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Based on observation and staff interview, the facility failed to ensure that all patient care equipment was maintained in safe operating condition. Findings include:

Per observation during the tour of the physical plant on 3/26//13 at 11:10 AM, portable gas tanks were improperly stored. Three "E" size oxygen and airgas portable tanks in a basement storage room were stored unsecured on the floor, creating a potential safety hazard. The Director of Plant Operations stated that the tanks should be stored in a rack or chained to a wall to prevent them from falling over and confirmed that the tanks were improperly stored at the time of the observation.

Based on on staff interview and record review, the hospital failed to ensure infection control measures were consistently implemented during the three bay sink sanitizing process in the kitchen; during cleaning of equipment in operating rooms and ensuring staff wore appropriate hair coverings during involvement with a surgical procedure. Findings include:

1. During a tour of the kitchen on 3/25/13 at 11:15 AM, review of records for the three bay pot sink indicated that staff had not recorded sanitizer levels as required. Per interview with the Food Production Manager (FPM) on 3/26/13 at 9: 42 AM, sanitizer levels are to be checked whenever the water is changed, 3-5 times daily. Review of the sanitizer check lists showed that sanitizer levels had been checked sporadically in January and February 2013 and just twice in March 2013. These findings were confirmed by the FPM during the 3/26/13 9:42 AM interview.

2. During a tour of the perioperative area on 3/26/13 at 8:52 AM with the Nurse Manager for Surgical Services, in Operating Suite #1 the scrub nurse and circulating nurse were observed wearing PPE (hair coverings) that failed to completely cover their hair while actively involved in a surgical procedure. Per AORN (Association of periOperative Registered Nurses) Journal, January 2012 Vol 95 No 1 "Implementing AORN Recommended Practices for Surgical Attire, " states, "All personnel should cover their head and facial hair when in the semirestricted and restricted areas. Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair...." AORN further states " Skull caps are not recommended because they do not completely cover the wearer's hair and skin; they fail to cover the side hair above and in front of the ears and the hair on the nape of the neck". The Nurse Manager confirmed at the time of observation, staff were not meeting standards of practice. Although the Nurse Manager confirmed the hospital had policies and procedures directing staff regarding proper surgical attire, the policy could not be provided for review at the time of survey.

3. On 3/26/13 at 8:52 AM a staff member of Environmental Services was observed cleaning in OR #2. As the staff member cleaned per hospital policy "OR-Between Case Cleaning" effective date 04/05, the computer keyboard was not wiped down with disinfectant as the rest of the equipment surfaces had been cleaned. When asked if the computer keyboards were included in the process due to the multiple contacts made by staff during surgical procedures, the staff person acknowledged it was not a surface s/he was familiar with wiping down. Per interview on the morning of 3/27/13 the Director of Surgical Services confirmed the present hospital policy did not include the disinfecting of computer keyboards within the peri-Operative areas. Per American Journal of Infection Control, Vol 33, Issue 5, June 21, 2005, "Computer Equipment used in Patient Care within Multihospital System: Recommendations for cleaning and disinfection" states: When cleaning/disinfecting computer hardware, use the same type of cleaner/disinfectant and the same frequency of cleaning as would normally be used for other devices in that area. 2) The use of plastic keyboard covers or immerseable keyboards should be considered for direct patient care areas. 3. To ensure hand washing is included when handling computer equipment.

Based on interview and record review, a History and Physical document was found to be written inaccurately for 1 of 21 applicable patients (Patient #6). Findings include:

Per review on 3/26/13, a History and Physical Examination was completed and dictated on 3/18/13 by a Physician Assistant (PA) for Patient #6, admitted to the hospital for a left hip arthroplasty. The PA initially accurately describes the gender for Patient #6 to be male. However, later within the document Patient #6's gender is then described as a female and weighing 136 pounds and whose height is 5 ft 5 inches. The nursing assessment correctly noted Patient #6's admission weight to be 260 pounds and height was measured at 5 ft 8 inches. In addition, the surgeon who performed the surgical procedure had signed the History and Physical document without correcting the identified errors. The inaccurate record was confirmed during interview with the Medical/Surgical Nurse Manager on 3/26/13 at 10:30 AM.

Based on interview and record review the present medical record systems are not unified and organizationally structured to be readily accessible and systematically organized. Findings include:

1. Per review the medical record for Patient #1, who had been discharged on 12/24/12, was requested by the surveyor on 3/26/13, was not accessible for review until the afternoon of 3/27/13. During interview at the time of record review the RN Unit Manager stated that the BC (Birthing Center) adopted a new EMR (electronic medical record) system in February of 2012. S/he stated that the medical records of patients on the BC are accessible, electronically, to staff for a period of 90 days post discharge at which time the record is archived onto a CD. The Unit Manager stated copies of each individual patient's CD are then physically stored only in the BC and with a specifically identified staff member in IT (information technology), and are accessible only through request to either the BC Unit Manager or the specified IT staff member. S/he stated the archived medical record (CD) is not stored in the Medical Records Department and the Director of Medical Records has no oversight of the archived records.

During interview, on 3/27/13 at 9:10 AM, the Director of Medical Records confirmed that s/he does not have any responsibility for obstetric medical records archived into Centricity which is an independent contracted medical record system.

Based on record review and confirmed through staff interview the facility failed to assure that all medical record entries were dated, timed and authenticated for 1 of 21 applicable records reviewed. (Patient #8). Findings include:

Per review Patient #8, who underwent a surgical procedure on 2/12/13 requiring administration of general anesthesia, had an intraoperative anesthesia monitoring record that lacked the date, time and signature of the person who completed the form. This was confirmed by the VP of Quality Management Programs during interview on the morning of 3/27/13.

Based on staff interview and record review the facility failed to assure an anesthesia evaluation to determine proper recovery from anesthesia was conducted prior to discharge for 1 applicable patient. (Patient #8). Findings include:

Per review the record for Patient #8, who underwent a surgical procedure requiring the use of general anesthesia on 2/12/13, did not contain evidence of a post anesthesia evaluation, conducted to determine the patient's recovery from anesthesia. The Manager for Peri-Operative Services confirmed the lack of a post - anesthesia evaluation during interview at 1:10 PM on 3/27/13.