There was no documentation to indicate the time of the Medical Screeing Examination (MSE).

6. The medical record of Pt #30 was reviewed on 7/15/10. Pt #30 was admitted to the Hospital on 6/7/10 with the diagnosis Abdominal Pain. There was no documentation to indicate the time of the MSE.
7. During an interview with the Chief Nursing Officer on 7/15/10 at 2:30 PM, the above findings were confirmed.

A. Based on a review of the Medical/Dental Staff Bylaws, Rules and Regulations, a written statement of delinquent medical records and staff interview, it was determined that the Hospital failed to ensure all medical records were processed in a timely manner.

Findings include:

1. A review of the Medical/Dental Staff Bylaws, Rules and Regulations was conducted on 07/13/10. It indicated under, "6.8 Timelines for Completion of Medical Record. Practitioners shall have 14 days to complete the record dictation after discharge and an additional 14 days to complete record signatures."

2. The number of medical records over 28 days was 143 as of 07/15/10.

3. During an interview conducted on 07/15/10 at 1:00 PM with the Quality Improvement Coordinator, the above finding was confirmed.

A. Based on a review of Hospital policy, observation, and staff interview, it was determined that the Hospital failed to ensure that all controlled substances were secured under double lock.

Findings include:

1. The Hospital policy titled "Controlled Substances" was reviewed on 7/15/10. It indicated "Storage: 3. Non AcuDose Storage Areas: a. Controlled Substances will be stored under double lock."

2. A tour of the surgery department was conducted with the Director of Surgery on 7/15/10 at 11:00 AM. Upon entering the locked Bronchoscopy Room, the conscious sedation cart was observed to be open and the top drawer contained a clear container with Versed and Fentanyl.

3. During a staff interview, conducted with the Director of Surgery on 7/15/10 at 11:45 AM, the above finding was confirmed.

A. Based on a review of policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure that all expired/outdated drugs and biologicals were removed from patient areas.

Findings include:

1. The Hospital policy titled, "STORAGE OF PHARMACEUTICALS" under "Procedure: 10. There shall be a separate, approved, properly identified area for the storage of outdated and/or recall drugs so that they will not be confused with active stocks."

2. During a tour of the Medical-Surgical 3400 unit on 7/13/10 at 1:00 PM, the following observations were made in the medication room:

(1) blue top BD vacutainer 4.5 ml found in the "Type an Cross" bucket expired 9/09
(100) red top BD vacutainers 10 ml expired 6/10
(83) red top BD vacutainers 10 ml expired 4/10
(1) Flex-Cap Disconnect with Providine/Iodine expired 4/2010
(1) Epinephrine injectable expired 7/1/10

3. During a tour of PT/OT/ST area the following medications were found to be expired in the crash cart:
(2) .9% NaCl 1000 cc bags of intravenous IV solution -expired 07/01/10
(1) 500 cc bag of Dopamine 1600 mcg expired 07/01/10
(1) Endotracheal tube expired on 06/01/10

4. During an interview with the Chief Nursing Officer on 7/15/10 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy, observation, and staff interview, it was determined that the Hospital failed to ensure that food was labeled with all required information.

Findings include:

1. The Hospital policy titled "Food and Nutrition Safety and Sanitation Guide" was reviewed on 7/16/10. It indicated "Food Storage: All food items should be stored in NSF approved food containers. Food items should be properly covered and labeled with the following information: 1. Name of item 2. Date 3. Time Temperature are taken 4. Initials of person storing food and monitoring cooling 5. Shelf Life."

2. During a tour of the dietary department, conducted on 7/14/10 at 2:00 PM with the CNO and Dietary Supervisor, a storage rack containing staff prepared lettuce salads were observed in the Vegetable Refrigerator and in the kitchen area, a storage rack containing staff prepared lemon bars was observed. There was no documentation of date, time, or shelf life observed on any of the items.

3. During a staff interview, conducted with the Dietary Supervisor on 7/14/10 at 2:30 PM, the above findings were confirmed. It was verbalized further that these items are labeled with name and initials as they are used in the cafeteria and thrown away at the end of the day.

B. Based on observation and staff interview, it was determined that the Hospital failed to ensure that frozen meat was stored in a manner to prevent contamination.

Findings include:

1. During a tour of the dietary department, conducted on 7/14/10 at 2:00 PM the the CNO and Dietary Supervisor, a large piece of beef was observed on the right top shelf in Freezer #2 with no wrapping on it. A dietary staff member was observed removing the beef from the freezer with bare hands and taking it to a counter and the beef was then observed to have been placed in a plastic wrap to be returned to the freezer. The following items were also observed in Freezer #2: one open plastic bag of fish fillets with no label or date; 3 large packages of beef with no dates; one aluminum wrapped package that contained tortilla with no date or label; and an aluminum pan of some type of casserole with no date or label.

2. During a staff interview, conducted with the CNO and the Dietary Supervisor on 7/14/10 at 3:00 PM, the above findings were confirmed.

C. Based on a review of Hospital policy, a review of temperature logs (Pot and Pan Temperature Log, Dish Machine Temperature Log, Refrigerator/Freezer Temperature Logs, Trayline Temperature Logs), and staff interview, it was determined that the Hospital failed to ensure that temperatures were recorded and that outlying temperatures were acted upon, as per Hospital policy.

Findings include:

1. The Hospital policy "Food and Nutrition Safety and Sanitation Guide" was reviewed on 7/16/10. It indicated that "all temperatures should be recorded on the temperature log sheet along with any discrepancies and corrective action... Discrepancies should be reported to a supervisor immediately."

2. The following logs (for the period of 6/20/10 thru 7/14/10) were reviewed on 7/15/10. The following discrepancies were not recorded and/or acted upon: Pot and Pan temperature log- 4 out of 74 Washes were not recorded; 5 out of 74 Final rinses were out of range and no documentation of follow up. Dish Machine temperature log- 1 out of 25 morning meals; 3 out of 25 noon meals; and 3 out of 25 supper meals were not recorded. Refrigerator #3- one out of 25 morning temperatures and 11 out of 25 evening temperatures were not recorded..

3. During a staff interview, conducted with the CNO and the Dietary Supervisor on 7/14/10 at 3:00 PM, the above findings were confirmed.

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 July 13 - 15, 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 A710.

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 July 13 - 15, 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 July 15, 2010.

A. Based on Hospital policy, review of dialysis water cultures and staff interview, it was determined that the Hospital failed to ensure validation of cultures were reviewed and appropriate actions were implemented.

Findings include:

1. The Acute Portable Water Culture policy was faxed to the Hospital from an adjacent Davita unit on 07/15/10. The policy indicates a designee, (" Hospital biomedical personnel"), is responsible for ensuring that cultures are obtained, results recorded, reviewed and necessary actions taken, as applicable.

2. Water culture results for the period of 06/01/10- 06/30/10 were reviewed on 07/15/10. On 06/09/2010 water cultures were obtained at the RO port #2 and the pre inlet site. Both cultures were above the required 50 CFUs (colony forming units) where action and repeat cultures are to be collected. There was no documentation presented that the Facility Administrator of Davita was not notified of the elevated results. There was no evidence of water disinfection and the samples were not redrawn as necessary to prevent the potential transmission of contagions to patients. There was documentation to indicate a resumption or continuance of routine monthly testing for July had been conducted. The unit staff failed to collect monthly cultures every 30 days and there was no documentation presented that Hospital staff performed disinfection within 72 hrs before recollecting specimens.

3. The above findings were verified with Chief Nursing Officer on 07/15/10 at 10:00 am.

A. Based on a review of policy and procedure and observation, it was determined that the Hospital failed to ensure the surgical dress code was always followed.

Findings include:

1. The Hospital policy and procedure titled, "Dress Regulation in the OR" was reviewed. It indicated under "Procedure: 1. All persons who enter the semi-restricted areas of the surgical suite will don a freshly laundered current two piece pantsuit. Head and facial hair will be covered."

2. During a tour of the surgical area, conducted on 7/15/10 at 10:30 AM, it was observed that a male staff member was in the semi-restricted area with a goatee that was not covered. It was also noted that the male dressing room provided surgical "skull caps". It was noted throughout the surgical areas that several males were observed to be wearing the skull caps which does not cover the hair on the back of the head.

3. During an interview with the Chief Nursing Officer, conducted on 7/15/10 at 11:45 AM, the above findings were confirmed.

B. Based on a review of Hospital policy and procedure, a review of the endoscope processing logs, and staff interview, it was determined that the Hospital failed to ensure the endoscopes were always processed in accordance with their policy and procedure.

Findings include:

1. The Hospital policy and procedure titled, "Endoscope Reprocessing" was reviewed on 7/15/10. It indicated under "Procedure: D. Cleaning: Manual cleaning of endoscopes is necessary immediately after removing the endoscope from the patient and prior to automated or manual disinfection. This is the first and most important step in removing the microbial burden from an endoscope. Retained debris may inactivate or interfere with the capability of the active ingredient of the chemical solution to effectively kill and/or inactivate microorganisms."

2. The endoscope reprocessing logs from 6/20/10 through 7/15/10 were reviewed. Twenty-three out of 64 had no documentation that indicated the scope had an ultrasonic wash with Enzol or an ultrasonic rinse.

3. During an interview with the Director of Surgery, conducted on 7/15/10 at 11:50 AM, the above findings were confirmed.

C. Based on a review of policy and procedure, a review of the glutaraldehyde sterilization solution logs, and staff interview, it was determined that the Hospital failed to ensure the log was completed as per policy.

Findings include:

1. The Hospital policy and procedure titled, "Testing Glutaraldehyde Sterilization Solution" was reviewed on 7/15/10. It indicated under "Procedure: 8. Record findings on the monitoring log. Date, technician, solution activation date, operator test findings (check mark indicates safe to use), medical record number, probe number, time in and out."

2. The monitoring log was reviewed from 6/20/10 through 7/14/10. There were 9 boxes on the log that did not contain the required information.

3. During an interview with the Director of Surgery, conducted on 7/15/10 at 12:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 1 (Pt #26) medical records reviewed in which the patient was to receive chest percussion therapy, the Hospital failed to ensure the treatments were administered as ordered.

Findings include:

1. The medical record of Pt #26 was reviewed on 7/14/10. It indicated Pt #26 was admitted on 2/24/10 with a diagnoses of Pulmonary Edema and Respiratory Failure. A physician's order, dated 2/25/10, was for "chest physiotherapy every 8 hours with left side up and in Trendelenburg." There was no documentation that the therapy was ever administered or that the physician was contacted and the order discontinued.

2. During an interview with the Director of Nursing, conducted on 7/14/10 at 10:30 AM, the above finding was confirmed.