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Based on observations, interviews and document review the facility staff failed to ensure each patient and or family member had the correct information for the state agency in order to express a complaint or concern.

The findings include:

During a tour on 7/10/12 and 7/11/12 with the Assistant Chief Nursing Officer (ACNO) of the facility's Emergency Department (ED), Inpatient Psychiatric Services, Ambulatory Surgical Services and the following clinics: Diabetes and Endocrinology, Gastroenterology, Spine Center, Wound Care Center, Pain Management, Rheumatology and Osteoporosis, Outpatient Behavioral Health Services, 2 Urgent Care Centers or Outpatient Laboratory Services signs were posted titled, "Patient Rights and Responsibilities." The signs contained a Post Office Box as an address for the state agency that was not the correct address and did not contain the toll free complaint line telephone number.

The Director of the ED provided a copy of the information that is given to each patient and or family at the time of registration. The information provided did not contain the state agency information for making a complaint.

The ED waiting area was a large room with a walk-in area separating the room into about 2/3 on one side and 1/3 on the side were the registration desk were located. On the wall of the ED waiting area, adjacent to the registration area, was as sign stating "Notice. Payment for ED service is expected up front."

The Chief Nursing Officer stated, "It was not our intent to ask for money up front, we wanted to make sure patients knew we had financial counselor available to help them. I am having the sign removed."

The ACNO stated, "All the signs are the same. They do not contain the correct information. They will be corrected immediately."

Based on interviews and document review the facility staff failed to ensure the medical staff followed the bylaws pertaining to discharge orders for 4 of 4 patients medical records reviewed (Patients #34, 35, 36 and 37).

The findings include:

On 7/12/12 at approximately 11:30 A.M. during the tour of the surgical service area with the Assistant Chief Nursing Officer (ACNO) and the Director of Surgical Services (DSS) the medical record of Patient #34 was reviewed. The medical record revealed the following: Patient #34 was a 38 year old who had a lumbar epidural injection performed on 7/12/12. The medical record did not contain any physician's orders including orders for discharge.

The DSS attempted to locate the orders and stated, "There are no orders. He (the physician who performed the procedure) does not write discharge orders, he only writes a discharge summary."

On 7/12/12 at approximately 2:30 P.M. the medical records of Patient's #35, 36 and 37 were reviewed in the Health Information (HI) Department with the ACNO and the HI Director. The record review revealed the following:
Patient #35 was admitted and discharged on 5/8/12 for lumbar injection for pain, had no physician orders on the medical record.
Patient #36 was admitted and discharged on 6/18/12 for lumbar injection for pain, had no physician orders on the medical record.
Patient #37 was admitted and discharged on 6/27/12 for cervical epidural injection for pain, had no physician orders on the medical record.

The Director of HI stated, "We (HI) don't review out patient surgery records for completeness."

The Medical Director was interviewed on 7/12/12 at approximately 2:40 P.M. and stated, "There should be a physician's order for discharge on the medical record."

The Medical Staff Rules and Regulations were reviewed on 7/12/12 and page 19 # 5.1 stated, "A patient may be discharged only by order of the attending practitioner."

Based on interviews and document review the facility staff failed to ensure the medical staff followed the bylaws pertaining to discharge orders for 4 of 4 patients medical records reviewed (Patients #34, 35, 36 and 37).

The findings include:

On 7/12/12 at approximately 11:30 A.M. during the tour of the surgical service area with the Assistant Chief Nursing Officer (ACNO) and the Director of Surgical Services (DSS) the medical record of Patient #34 was reviewed. The medical record revealed the following: Patient #34 was a 38 year old who had a lumbar epidural injection performed on 7/12/12. The medical record did not contain any physician's orders including orders for discharge.

The DSS attempted to locate the orders and stated, "There are no orders. He (the physician who performed the procedure) does not write discharge orders, he only writes a discharge summary."

On 7/12/12 at approximately 2:30 P.M. the medical records of Patient's #35, 36 and 37 were reviewed in the Health Information (HI) Department with the ACNO and the HI Director. The record review revealed the following:
Patient #35 was admitted and discharged on 5/8/12 for lumbar injection for pain, had no physician orders on the medical record.
Patient #36 was admitted and discharged on 6/18/12 for lumbar injection for pain, had no physician orders on the medical record.
Patient #37 was admitted and discharged on 6/27/12 for cervical epidural injection for pain, had no physician orders on the medical record.

The Director of HI stated, "We (HI) don't review out patient surgery records for completeness."

The Medical Director was interviewed on 7/12/12 at approximately 2:40 P.M. and stated, "There should be a physician's order for discharge on the medical record."

The Medical Staff Rules and Regulations were reviewed on 7/12/12 and page 19 # 5.1 stated, "A patient may be discharged only by order of the attending practitioner."

Based on review of the Life Safety Code survey report of the Life Safety survey conducted July 25, 2012 through August 09, 2012, it was determined the hospital was not in compliance with 42 CFR Part 482: Conditions of Participation for Hospitals (Rev. October 11/2008) for Physical Environment.

Findings:

Please refer to the Life Safety Code report of August 09, 2012.

Based on observations, interview and record review the facility failed to implement measures to control the spread of infection by not disinfecting items between patients within the:

1. Emergency Department (ED)- 1 of 1 electrocardiogram chair, 4 of 6 seizure pads, and 1 of 1 viewed gurneys.
2. Diagnostic Radiology 4 of 5 viewed radiology table pads, Special Procedure room 2 of 2 table pads and a porous surface positioning device.
3. Post-Anesthesia Care Unit 4 of 5 suction machines designated as ready for patient care.
4. Surgical Department 1 of 3 specialty beds for back surgery and 1 of 1 specialty beds with patient transfer assist roller.

The findings included:

1. Observations conducted on July 10, 2012 from 3:30 p.m. to 6:00 p.m., within the facility's Emergency Department (ED) revealed one of one electrocardiogram (EKG) chair did not have an intact surface. The chair utilized for EKG had tears and frays, which prevented disinfection between patients. One of one viewed ED gurney was torn in the center with a transparent dressing over the tear. Four of six ED seizure pads were torn and could not be disinfected between patients. The observations were conducted in the presence of the facility staff (Staff #12 and Staff #10). Staff #2 and Staff #10 acknowledged the findings and reported the items could not be disinfected between patients. Staff #2 and Staff #10 reported the transparent dressing used for wound care should not have been used to repair the tear on the ED gurney.

2. Observations were conducted within the Diagnostic Radiology department on July 11, 2012 at 11:00 a.m. with Staff #13, Staff #45 and Staff #46. The observation revealed four of five radiology table pads viewed were torn in multiple areas with worn and frayed areas. Staff #46 reported the pads could not be disinfected between patients. Staff #46 reported it was his/her responsibility to ensure the pads are intact and in good repair. Observations conducted on July 11, 2012 at 11:09 a.m. in the Special Procedure rooms revealed two of two table pads were torn. The edge of the table and pad had a buildup of sticky residue. Staff #46 identified the residue as the results of utilizing tape during procedures. Staff #46 acknowledged the table and pad could not be disinfected between patients. An observation revealed a gray foam wedge in a container; the wedge was made of porous material, which could not be disinfected between patients. Staff #46 acknowledged the foam-positioning device was worn, had multiple holes in its surface and could not be cleaned between patients.

3. Observations conducted in the Post-Anesthesia Care Unit (PACU) on July 12.2012 at 9:50 a.m., revealed four of the five suction machines were sticky and covered with a gray lint. The observation was conducted in the presence of Staff #41. Staff 41 reported the condition of the suction machines was unacceptable.

4. Observations were conducted in the Surgical Department on July 12, 2012 from 10:00 a.m. to 10:50 a.m. with Staff # 53 and Staff #65. The observation revealed one of three specialty beds used for back surgery had a torn pad. The observation revealed one of one-specialty beds with a roller to assist in the transfer of the patient. The specialty bed had a sticky residue along the edges of the bed/pad and the roller's surface was cracked. Staff #53 acknowledged the roller's surface could not be disinfected between patients. Staff #53 agreed the sticky residue prevented the bed/pad from being disinfected between patients.

The above findings were discussed during the end of the meeting on July 12, 2012 at approximately 4:46 p.m., with the administrative staff.

Review of the facility's policy titled "Infection Prevention and Control" issued "10/1/2011" read: "The goal of Infection Prevention and Control is to prevent the spread of infections to patients, visitors, and staff. The spread of infections can be controlled by ... cleaning and disinfection of the environment and patient care equipment."

Review of the facility's policy titled "Equipment Cleaning and Disinfection" provided what and when equipment was to be cleaned and disinfected. The policy read: "Stretchers" should be disinfected "Between Patient" contact.

Review of the facility's "Medical Equipment Management Plan 2012" list as an objective "Equipment is maintained appropriately by qualified individuals." Under "Implementation Activities" and "Inspection & (and) Maintenance Strategies" read: "Plant Operations performs maintenance, and repairs on other pieces of medical equipment (e.g., beds, stretchers, OR [operation room] tables ...)."

Based on the Code of Virginia and interview with Staff #55, it was determined that Augusta Health failed to provide adequate discharge planning that included a list of Family Planning Clinics in the Commonwealth of Virginia for all maternity patients .

The finding included:

The Code of Virginia under Section 32.1-134 stated, "Family planning information in hospitals providing maternity care. Each hospital providing maternity care shall, prior to releasing each maternity patient, make available to such patient family planning information and a list of family planning clinics located in the Commonwealth..." No policy or procedure for maternity discharge, including a list of Family Planning Clinics, in the Commonwealth of Virginia, was available for the Surveyor to review.

Staff Member #55 acknowledged during interview, that no policy and procedure for maternity discharge had been developed for maternity patients that included a list of Family Planning Clinics in the State of Virginia. This interview occurred in the conference room, on July 12, 2012 at 4:30 p.m.