HospitalInspections.org

A. Based on observation, a review of Critical Access Hospital (CAH) policy, and staff interview, it was determined that the CAH failed to ensure that outdated emergency medications were not available for use in patient care areas.

Findings include:

1. During a tour of the CAH, conducted on 5/18/10 at 12:30 PM, the following outdated items were observed in the "Radiology Crash Carts": In the Computed Tomography Room: 2 vials of 1 ml Diphenhydramine 50 mg/ml- expired 4/10; 2 Furosemide 40 mg tablets- expired 4/10; 1 box of 12 Ammonia Inhalants- expired 3/10; 2 ampules Epinephrine 1:1000- expired 5/1/10; 1 bag 500 ml 5% Dextrose in Water (D5W)- expired 4/1/10; and 1 bag 250 ml D5W with 400 mg Dopamine- expired 4/1/10. In Radiology Room #2: 1 box of 12 Ammonia Inhalants- expired 3/10; 2 Furosemide 40 mg tablets- expired 4/10; 1 bag 500 ml D5W- expired 4/1/10; and 1 bag 250 ml D5W with 400 mg Dopamine- expired 4/1/10. Both Crash Carts were observed with tags which indicated "date checked: 11/5/09...first expiration 4/10."

2. The CAH policy titled "Emergency Kit Procedure" was reviewed on 5/18/10. It indicated "A label shall be affixed to the outside of the emergency kit indicating the expiration date of the emergency kit... The Emergency Kits and the Crash Cart are checked by the pharmacy Technician or Pharmacist on a routine (at least monthly) basis."

3. During a staff interview, conducted with the Chief Nursing Officer (CNO) and the Radiology Director on 5/18/10 at 1:00 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 an Annual Re-Certification Survey conducted. The surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
Refer to the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567.

A. Based on a review of CAH policy, observation, and staff interview, it was determined that the CAH failed to ensure that all outdated biologicals were not available for patient use to prevent the potential for cross contamination of contagions.

Findings include:

1. The CAH policy titled "Pharmacy Storage of Medication" was reviewed on 5/19/10. It indicated that medication outdates would be monitored. There was no reference to indicate that biologicals would be monitored for outdates.

2. During a tour of the CAH, conducted on 05/19/10 at 9:30 AM, the OR area was observed. Seventeen microbial verification indicator kits, utilized prior to sterilization, expired on 04/23/10 were observed in the sterilizing area. Active sterilization was in progress and the kits were available for use.

3. During a staff interview, conducted with the CNO on 5/19/10 at 10:00 AM, the above findings were confirmed.

B. Based on a review of CAH policy, observation, and staff interview, it was determined that the CAH failed to ensure that outdated drugs were not available for use in patient care areas.

Findings include:

1. The CAH policy titled "Outdated Drug Control" was reviewed on 5/18/10. It indicated "The Pharmacy has instructed Nursing to remove any outdated meds from their departments...The Pharmacy should remove all outdated medications at the time of Unit Audits...5. Nursing stations will be checked periodically for outdated items with replacement effected immediately. Refer to procedure titled "Unit Audits." The policy titled "Storage of Medications" was reviewed on 5/18/10. It indicated "Pharmacy will perform monthly audits of patient care areas... Multiple dose vials must be discarded 28 days after opening..."

2. During a tour of the CAH, conducted on 5/18/10 thru 5/19/10, the following were observed: in the Nuclear Medicine Storage Room- 1 open 20 ml Kinevac 5 mg, 1 open 20 ml Sterile Water, and 1 open 10 ml Heparin Flush- all without dates as to when opened; in the Hospital based Podiatry clinic- 1 open Bupivacaine with no date as to when opened; and in the M/S medication room- 1 vial 10 ml Marcaine 0.5%- expired 7/1/09, 3 H1N1 Multitrans System for Virus- expired 1/16/10, and 2 H1N1 Multitrans System for Virus- expired 4/16/10.

3. During a staff interview, conducted with the CNO on 5/19/10 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 an Annual Re-Certification Survey conducted . The surveyor finds 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.

A. Based on a review of CAH policy, a review of Emergency Room (ER) Registered Nursing (RN) competency files, and staff interview, it was determined in 5 out of 5 ER RN files reviewed, that the CAH failed to ensure that ER RN staff were competent in performing tasks outside of their regularly required training, as per CAH policy.

Findings include:

1. The CAH policy titled "Arterial Blood Gas (ABG) Sampling" was reviewed on 5/19/10. It indicated "IV. Practice: A. RN's who have completed orientation directly relating to ABGs may be trained to do sampling... C. Personnel must have three successful, witnessed, and documented samplings before they may proceed on their own..."

2. On 5/19/10, 5 ER RN competency files were reviewed. There was no documentation to indicate that any of the ER RNs had demonstrated competency in the performance of ABG sampling. It was verbalized by the CNO and the M/S Director that the ER RNs perform ABG sampling after hours, when Respiratory Therapy is not present.

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.

A. Based on observation and staff interview, it was determined that the CAH failed to ensure that patient care items were stored in a manner to prevent potential contamination/infection.

Findings include:

1. During a tour of the CAH, conducted on 5/18/10 thru 5/19/10, the following items were observed: in the Computerized Tomography and Radiology Exam Room 2, the "Emergency Crash Carts" were both observed on the floor in each room; In the Nuclear Medicine Room, a box with nebulizer tubing and a box with Intravenous (IV) tubing under the sink; in the hospital based podiatry clinic room, patient records observed scattered on the floor and a back pack type bag with medical supplies sitting on the floor; in Medical Surgical (M/S) Exam Room, 3 electric razors (1 Norelco and 2 Braun) were observed in a container. It was verbalized by the M/S Director that these are cleaned with hospital disinfectant or cloths. There were no manufacturer guidelines as to the cleaning/disinfection of electric razors. In the M/S Soiled Utility, a plastic container was observed in the cabinet with 1 Barbasol shaving cream, 2 lotion, 3 baby powder, 2 mouthwash, 1 Perineal Skin Cleanser, and 2 Deodorant. In the Emergency Department (ED) there were clean items (boxes of unopened examination gloves, boxes of disposable vaginal speculums, sterilized surgical instruments wrapped in blue sterilization paper) stored in the dirty room that contained a hopper that was used for the disposal of bedpan contents. In the ED Trauma Room there was one box of 3-0 Surgipro C-13 cutting sutures, 3 dozen, outdated 5/09.

2. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.

B. Based on observation, a review of CAH policy, and staff interview, it was determined that the CAH failed to ensure that all patient care services were maintained to ensure proper infection control practices were implemented/followed.

Findings include:

1. The CAH policy titled "Physical Therapy Equipment Cleaning" was reviewed on 5/19/10. It indicated "I. Hydrocollator Units: A. Units are cleaned monthly...When the light on front of unit goes off, the water temperature is checked and adjusted within the 130 to 150 degree F range."

2. During a tour of CAH, conducted on 5/18/10 thru 5/19/10, a Hydrocollator Unit was observed in the M/S Storage Room. There was no documentation of cleaning and/or temperature maintenance to review. In the laundry services, it was observed that all laundry was sent out for processing. During an interview with the Director of Laundry, conducted on 5/19/10 at 10:15 AM, it was verbalized that the laundry is sent out for processing. He could not state any infection control practices utilized by the purveyor. (if the purveyor used heat, chemical, or both to disinfect the laundry, how laundry tubs are cleaned/disinfected, etc.) It was verbalized that there has never been a survey of the processing plant (a local prison).

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above finding was confirmed.

C. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 3 of 20 (Pts #14, #19, #20) medical records reviewed, that the CAH failed to ensure that infection control policies were followed.

Findings include:

1. The CAH policy titled "Methicillin-Resistant Staphylococcus Aureus (MRSA) Screening Program- Phase 1" was reviewed on 5/20/10. It indicated "V. Nursing Staff: MCH Nursing staff will screen all patients admitted to the clinical unit for active MRSA infections and to determine those at high risk for MRSA colonization... Nursing will treat all patients at high risk for MRSA colonization appropriately: 1) Place the patient on contact isolation until final results of the nasal culture Screen are negative or treatment for MRSA is complete...to be done upon admission."

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. Nursing documentation indicated that Pt #14 had draining wounds and a history of MRSA. There was no documentation to indicate that Pt #14 was placed in contact isolation upon admission until the results of the MRSA screen were obtained.

3. The medical record of Pt #19 was reviewed on 5/20/10. Pt #19 was admitted to the CAH on 4/10/10 with the diagnosis of Congestive Heart Failure. Documentation indicated that Pt #19 was in a high risk category for MRSA (resident of nursing home and history of MRSA). There was no documentation of completion of an MRSA screen being completed upon admission or that Pt #19 was placed in contact isolation. On 4/11/10, there was a physician's order to screen for MRSA. Laboratory results on 4/12/10, indicated positive results.

4. The medical record #20 was reviewed on 5/20/10. Pt #20 was admitted to the CAH on 4/3/10 with the diagnosis of Pneumonia. Documentation indicated that Pt #20 was in a high risk category for MRSA (resident of nursing home). There was no documentation to indicate that the MRSA screen was conducted upon admission or that Pt #20 was placed in contact isolation. It further indicated that Pt #20 tested positive for Clostridium Difficile Antigen on 4/4/10. There was no documentation that isolation was instituted and/or maintained.

5. During a staff interview, conducted with the CNO (also the Infection Control Nurse) on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of dietary instructions and staff interview, it was determined that the CAH failed to ensure the chemical disinfection solutions in the 3 sink pan wash system were checked for proper solution.

Findings include:

1. The instructions for the manual dishwashing procedure was reviewed. It indicated under, "Before You Begin 5. ...Change sanitizing solutions when visibly soiled. Check solution strength frequently with test papers."

2. During an interview with the Dietary Manager, conducted on 5/18/10 at 10:45 AM, it was verbalized that the solutions are rarely checked for the proper strength as the automated dispensing system was checked monthly by the company providing the service.

A. Based on medical record review and staff interview, it was determined in 2 of 20 (Pts #4, #14) medical record reviewed, that the CAH failed to ensure all nursing care was provided as ordered and in accordance with the individual needs of the patient.

Findings include:

1. Pt. # 4 was admitted to the CAH on 04/06/10 with diagnoses of Dehydration and Renal Insufficiency. On 4/6/10, the physician ordered the patient to be weighed daily. Pt #4 expired on 4/13/10. The only weight documented was upon admission. On 4/13/10, nursing documentation indicated that a dressing was changed to the coccyx. There was no documentation of the presence of a coccyx wound prior to this time and no physician's order for a dressing change.

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. Nursing Admission documentation indicated that Pt #14 had a Stage II pressure ulcer to the Right buttock, an abrasion to the Left buttock, and a venous ulcer on medial left calf 3 cm around, open necrotic, draining serosanguinous. There was no documentation to indicate that the physician was notified. There was no documentation of wound care provided throughout hospitalization. There was no documentation of patient education as to pressure prevention, infection, etc.

3. During a staff interview, conducted with the CNO on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #10) medical records reviewed in which the patient received a blood transfusion, the CAH failed to ensure all vital signs were recorded per policy.

Findings include:

1. The policy and procedure titled, "Blood Transfusion" was reviewed on 5/19/10. It indicated under IV. PRACTICE: G. Vitals are to be taken immediately prior to the start of transfusion. The RN will remain with the patient for the beginning 15 minutes, repeating vitals every 5 minutes x 3 times...."

2. The medical record of Pt #10 was reviewed on 5/19/10. It indicated Pt #10 was admitted on 3/5/10 with a diagnosis of Pneumonia. Documentation indicated that the patient received 4 units of packed red blood cells (PRBC). The nurses notes for unit #40FV22433, hung on 3/5/10 at 1627, indicated that the patient's temperature was recorded only once out of 8 sets of vital signs. For unit #40FV22432, hung on 3/5/10 at 1935, no temperatures were recorded on 8 sets of vital signs (vs). On unit #40KF19735, hung on 3/6/10 at 1000, only 1 temperature was recorded out of 8 sets of vs. And on unit #40KF19741, hung on 3/6/10 at 1330, there were no temperatures recorded out of 9 sets of vs.

3. During an interview with the CNO, conducted on 5/19/10 at 2:45 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 2 of 20 (Pts #2, #5) medical records reviewed, the CAH failed to ensure there was documentation that indicated the nursing interventions were implemented.

Findings include:

1. The medical record of Pt #2 was reviewed on 5/18/10. It indicated Pt #2 was admitted on 2/16/10 with a diagnosis of Cellulitis. On admission the patient scored a 16 (high risk) on the Braden Scale. He also scored as "extremely high risk" for falls. There was no documentation in the medical record that indicated the protocols for both assessments were implemented.

2. The medical record of Pt #5 was reviewed on 5/18/10. It indicated that Pt #5 was admitted on 5/13/10 with a diagnosis of Lower Respiratory Tract Infection. The patient was scored as "moderate risk" on the Braden Scale and as "high risk" for falls. There was no documentation that indicated the protocols for both assessments were implemented.

3. During an interview with the Chief Nursing Officer, conducted on 5/18/10 at 10:45 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 10 of 10 medical records reviewed between 5/18/10 and 5/21/10, in which portions of the medical record were printed for review, the CAH failed to ensure it's electronic medical record (EMR) was easily retrievable and reflected the care provided.

Findings include:

1. During the recertification survey conducted 5/18/10 thru 5/21/10, 10 out of 10 medical records, in which sections of the EMR were requested to be printed out for surveyor review, each hard copy had entries of date and time stamp that were incorrect. Rather than reflecting the date and time of the entry by the CAH personnel, it reflected the date and time the record was queried to print out the requested sections. However, it did not change the authentication of the author or the entry itself. The entries were not related to the specific patient queried. It was verbalized by the M/S Director that when a patient care plan or record is "modified" that whatever the area is that is modified "drops off" and cannot be seen after that point. If an entry is corrected, it does not keep the entry that was corrected and then the correction made.

2. During an interview with the Chief Nurse Officer, conducted on 5/20/10 at 3:10 PM, the above findings were confirmed.

Based on a review of CAH policy and procedure, medical record review, and staff interview, it was determined that in 2 of 2 (Pts #16, #17) medical records reviewed in which the patient received subcutaneous (sq) injections, the CAH failed to ensure nursing staff documented the injection site of all sq medication administrations.

Findings include:

1. The CAH policy and procedure titled, "Clinical Nursing Skills - Procedures" indicated under "IV. EQUIPMENT: Perry, A. G., Potter, P. A., (2006), Clinical Nursing Skills and Techniques, (6th ed.), St. Louis, MO., Elsevier Mosby...." and under V. PRACTICE: 1.) Utilize the Clinical Nursing Skills and Techniques book as a resource for nursing procedures." In the Perry and Potter Clinical Nursing Skills and Techniques, 6th edition, it indicated on page 722 "Recording and Reporting Immediately after administration, chart medication dose, route, site..."

2. The medical record of Pt #16 was reviewed on 5/20/10. It indicated Pt #16 was admitted on 4/5/10 with diagnoses of Atrial Fibrillation, Pneumonia, and Congestive Heart Failure. There was no nursing documentation of the injection sites when insulin was administered sq on 4/5/10 at 9:53 PM, on 4/6/20 at 9:47 PM. and on 4/7/10 at 9:15 PM.

3. The medical record of Pt #17 was reviewed on 5/20/10. It indicated Pt #17 was admitted on 3/12/10 with diagnoses of Diabetes Mellitis and Morbid Obesity. There was no nursing documentation of the injection sites when insulin was administered sq on 3/16/10 at 9:25 PM and on 3/17/10 at 9:22 PM.

4. During an interview with the Chief Nursing Officer, conducted on 3/20/10 at 11:45 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 4 of 20 (Pts #13, #14, #19, #20) medical records reviewed, that the CAH failed to ensure that documentation was complete.

Findings include:

1. The medical record of Pt #13 was reviewed on 5/19/10. Pt #13 was admitted to the CAH on 4/4/10 with the diagnosis of Cholecystitis with Cholelithiasis. There was no documentation as to the time of the ER triage or the ER physician assessment.

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. There was no documentation as to the time of the ER physician assessment. There was no documentation as to the triage status of the patient. There was no documentation of an RN assessment in the ER.

3. The medical record of Pt #19 was reviewed on 5/20/10. Pt #19 was admitted to the CAH on 4/10/10 with the diagnosis of Congestive Heart Failure. There no documentation as to the time of the ER physician assessment. There was no documentation as to the triage status of the patient.

4. The medical record of Pt #20 was reviewed on 5/20/10. Pt #20 was admitted to the CAH on 4/3/10 with the diagnosis of Pneumonia. There was no documentation as to the time of the ER physician assessment.

5. During a staff interview, conducted with the CNO on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of CAH policy, a review of contracted services, and staff interview, it was determined that the CAH failed to ensure that all contracted services were evaluated for compliance with applicable conditions of participation and included in the Annual Program Evaluation.

Findings include:

1. The CAH policy titled "Annual Evaluation of Contracts and Contractors" was reviewed on 5/18/10. It indicated "Annual review of all patient related contract and contractors according to the terms of the contracts. Will follow the Conditions of Participation..."

2. The list of contracted services was reviewed on 5/18/10. There was no documentation to indicate that the evaluation of all contracted services, for compliance with the Conditions of Particiapation, was completed and the report included in the Annual Program Evaluation.

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.

A. Based on observation, a review of Critical Access Hospital (CAH) policy, and staff interview, it was determined that the CAH failed to ensure that outdated emergency medications were not available for use in patient care areas.

Findings include:

1. During a tour of the CAH, conducted on 5/18/10 at 12:30 PM, the following outdated items were observed in the "Radiology Crash Carts": In the Computed Tomography Room: 2 vials of 1 ml Diphenhydramine 50 mg/ml- expired 4/10; 2 Furosemide 40 mg tablets- expired 4/10; 1 box of 12 Ammonia Inhalants- expired 3/10; 2 ampules Epinephrine 1:1000- expired 5/1/10; 1 bag 500 ml 5% Dextrose in Water (D5W)- expired 4/1/10; and 1 bag 250 ml D5W with 400 mg Dopamine- expired 4/1/10. In Radiology Room #2: 1 box of 12 Ammonia Inhalants- expired 3/10; 2 Furosemide 40 mg tablets- expired 4/10; 1 bag 500 ml D5W- expired 4/1/10; and 1 bag 250 ml D5W with 400 mg Dopamine- expired 4/1/10. Both Crash Carts were observed with tags which indicated "date checked: 11/5/09...first expiration 4/10."

2. The CAH policy titled "Emergency Kit Procedure" was reviewed on 5/18/10. It indicated "A label shall be affixed to the outside of the emergency kit indicating the expiration date of the emergency kit... The Emergency Kits and the Crash Cart are checked by the pharmacy Technician or Pharmacist on a routine (at least monthly) basis."

3. During a staff interview, conducted with the Chief Nursing Officer (CNO) and the Radiology Director on 5/18/10 at 1:00 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 an Annual Re-Certification Survey conducted. The surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
Refer to the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567.

A. Based on a review of CAH policy, observation, and staff interview, it was determined that the CAH failed to ensure that all outdated biologicals were not available for patient use to prevent the potential for cross contamination of contagions.

Findings include:

1. The CAH policy titled "Pharmacy Storage of Medication" was reviewed on 5/19/10. It indicated that medication outdates would be monitored. There was no reference to indicate that biologicals would be monitored for outdates.

2. During a tour of the CAH, conducted on 05/19/10 at 9:30 AM, the OR area was observed. Seventeen microbial verification indicator kits, utilized prior to sterilization, expired on 04/23/10 were observed in the sterilizing area. Active sterilization was in progress and the kits were available for use.

3. During a staff interview, conducted with the CNO on 5/19/10 at 10:00 AM, the above findings were confirmed.

B. Based on a review of CAH policy, observation, and staff interview, it was determined that the CAH failed to ensure that outdated drugs were not available for use in patient care areas.

Findings include:

1. The CAH policy titled "Outdated Drug Control" was reviewed on 5/18/10. It indicated "The Pharmacy has instructed Nursing to remove any outdated meds from their departments...The Pharmacy should remove all outdated medications at the time of Unit Audits...5. Nursing stations will be checked periodically for outdated items with replacement effected immediately. Refer to procedure titled "Unit Audits." The policy titled "Storage of Medications" was reviewed on 5/18/10. It indicated "Pharmacy will perform monthly audits of patient care areas... Multiple dose vials must be discarded 28 days after opening..."

2. During a tour of the CAH, conducted on 5/18/10 thru 5/19/10, the following were observed: in the Nuclear Medicine Storage Room- 1 open 20 ml Kinevac 5 mg, 1 open 20 ml Sterile Water, and 1 open 10 ml Heparin Flush- all without dates as to when opened; in the Hospital based Podiatry clinic- 1 open Bupivacaine with no date as to when opened; and in the M/S medication room- 1 vial 10 ml Marcaine 0.5%- expired 7/1/09, 3 H1N1 Multitrans System for Virus- expired 1/16/10, and 2 H1N1 Multitrans System for Virus- expired 4/16/10.

3. During a staff interview, conducted with the CNO on 5/19/10 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 an Annual Re-Certification Survey conducted . The surveyor finds 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.

A. Based on a review of CAH policy, a review of Emergency Room (ER) Registered Nursing (RN) competency files, and staff interview, it was determined in 5 out of 5 ER RN files reviewed, that the CAH failed to ensure that ER RN staff were competent in performing tasks outside of their regularly required training, as per CAH policy.

Findings include:

1. The CAH policy titled "Arterial Blood Gas (ABG) Sampling" was reviewed on 5/19/10. It indicated "IV. Practice: A. RN's who have completed orientation directly relating to ABGs may be trained to do sampling... C. Personnel must have three successful, witnessed, and documented samplings before they may proceed on their own..."

2. On 5/19/10, 5 ER RN competency files were reviewed. There was no documentation to indicate that any of the ER RNs had demonstrated competency in the performance of ABG sampling. It was verbalized by the CNO and the M/S Director that the ER RNs perform ABG sampling after hours, when Respiratory Therapy is not present.

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.

A. Based on observation and staff interview, it was determined that the CAH failed to ensure that patient care items were stored in a manner to prevent potential contamination/infection.

Findings include:

1. During a tour of the CAH, conducted on 5/18/10 thru 5/19/10, the following items were observed: in the Computerized Tomography and Radiology Exam Room 2, the "Emergency Crash Carts" were both observed on the floor in each room; In the Nuclear Medicine Room, a box with nebulizer tubing and a box with Intravenous (IV) tubing under the sink; in the hospital based podiatry clinic room, patient records observed scattered on the floor and a back pack type bag with medical supplies sitting on the floor; in Medical Surgical (M/S) Exam Room, 3 electric razors (1 Norelco and 2 Braun) were observed in a container. It was verbalized by the M/S Director that these are cleaned with hospital disinfectant or cloths. There were no manufacturer guidelines as to the cleaning/disinfection of electric razors. In the M/S Soiled Utility, a plastic container was observed in the cabinet with 1 Barbasol shaving cream, 2 lotion, 3 baby powder, 2 mouthwash, 1 Perineal Skin Cleanser, and 2 Deodorant. In the Emergency Department (ED) there were clean items (boxes of unopened examination gloves, boxes of disposable vaginal speculums, sterilized surgical instruments wrapped in blue sterilization paper) stored in the dirty room that contained a hopper that was used for the disposal of bedpan contents. In the ED Trauma Room there was one box of 3-0 Surgipro C-13 cutting sutures, 3 dozen, outdated 5/09.

2. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.

B. Based on observation, a review of CAH policy, and staff interview, it was determined that the CAH failed to ensure that all patient care services were maintained to ensure proper infection control practices were implemented/followed.

Findings include:

1. The CAH policy titled "Physical Therapy Equipment Cleaning" was reviewed on 5/19/10. It indicated "I. Hydrocollator Units: A. Units are cleaned monthly...When the light on front of unit goes off, the water temperature is checked and adjusted within the 130 to 150 degree F range."

2. During a tour of CAH, conducted on 5/18/10 thru 5/19/10, a Hydrocollator Unit was observed in the M/S Storage Room. There was no documentation of cleaning and/or temperature maintenance to review. In the laundry services, it was observed that all laundry was sent out for processing. During an interview with the Director of Laundry, conducted on 5/19/10 at 10:15 AM, it was verbalized that the laundry is sent out for processing. He could not state any infection control practices utilized by the purveyor. (if the purveyor used heat, chemical, or both to disinfect the laundry, how laundry tubs are cleaned/disinfected, etc.) It was verbalized that there has never been a survey of the processing plant (a local prison).

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above finding was confirmed.

C. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 3 of 20 (Pts #14, #19, #20) medical records reviewed, that the CAH failed to ensure that infection control policies were followed.

Findings include:

1. The CAH policy titled "Methicillin-Resistant Staphylococcus Aureus (MRSA) Screening Program- Phase 1" was reviewed on 5/20/10. It indicated "V. Nursing Staff: MCH Nursing staff will screen all patients admitted to the clinical unit for active MRSA infections and to determine those at high risk for MRSA colonization... Nursing will treat all patients at high risk for MRSA colonization appropriately: 1) Place the patient on contact isolation until final results of the nasal culture Screen are negative or treatment for MRSA is complete...to be done upon admission."

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. Nursing documentation indicated that Pt #14 had draining wounds and a history of MRSA. There was no documentation to indicate that Pt #14 was placed in contact isolation upon admission until the results of the MRSA screen were obtained.

3. The medical record of Pt #19 was reviewed on 5/20/10. Pt #19 was admitted to the CAH on 4/10/10 with the diagnosis of Congestive Heart Failure. Documentation indicated that Pt #19 was in a high risk category for MRSA (resident of nursing home and history of MRSA). There was no documentation of completion of an MRSA screen being completed upon admission or that Pt #19 was placed in contact isolation. On 4/11/10, there was a physician's order to screen for MRSA. Laboratory results on 4/12/10, indicated positive results.

4. The medical record #20 was reviewed on 5/20/10. Pt #20 was admitted to the CAH on 4/3/10 with the diagnosis of Pneumonia. Documentation indicated that Pt #20 was in a high risk category for MRSA (resident of nursing home). There was no documentation to indicate that the MRSA screen was conducted upon admission or that Pt #20 was placed in contact isolation. It further indicated that Pt #20 tested positive for Clostridium Difficile Antigen on 4/4/10. There was no documentation that isolation was instituted and/or maintained.

5. During a staff interview, conducted with the CNO (also the Infection Control Nurse) on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of dietary instructions and staff interview, it was determined that the CAH failed to ensure the chemical disinfection solutions in the 3 sink pan wash system were checked for proper solution.

Findings include:

1. The instructions for the manual dishwashing procedure was reviewed. It indicated under, "Before You Begin 5. ...Change sanitizing solutions when visibly soiled. Check solution strength frequently with test papers."

2. During an interview with the Dietary Manager, conducted on 5/18/10 at 10:45 AM, it was verbalized that the solutions are rarely checked for the proper strength as the automated dispensing system was checked monthly by the company providing the service.

A. Based on medical record review and staff interview, it was determined in 2 of 20 (Pts #4, #14) medical record reviewed, that the CAH failed to ensure all nursing care was provided as ordered and in accordance with the individual needs of the patient.

Findings include:

1. Pt. # 4 was admitted to the CAH on 04/06/10 with diagnoses of Dehydration and Renal Insufficiency. On 4/6/10, the physician ordered the patient to be weighed daily. Pt #4 expired on 4/13/10. The only weight documented was upon admission. On 4/13/10, nursing documentation indicated that a dressing was changed to the coccyx. There was no documentation of the presence of a coccyx wound prior to this time and no physician's order for a dressing change.

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. Nursing Admission documentation indicated that Pt #14 had a Stage II pressure ulcer to the Right buttock, an abrasion to the Left buttock, and a venous ulcer on medial left calf 3 cm around, open necrotic, draining serosanguinous. There was no documentation to indicate that the physician was notified. There was no documentation of wound care provided throughout hospitalization. There was no documentation of patient education as to pressure prevention, infection, etc.

3. During a staff interview, conducted with the CNO on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that in 1 of 3 (Pt #10) medical records reviewed in which the patient received a blood transfusion, the CAH failed to ensure all vital signs were recorded per policy.

Findings include:

1. The policy and procedure titled, "Blood Transfusion" was reviewed on 5/19/10. It indicated under IV. PRACTICE: G. Vitals are to be taken immediately prior to the start of transfusion. The RN will remain with the patient for the beginning 15 minutes, repeating vitals every 5 minutes x 3 times...."

2. The medical record of Pt #10 was reviewed on 5/19/10. It indicated Pt #10 was admitted on 3/5/10 with a diagnosis of Pneumonia. Documentation indicated that the patient received 4 units of packed red blood cells (PRBC). The nurses notes for unit #40FV22433, hung on 3/5/10 at 1627, indicated that the patient's temperature was recorded only once out of 8 sets of vital signs. For unit #40FV22432, hung on 3/5/10 at 1935, no temperatures were recorded on 8 sets of vital signs (vs). On unit #40KF19735, hung on 3/6/10 at 1000, only 1 temperature was recorded out of 8 sets of vs. And on unit #40KF19741, hung on 3/6/10 at 1330, there were no temperatures recorded out of 9 sets of vs.

3. During an interview with the CNO, conducted on 5/19/10 at 2:45 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 2 of 20 (Pts #2, #5) medical records reviewed, the CAH failed to ensure there was documentation that indicated the nursing interventions were implemented.

Findings include:

1. The medical record of Pt #2 was reviewed on 5/18/10. It indicated Pt #2 was admitted on 2/16/10 with a diagnosis of Cellulitis. On admission the patient scored a 16 (high risk) on the Braden Scale. He also scored as "extremely high risk" for falls. There was no documentation in the medical record that indicated the protocols for both assessments were implemented.

2. The medical record of Pt #5 was reviewed on 5/18/10. It indicated that Pt #5 was admitted on 5/13/10 with a diagnosis of Lower Respiratory Tract Infection. The patient was scored as "moderate risk" on the Braden Scale and as "high risk" for falls. There was no documentation that indicated the protocols for both assessments were implemented.

3. During an interview with the Chief Nursing Officer, conducted on 5/18/10 at 10:45 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined that in 10 of 10 medical records reviewed between 5/18/10 and 5/21/10, in which portions of the medical record were printed for review, the CAH failed to ensure it's electronic medical record (EMR) was easily retrievable and reflected the care provided.

Findings include:

1. During the recertification survey conducted 5/18/10 thru 5/21/10, 10 out of 10 medical records, in which sections of the EMR were requested to be printed out for surveyor review, each hard copy had entries of date and time stamp that were incorrect. Rather than reflecting the date and time of the entry by the CAH personnel, it reflected the date and time the record was queried to print out the requested sections. However, it did not change the authentication of the author or the entry itself. The entries were not related to the specific patient queried. It was verbalized by the M/S Director that when a patient care plan or record is "modified" that whatever the area is that is modified "drops off" and cannot be seen after that point. If an entry is corrected, it does not keep the entry that was corrected and then the correction made.

2. During an interview with the Chief Nurse Officer, conducted on 5/20/10 at 3:10 PM, the above findings were confirmed.

Based on a review of CAH policy and procedure, medical record review, and staff interview, it was determined that in 2 of 2 (Pts #16, #17) medical records reviewed in which the patient received subcutaneous (sq) injections, the CAH failed to ensure nursing staff documented the injection site of all sq medication administrations.

Findings include:

1. The CAH policy and procedure titled, "Clinical Nursing Skills - Procedures" indicated under "IV. EQUIPMENT: Perry, A. G., Potter, P. A., (2006), Clinical Nursing Skills and Techniques, (6th ed.), St. Louis, MO., Elsevier Mosby...." and under V. PRACTICE: 1.) Utilize the Clinical Nursing Skills and Techniques book as a resource for nursing procedures." In the Perry and Potter Clinical Nursing Skills and Techniques, 6th edition, it indicated on page 722 "Recording and Reporting Immediately after administration, chart medication dose, route, site..."

2. The medical record of Pt #16 was reviewed on 5/20/10. It indicated Pt #16 was admitted on 4/5/10 with diagnoses of Atrial Fibrillation, Pneumonia, and Congestive Heart Failure. There was no nursing documentation of the injection sites when insulin was administered sq on 4/5/10 at 9:53 PM, on 4/6/20 at 9:47 PM. and on 4/7/10 at 9:15 PM.

3. The medical record of Pt #17 was reviewed on 5/20/10. It indicated Pt #17 was admitted on 3/12/10 with diagnoses of Diabetes Mellitis and Morbid Obesity. There was no nursing documentation of the injection sites when insulin was administered sq on 3/16/10 at 9:25 PM and on 3/17/10 at 9:22 PM.

4. During an interview with the Chief Nursing Officer, conducted on 3/20/10 at 11:45 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 4 of 20 (Pts #13, #14, #19, #20) medical records reviewed, that the CAH failed to ensure that documentation was complete.

Findings include:

1. The medical record of Pt #13 was reviewed on 5/19/10. Pt #13 was admitted to the CAH on 4/4/10 with the diagnosis of Cholecystitis with Cholelithiasis. There was no documentation as to the time of the ER triage or the ER physician assessment.

2. The medical record of Pt #14 was reviewed on 5/20/10. Pt #14 was admitted to the CAH on 2/23/10 with the diagnosis of Altered Mental Status. There was no documentation as to the time of the ER physician assessment. There was no documentation as to the triage status of the patient. There was no documentation of an RN assessment in the ER.

3. The medical record of Pt #19 was reviewed on 5/20/10. Pt #19 was admitted to the CAH on 4/10/10 with the diagnosis of Congestive Heart Failure. There no documentation as to the time of the ER physician assessment. There was no documentation as to the triage status of the patient.

4. The medical record of Pt #20 was reviewed on 5/20/10. Pt #20 was admitted to the CAH on 4/3/10 with the diagnosis of Pneumonia. There was no documentation as to the time of the ER physician assessment.

5. During a staff interview, conducted with the CNO on 5/21/10 at 11:00 AM, the above findings were confirmed.

A. Based on a review of CAH policy, a review of contracted services, and staff interview, it was determined that the CAH failed to ensure that all contracted services were evaluated for compliance with applicable conditions of participation and included in the Annual Program Evaluation.

Findings include:

1. The CAH policy titled "Annual Evaluation of Contracts and Contractors" was reviewed on 5/18/10. It indicated "Annual review of all patient related contract and contractors according to the terms of the contracts. Will follow the Conditions of Participation..."

2. The list of contracted services was reviewed on 5/18/10. There was no documentation to indicate that the evaluation of all contracted services, for compliance with the Conditions of Particiapation, was completed and the report included in the Annual Program Evaluation.

3. During a staff interview, conducted with the CNO on 5/19/10 at 3:00 PM, the above findings were confirmed.