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Based on observations and interviews, the facility failed to ensure that patient care equipment was maintained, through a preventive maintenance program, and safe for patient use.

This failure created the potential for patient harm due to the facility's lack of knowledge that certain patient care equipment had either no preventive maintenance sticker on the equipment or the preventive maintenance stickers indicated that equipment was past due for preventive maintenance.

Findings:

1. The facility had patient care equipment, readily available for use by staff, with either no preventive maintenance sticker indicating when the equipment was last checked/maintained, or equipment with preventive maintenance stickers in place that indicated that the equipment was overdue to be checked/maintained.

a) On 04/22/13 at 2:25 p.m., an interview was conducted with the facility's Chief Quality Officer (CQO) who stated the contracted service used by the facility to maintain most of the facility's patient care equipment would be fazed out in the next few months and maintenance of this equipment would then be performed by facility personnel. The CQO stated that recently, the facility had conducted a review of equipment and pulled equipment from use that the facility could not state with certainty had received preventive maintenance or could not confirm was working properly.

b) On 04/23/13 at 12:55 p.m., observation was conducted of the facility's Special Care Units (SCU). In the storage room for this unit, the following equipment was found to have equipment that was overdue to receive preventive maintenance (PM). One Bipap Vision machine with a PM sticker dated 3/2012 was found in the storage room. In the designated sleep study room of the SCU, a Bipap Vision machine was found to have a PM sticker dated 5/2012.

c) On 04/23/13 at 2:11 p.m., an interview with the facility's Physical Plant Director was conducted. The Director stated the Bipap machines should receive preventive maintenance every 6 months. The Director, along with the Director of Cardiopulmonary Services, confirmed the PM stickers on these pieces of equipment indicated they were both overdue for preventive maintenance. The facility's Physical Plant Director stated that patient care equipment should receive preventive maintenance at least annually.

d) On 04/23/13 at 2:15 p.m., observation of the Medical /Surgical area storage room revealed a Chest Physical Therapy machine with a PM sticker dated 6/2004. The date was confirmed by the facility's EMS Director.

e) On 04/23/13 at 3:56 p.m., observation of the facility's Pulmonary Function Test (PFT) room revealed a PFT machine with no preventive maintenance sticker present. In the Electroencephalography (EEG) room the EEG machine was found to have a preventive maintenance sticker in place with a sticker placed over the PM date which read, "Inventory Tracking." The Director of Cardiopulmonary Services confirmed that there was no PM sticker found on the PFT machine and that s/he was unaware of the "Inventory Tracking" sticker on the EEG machine and could not state what this sticker meant. The facility's EMS Director and Laboratory Director, after looking into the "Inventory Tracking" sticker, stated the PFT machine should have been receiving annual preventive maintenance.

f) On 04/24/13 at 9:37 a.m., observation of the facility's Surgical Unit was conducted. The Rapid Blood fill /Ranger machine was found to have a PM sticker dated 1/2009. The facility's EMS Director confirmed this preventive maintenance date.

g) On 04/24/13 at 12:14 p.m., observations were conducted in the facility's outpatient clinic areas. Two patient blood pressure monitors, with no preventive maintenance stickers, were found in the hallway outside of the Family Practice rooms. The clinic's Staff Supervisor confirmed that no PM sticker was found on the equipment and stated that PM stickers should have been present. Two other blood pressure monitors found in the same hallway had current PM stickers present.

h) On 04/25/13 at 2:39 p.m., a review of the facility's maintenance policy was conducted. The CQO stated the policy titled, "Medical Equipment Management Plan," #EOC-0007, dated 04/25/13, was in response to a previous survey by another organization associated with the facility. Prior to 04/25/13, the CQO stated the facility did not have a policy written to ensure that equipment was checked on a regular basis and maintained. The COQ stated s/he was unaware of the number of pieces of equipment throughout the facility with overdue preventive maintenance stickers.

Based on observations, interviews, and document review, the facility failed to ensure that medications and supplies available for patient use were appropriately stored.
This failure created the potential for negative patient outcomes by the facility having expired medications and supplies readily available for staff to use in providing patient care.

Findings:

1. The facility failed to remove expired supplies and medications from patient care areas.

a) On 04/23/13 at 8:36 a.m., observation of the facility's off-site rehabilitation clinic was conducted. The following expired patient care items were found in a drawer, readily available for staff to use while providing patient care: 4 packages of StimCare electrodes with manufacturer's expiration dates of 2/2007, 4/2007, and 5/2006; 4 packages of StimCare Ortho DX Electrodes with manufacturer's expiration dates of 4/2010, 7/2012, and 11/2012. The Director of Rehabilitation Services confirmed the expired products.

b) On 04/23/13 at 11:14 a.m., observation of the facility's Emergency Department was conducted. In trauma room #2 the following expired supplies were found in a cabinet, readily available for staff to use while providing patient care: 1 Pedi-Cap CO2 Detector with manufacturer's expiration date of 8/2012; 1 Ezy-Cap CO2 Detector with manufacturer's expiration date of 8/2012; 4 prefilled inhalation solutions of 0.9% sodium chloride with manufacturer's expiration date of 8/2011, 6 arterial blood sample test kits with manufacturer's expiration dates of 7/2011 and 2/2012; 1 Bard Urethral catheterization tray with manufacturer's expiration date of 2/2012; 1 Ocean Chest Drain kit with manufacturer's expiration date of 8/2012; 2 packets of EZ Lubricating Jelly with manufacturer's expiration date of 2/2013; and 3 ScrubCare surgical scrub brush-sponge kits with manufacturer's expiration date of 9/2012. A chest tube bag was found with the following expired items: 3 packages of providone iodine swabs with manufacturer's expiration date of 2/2012, 1 Vaseline gauze dressing with manufacturer's expiration date of 4/2011, and 6 chest tubes with manufacturer's expiration dates of 3/2012, 3/2013, 2/2012, and 9/2012. The facility's EMS Director and the facility's Laboratory Director confirmed the expired supplies and medications.

c) On 04/23/13 at 11:37 a.m., observation of the Emergency Department storage room revealed the following expired medications and supplies: approximately 75 packets of EZ Lubricating Jelly with manufacturer's expiration date of 8/2012; 3 Medline connecting tubes with manufacturer's expiration date of 2/2013; 4 purple top BD vacutainer blood specimen tubes with manufacturer's expiration dates of 6/2011, 9/2011, and 1/2012; 3 serum blood specimen tubes with manufacturer's expiration dates of 3/2012, 4/2012, and 9/2012; 3 sodium citrate blood specimen tubes with manufacturer's expiration dates of 5/2011, 1/2012, and 4/2012; 2 lithium heparin blood specimen tubes with expiration dates of 8/2011 and 12/2011. The facility's EMS Director confirmed the expired supplies.

d) On 04/23/13 at 11:42 A.M., the Registered Nurse IV cart located in the Emergency Department was found to contain 2 packets of providone iodine with manufacturer's expiration date of 2/2012. The facility's Emergency Room Director confirmed the expired product.

e) On 04/25/13 at 11:48 a.m., in the Emergency Department's treatment room #4, 1 packet of providone iodine was found with a manufacturer's expiration date of 2/2012. The facility's EMS Director confirmed the expired product.

f) On 04/23/13 at 11:51 a.m., observation of the clean storage area in the facility's Emergency Department was conducted. Control solutions for the patient glucometer were found to be open with no date provided of when the controls were opened or when the solutions should be discarded. The facility's Laboratory Director confirmed that the control solutions, per the manufacturer, should be discarded 90 days after being opened. The Laboratory Director confirmed that the control solutions were not dated with an "open" date or a "discard" date. The refrigerator located in the storage room was found to contain 3 bags of normal saline with manufacturer's expiration date of 2/2012. The facility's Laboratory Director confirmed the expired normal saline.

g) On 04/23/13 at 12:55 p.m., observation of the facility's Intensive Care area/rooms was conducted. The Ear Nose and Throat cart was found to contain 4 sterile packets of ear wicks with manufacturer's expiration date of 11/2012 and 1 packet of coated Vicryl sutures with expiration date of 7/2011. The facility's Medical/Surgical Director confirmed the expired items.

h) On 04/25/13 at 1:13 p.m., the following supplies were found in the facility's Special Care Unit: 13 Tegaderm dressings with manufacturer's expiration date of 8/2008; 7 piggy-tail IV sets with manufacturer's expiration date of 8/2012; 1, 20-gauge IV needle with manufacturer's expiration date of 9/2012; 2, 18 gauge IV needles with manufacturer's expiration date of 1/2013; 2, 22 gauge IV needles with manufacturer's expiration date of 2/2013; sterile gloves with manufacturer's expiration date of 8/2012; and 1 blue top blood specimen tube with manufacturer's expiration date of 1/2013. The facility's Medical/Surgical Director confirmed the expired items.

i) On 4/23/13 at 1:29 p.m., observation of the facility's sleep study room revealed a 6 ounce container of Green-Prep, skin prep, with a manufacturer's expiration date of 6/2005. The expired product was confirmed by the facility's Director of Cardiopulmonary services.

j) On 04/23/13 at 2:06 p.m., 1 multi dose vial of Romazicon was found in the Medical/Surgical medication room cart, open with no indication of when the medication was opened or when it should be discarded. The facility's Medical /Surgical Director of Nursing stated that per pharmacy, this medication should have been disposed of after being opened for 5 hours.

k) On 04/23/13 at 2:29 p.m., observation of the facility's labor and delivery rooms was conducted. The crash cart in labor and delivery was found to contain the following expired supplies: MarQuest, Micro arterial blood gas kit with manufacturer's expiration date of 7/2009; 1 lubricating jelly packet with manufacturer's expiration date of 1/2009; 2 corroded batteries; 4 infusion tubing set with manufacturer's expiration dates of 1/2011 and 2/2011; and 4 SmartSet extension sets with manufacturer's expiration date of 2/2011. In a cabinet next to the crash cart, 2 coated Vicryl suture kits with manufacturer's expiration date of 1/2013 were found. A cord blood kit was found to contain a green top blood specimen tube with manufacturer's expiration date of 10/2006. The Nursery was found to contain a pair of sterile gloves with manufacturer's expiration date of 3/2012. A storage closet in Labor and Delivery was found to contain 2 spinal needles with manufacturer's expiration dates of 10/2005 and 8/2009. The expired items were confirmed by the facility's Medical /Surgical Director of nursing and the facility's EMS Director.

l) On 04/23/13 at 4:04 p.m.., observation of the facility's cardiopulmonary unit was conducted. In the Electrocardiography (ECG) room, 6 packs of ECG electrodes were found with manufacturer's expiration date of 9/2009. The crash cart in the hallway of the cardiopulmonary unit was found to have the following expired supplies: 1 blue top blood specimen tube with manufacturer's expiration date of 1/2013; 1 red top blood specimen tube with manufacturer's expiration date of 12/2012; 3 infusion sets with manufacturer's expiration date of 1/2011; 1 Penrose drain with manufacturer's expiration date of 12/2007; 1 buff cap with manufacturer's expiration date of 2/2011; 2 Tegaderm gauze packets with manufacturer's expiration date of 1/2006; 3 needles with manufacturer's expiration date of 10/2007; 2 extension set with manufacturer's expiration dates of 2/2011; and 2 arterial blood gas sample kits with manufacturer's expiration date of 8/2007. The expired supplies were confirmed by the facility's Director of Cardiopulmonary services.

m) On 04/26/13 at 8:42 a.m., the facility's surgical area/surgical suites was observed. In the Post Anesthesia Care Unit (PACU) crash cart, 3 red top blood specimen tubes were found with manufacturer's expiration date of 10/2007. In the PACU Malignant Hyperthermia cart the following items were found to be expired: 2 infusion sets with manufacturer's expiration date of 1/2011; 1 Tegaderm gauze with manufacturer's expiration date of 3/2012; and 2 Foley catheters with manufacturer's expiration date of 12/2012. In the Endoscopy procedure room, 1 infusion set with manufacturer's expiration date of 10/2012 was found in a supply cart. In the anesthesia work room, more than 20 Tegaderm gauze were found with manufacturer's expiration date of 9/2012 and 1 with an expiration date of 3/2012. The expired items were confirmed by the facility's Medical /Surgical Director of Nursing and the facility's EMS Director.

n) On 04/24/13 at 11:38 a.m., observation was conducted of the facility's outpatient clinics. In a central area procedure room and medication preparation and storage area a glucometer was found with 2 vials of control solution, open, and with no date indicating when the solutions were opened or when they should be discarded. The clinic's Practice Manager confirmed that. per the manufacturer's instructions, the solutions should be discarded after being opened for 90 days. The crash cart in the central area was found to have the following expired items: 2, 16 gauge IV needle kits with expiration date of 2/2012; 2, 22 gauge IV needle kits with expiration dates of 5/2012; 2, 18 gauge IV needle kits with expiration dates of 1/2012; 2, 20 gauge IV needle kits with an expiration date of 4/2012; 2 extension sets with an expiration date of 2/2011; 13 IV tubing sets with an expiration date of 1/2011; 10, Tegadern gauze with an expiration date of 7/2012; and 1 green top blood specimen tube with an expiration date of 9/2012. In a storage cabinet in the procedure room, 2 Tegaderm gauze were found with and expiration date of 10/2011, and 7 were found with an expiration date of 1/2010. In the OB/GYN area of the clinics,1 cystometry tube set was found with an expiration date of 5/2012, 3 were found with an expiration date of 2/2013, and 1 with an expiration date of 3/2011. The expired supplies were confirmed by the clinic's Practice Manager.

Based on observations, document review, and staff interviews, the facility failed to ensure that facility practices were performed in a manner that would prevent communicable diseases and food-bourne illnesses.

These failures created the potential for harm to patients from infectious agents and food-borne pathogens.

FINDINGS:

1. The facility did not ensure that cleaning solutions were properly diluted to ensure effective cleaning and disinfection of equipment used during patient procedures prior to sterilization

a) On 04/24/13 at 9:51 a.m., a tour of the facility's surgical area was conducted with the facility's Director of Surgical Services. During the tour, the facility's sterile instrument cleaning area was viewed and an interview was conducted with the Technician responsible for the processing of surgical instruments. The Technician stated that sterile equipment was pre-cleaned in a cleaning solution that s/he mixed prior to putting them into the sterile instrument washer. The Technician confirmed that the manufacturer had specifications on the proper dilution of the solutions used, but admitted that the amount of water used was not measured. S/he stated there was no marking on the sink to indicate the level of water in the sink or how many gallons it could hold. The facility's Technician was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

b) On 04/24/13 at 12:14 p.m., a tour of the facility's offsite clinic's procedure room was conducted with the facility's Clinic's Nurse Clinic Staff Supervisor. During the tour, the clinic's area for instrument decontamination was viewed and an interview was conducted with the Nurse Clinic Staff Supervisor who was responsible for the processing of surgical instruments in the clinic. The Supervisor stated that sterile equipment was pre-cleaned in the clinic prior to being sent to the hospital for sterilization. S/he confirmed that the manufacturer had specifications on the proper dilution of the solutions used, but admitted that the amount of water used was not measured. S/he stated there was no marking on the sink to indicate the level of water in the sink or how many gallons it could hold. The clinic's Supervisor was unable to verbalize how s/he was able comply with the manufacturer's instructions without knowing the exact amount of water contained in the sink.

2. The facility failed to ensure that instruments for surgery were properly sterilized following manufacturer's specifications and nationally recognized standards.

Cross Reference to C-0320 Surgical Services: for findings related to the facility's failure to ensure that surgical procedures were being performed in a safe manner.

3. The facility did not ensure that masks used for respiratory equipment that were not intended for patient use were stored in areas where patient care was performed.

a. The facility's policy "Protocol for cleaning Sleep Lab Equipment" stated that "All monitoring equipment which comes into contact with the patient are wiped down with an EPA-approved germicidal disposable cloth after each patient contact.

b. Observations were conducted on 04/23/13 at 1:27 p.m., with the facility's Director of Emergency Services and the facility's Laboratory Director, of the facility's Sleep Lab. A dresser with drawers was at the foot of the bed in the room used for sleep lab testing. Within each drawer were numerous masks and equipment for CPAP and BIPAP machines. Some were still wrapped in plastic, but the majority were not. One mask was found with multiple gray hairs remaining on the Velcro straps that were attached. This observation was confirmed with the staff present and the mask was removed from the drawer.

c. A review of manufacturers' documentation that was found in the drawers with some of the masks indicated that the masks were not to be used for multiple patients.

d. An interview was conducted on 04/23/13 at 2:22 p.m. with the Sleep Lab Technician. S/he stated that the masks within the dresser were not used for patients and could not explain why the masks remained in the patient care area when they were dirty and not to be reused.



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4. The facility did not ensure that food stored in patient care areas was discarded per the facility's policy, or per manufacturer's expiration dates.

a) On 04/23/13 at 11:51 a.m., observation was conducted of the facility's Emergency Department. A refrigerator, used for storage of food items available for patient use, was found to contain a ham sandwich labeled "exp 4/22/13." The Director of Laboratory Services confirmed the date.

b) On 04/23/13 at 1:47 p.m., a refrigerator in the facility's Medical/Surgical nourishment area was found to contain cheese slices labeled, "4/4." The EMS Director stated s/he thought the date meant that the cheese should have been discarded on 4/4/13, but could not say with certainty. The staff confirmed that the cheese slices looked hard and did not look fresh. Staff present stated the refrigerator contained food items for patients. In the same room, a 6 ounce container of Ensure was found with a manufacturer's expiration date of 10/1/12. The facility's EMS Director confirmed this date.

c) On 4/24/13 at 10:20 a.m., an interview was conducted with the facility's Chef and Kitchen Manager who stated food items stored in refrigerators in the patient care areas would be discarded after 3 days and that nutrition staff was responsible for checking these refrigerators each day to discard outdated food items.

5. The facility failed to label and date food items stored in the facility's kitchen refrigerators according to facility policy and failed to store scoops used to obtain bulk items from bins in a sanitary manner.

a) On 04/24/13 at 10:20 a.m., observation of the facility's kitchen/ patient food preparation area was conducted with the facility's Chef and Kitchen Manager. The Manager stated food items stored in the refrigerators should be discarded after 3 days. The Manager also stated s/he was not certain how staff was dating refrigerated and frozen food items, meaning with the date the item was first stored or with the date the item should be discarded. The walk-in refrigerator was found to contain the following items: prepared brown rice dated 4/20, prepared brown gravy dated 4/21, prepared mashed potatoes dated 4/19, and prepared chicken gravy dated 4/17. The Manager stated these prepared food items were all past their discard date.

b) On 04/24/13 at 10:30 a.m., scoops were found inside large bins of flour and sugar, buried under the flour and sugar. The Manager confirmed this was where the scoops were stored. Infection control issues were reviewed with the Manager and the standard food service requirement that scoops should be stored outside of large bins and kept clean and sanitary.

c) On 04/24/13 at 10:38 a.m., the following food items were found in a freezer in the middle of the kitchen, with no label indicating the contents of the package, and no date of when the items were placed in the freezer or when items should be discarded: a large plastic bag of what the Manager stated was meatballs; a plastic bag of some type of berries; an unsealed brown bag with approximately 1 inch of frozen french fries; 3 plastic bags of different types of sliced bread; a small container of an item marked "CN" which the manager stated was chicken noodle soup; and a shrink wrapped package of meat dated 2/24, which the Manager stated should have been discarded after 30 days. The Manager confirmed these items and stated they should have been labeled as to the contents of the packages and should have been dated. In the refrigerator beside the freezer, the following items were found: a container of egg whites with an expiration date of 4/10/13; and a sirloin steak dated 4/18 that the Manager stated was placed in the refrigerator to thaw and should have been discarded after 3 days.

d) An interview was conducted with the Manager who stated that s/he started at the facility in January, 2013, and that although s/he had held staff meetings, none of the meetings were documented for review. The Manager stated again that s/he was not certain how staff was dating food items for storage but that his/her verbal instruction was that refrigerated food items should be discarded after 3 days of storage.

e) On 04/25/13 at 2:39 p.m., the facility's policy titled, "Storage and Use of Leftovers," was reviewed. the policy stated, "Leftover items which are not frozen are held no longer than 3 days before they are disposed of." The policy also stated, "All leftover cold food for storage in refrigerators is put into storage containers and completely covered. These are marked with the name of the item and dated. The date used is the date of disposal." Upon interview, the facility's Chief Quality Officer stated this policy was being revised, however the revisions had not been completed and the policy changes had not yet been presented to Governing Body for approval.

6. The facility failed to discard expired dry food items from the walk-in kitchen food storage room.

a) On 04/24/13 at 10:27 a.m., the walk-in pantry was observed and the following dry food items were found to be expired; chocolate sauce with a "use before" 1/2013 date, and 8 Jello gelatin products with expiration dates of 6/19/11, 3/30/11, 4/7/13, and 7/27/11. The Manager confirmed these expired food items.

Based on medical record review, facility policy/procedure review, and staff interview the facility failed to ensure that a nursing care plan was developed and kept current for each inpatient.

This failure created the potential for patients' care needs to not be addressed adequately by the nursing staff.

Findings:

1. The facility's nursing staff did not create and document a nursing care plan for 3 (Sample Patients #7, 8, and 12) of 20 patient records reviewed.

a. The facility's policy "Nursing Standards of Practice" stated that nursing staff were expected to create and update a nursing care plan for each patient. Additionally, the facility's policy "Care Planning" for the Labor and Delivery department stated that "within 8 hours of admission all patients shall have a computerized plan of care generated by the registered nurse."

b. A review of Sample Patient #7's record revealed that the facility's nursing staff had not created a nursing care plan for the patient. The patient was admitted to the hospital on 02/05/13 and was discharged home on 02/07/13. The patient underwent a cesarean section and required a blood transfusion during his/her admission.

c. A review of Sample Patient #8's record revealed that the facility's nursing staff had not created a nursing care plan for the patient. The patient was admitted to the hospital on 02/05/13 and was discharged home on 02/07/13. The patient was an infant child born in the facility.

d. A review of Sample Patient #12's record revealed that the facility's nursing staff had not created a nursing care plan for the patient. The patient was admitted to the hospital on 04/23/13 and was still an inpatient in the hospital during the review of the patient's record on 04/25/13. The patient had been admitted to the hospital for gastrointestinal bleeding.

e. An interview was conducted with the facility's Director of Medical Surgical Nursing and Emergency Department on 04/25/13 at 1:58 p.m. S/he confirmed that Sample Patient #12 did not have a nursing care plan documented. S/he stated that the facility's nursing staff was expected to create a nursing care plan for each patient and to document on each patient's care plan at least each day. S/he also stated that Sample Patient #7 and #8 should have had care plans.

Based on observations and staff interview the facility failed to ensure that staff maintained the confidentiality of record information and provided safeguards against loss, destruction, or unauthorized use of radiological records.

This failure created the potential for confidential and sensitive information to become compromised or lost.

Findings:

1. The facility staff did not secure the room that contained radiology films from unauthorized individuals.

a. Observations were conducted on 04/23/13 at 3:50 p.m. of the radiology department with the Director of Radiology. It was observed that the door to the room that was used to store radiology records was unlocked. No staff members were inside the room, nor were staff found near the door of the room.

b. An interview was conducted with the Director of Radiology at the time of the observations. S/he confirmed that door to the storage room was unlocked. S/he stated that the door was expected to be locked at all times.

Based on observations, facility document review, and staff interview the facility failed to be in compliance with the Condition of Participation of Surgical Services. The facility failed to ensure that surgical procedures were being performed in a safe manner.

Findings:

1. The facility failed to ensure that instruments for surgery were properly sterilized following manufacturer's specifications and nationally recognized standards.

a. A review of the the 2011 Edition of the Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Setting by the Association of periOperative Registered Nurses (AORN) stated the following within "Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment," pages 441 and 442, in pertinent part: "Special precautions should be taken for reprocessing ophthalmic surgical instruments: Toxic anterior segment syndrome (TASS) can result from contaminants introduce into the eye during ophthalmic surgery. An incidence of TASS can cause serious damage to a patient ' s intraocular tissue and result in vision loss...Most case of TASS appear to result from inadequate instrument cleaning and sterilization...After manual or ultrasonic cleaning, instruments should be wiped with alcohol before preparation for sterilization. Wiping with alcohol disinfects the instruments and renders them safe to handle. After cleaning and disinfection, instruments contacting viscoelastic material should be inspected for residue under magnification...An adequate inventory of instruments should be provided to allow for thorough instrument cleaning and sterilization. An adequate inventory of instruments facilitates compliance with proper decontamination and sterilization processes. Adequate time should be provided for thorough instrument cleaning and sterilization. Time constraints may create a disincentive for personnel to adhere to decontamination procedures and may result in noncompliance."

b. A review of the facility's policy titled, "Flash Sterilization", last revised 11/2009 stated: "Flash sterilization shall be avoided whenever possible."

c. Observations of the surgical services department of the hospital were conducted with the Director of Surgical Services on 04/24/13. At 9:40 a.m. s/he stated that the hospital performed cataract surgeries approximately one day monthly. S/he stated that the hospital used two instrument trays for cataract surgery and that due to the volume, the facility flash sterilized the trays due to not having enough instruments to perform the normal sterilization cycle. S/he stated that s/he had been in contact with one of the hospital's contracted services to discuss obtaining another instrument tray to avoid the utilization of flash sterilization for these instruments.

Based on policy/procedure review and staff interview the facility failed to ensure that it had written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation.

This failure created the potential for patient's visitation rights to be violated.

Findings:

1. The facility did not have policies and procedures that addressed patients' rights to have visitors or when those rights would be reasonably restricted or limited.

a. A review of the facility's policies/procedures conducted from 04/22/13 through 04/25/13 revealed that the facility did not have policies that addressed the rights of patients to have visitors or restrictions that staff would adhere to in regards to patients' visitors.

b. An interview was conducted with the facility's Chief Quality Officer/Interim Chief Nursing Officer on 04/25/13 at 3:50 p.m. S/he confirmed that the facility did not have policies to address the rights of patients to have visitors and when those rights would need to be restricted or limited.

c. An interview was conducted with the facility's Director of Medical Surgical and Emergency Department on 04/23/13 at 1:58 p.m. S/he confirmed that the facility did not have policies to address the rights of patients to have visitors and when those rights would need to be restricted or limited.

Based on policy/procedure review and staff interview the facility failed to ensure that it had written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation. The facility failed to inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, in advance of furnishing patient care whenever possible. Additionally the facility failed to inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

This failure created the potential for patient's visitation rights to be violated.

Findings:

Cross Reference to C1000 - Patient Visitation Rights: for findings related to the facility's failure to ensure that it had written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation.

Based on policy/procedure review and staff interview the facility failed to ensure that it had written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation. The facility failed to have policies that ensured that staff did not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Additionally the facility did not have a policy to ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

This failure created the potential for patient's visitation rights to be violated.

Findings:

Cross Reference to C1000 - Patient Visitation Rights: for findings related to the facility's failure to ensure that it had written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation.