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Based on record review and interview, the facility failed to adopt Medical Staff Bylaws which gave only the Governing Body the authority to grant medical staff privileges. The facility census was 37.

Findings included:

1. Record review of the facility's Medical Staff Bylaws approved 11/14/05 and revised 11/16/11 showed the following:

Section 8. Temporary Privileges
A. Upon receipt of an application for Medical Staff membership from an appropriately licensed Practitioner and receipt of the response from an inquiry to the National Practitioner Data Bank, the Administrator may, upon the basis of information then available which may reasonably be relied upon as to the competence and ethical standing of the applicant, including required insurance and after consulting with the department chairman concerned and the Chief of Staff, grant temporary admitting and clinical privileges to the applicant.

B. Temporary clinical privileges may be granted by the Administrator for the care of a specific patient, to a Practitioner who is not an applicant for membership in the same manner and upon the same conditions as set forth in paragraph A of this Section 8, provided that there shall first be obtained such Practitioner's written acknowledgment that Practitioner agrees to be bound by the terms of these Bylaws in all matters relating to Practitioner's temporary clinical privileges.

During an interview on 01/17/12 at 1:40 PM, Staff EE, Administrator, stated that he granted temporary privileges with input from the medical staff.

Based on interview, Governing Board Bylaws and policy review, the facility failed to formally designate a committee to be responsible for patient grievances. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Grievance" revised 03/22/10 showed the following direction:
- The Patient Advocate Department shall be responsible for tracking and trending all concerns, complaints, and grievances and generating reports of the same;
-The Patient Advocate Department shall report the tracking and trending of concerns, complaints, and grievances to the Patient Care Committee on a quarterly basis;
- Upon resolution, the Patient Advocate or appropriate manager will contact the complainant either by telephone or in writing regarding findings and actions taken to resolve the issue.

Record review of the Governing Board Bylaws revised 11/16/11 showed no delegation of the patient grievance responsibilities to a committee to review and resolve grievances.

Record review of the grievance log from July 2011 until January 2012 showed:
- 39 billing complaints;
- 19 patient care complaints.

2. During an interview on 01/18/12 at 11:45 AM, Staff B, Patient Advocate, stated that the patient advocate is ultimately in charge of all complaints/grievances, but could not find where these responsibilities had been formally delegated to the patient advocate by the Governing Board.

During an interview on 01/18/12 at 5:00 PM Staff A, Director of Nursing and Staff EE, Administrator stated they could not produce documentation to show delegation of the grievance process to Staff B.

Based on interview, review of facility grievances, and facility policy review, the facility failed to provide written notice regarding the steps taken to investigate the grievance, the results of the grievance investigation process, and the date of completion for two discharged patient's (#50 and #51) of two grievance files reviewed. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Grievance" revised 03/22/10, showed the following direction:
- The Patient Advocate Department shall be responsible for tracking and trending all concerns, complaints, and grievances and generating reports of the same;
- The receiver should attempt to resolve the issue immediately, if unable to do so, the issue should be forwarded to the Patient Advocate Department for resolution;
- The Patient Advocate Department will review the complaint and determine the department/s involved;
- The Patient Advocate Department and appropriate manager/supervisor will complete an investigation and make appropriate resolution within 20 business days of the grievance;
- Upon resolution, the Patient Advocate or appropriate manager will contact the complainant either by telephone or in writing regarding findings and actions taken to resolve the issue.
- The following information should be contained in a written reply:
a. Steps taken to investigate the grievance;
b. Results of the investigation;
c. Date of completion of the investigation;
d. Name of the hospital and contact person for further information.

2. Review of a Patient/Customer Complaint/Grievance Form showed Patient #50's spouse contacted the facility by telephone on 12/17/11 regarding an incident which had occurred with the patient on 10/18/11:
- The patient had been transported to the hospital for insertion of a feeding tube on 10/18/11;
- Staff were unable to place the feeding tube;
- A physician did not see the patient;
- The patient would need to return to the facility to have the feeding tube replaced.

The Response to Complainant portion of the form showed:
- The patient advocate telephoned the complainant and explained findings in the medical record;
- The complainant reported he/she would talk to the physician about the situation;
- Issue resolved with spouse.

3. During an interview on 01/18/12 at 11:25 AM, Staff B, Patient Advocate, stated that they were not aware that a letter needed to be sent if the complainant could be reached by telephone and resolve the issue.

4. Review of a Patient/Customer Complaint/Grievance Form showed a family member of Patient #51's contacted the facility by telephone on 12/11/11 regarding incidents which had occurred during the previous weekend:
- Complaints of less than adequate care over the weekend, which included long waits for assistance; no response to beeping intravenous line; the patient having to change own clothing without assist when the patient was a fall risk.

The Response to Complainant portion of the form showed:
- The patient advocate telephoned the complainant on 12/12/11 and explained that staff will be more attentive to the patient;
- Family to stay with the patient throughout the day;
- Resolved issue.

5. During an interview on 01/18/12 at 11:30 AM, Staff B, Patient Advocate, stated that a letter is never sent to a complainant unless the complaint/grievance cannot be resolved over the telephone.

Based on observation, interview, record review and policy review the facility failed to individualize and/or update the care plan for two patients (#25 and #44) out of three patient records reviewed with restraints. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Care Plans," dated 03/19/09, showed the following direction:
- The three most important problems will be addressed.
- Care needs will be reassessed every shift or 12 hours.

Record review of the facility's policy titled, "Restraints" revised 05/14/07, showed direction for facility staff to initiate the restraint care plan after initiation of a restraint.

2. Review of discharged Patient #25's medical record showed nursing documentation and a physician order that states the patient was in four-point restraints (all four limbs restrained) on 03/17/11 from 6:45 PM until 10:45 PM. Review of the patient's treatment plan/care plan showed staff failed to include the use of restraints in the patient's treatment plan/care plan.

During an interview on 01/11/12 at 2:30 PM, Staff P, Director of Nursing, Behavioral Health Unit, confirmed that the treatment plan did not include restraints.

Review of discharged Patient #44's medical record showed nursing documentation and a physician order that states the patient was in soft wrist restraints on 01/03/12 at 6:45 PM until 01/04/12 at 8:40 AM. Staff failed to include the use of restraint in the patient's plan of care.

During an interview on 01/17/12 at 3:00 PM, Staff C, RN, Rehabilitation Unit Manager, stated that she would expect the care plan to include the use of restraints.

Based on interview, record review, and policy review, the facility failed to obtain a physician order for a restraint for one discharged patient (#43) and failed to follow facility policy to obtain a physician order for a restraint which included the type of restraint to be used for one discharged patient (#25), out of three patient records reviewed with restraints. The facility census was 37.

Findings included:

1. Record review of the facility's policy for medical restraints titled "Restraints" revised 05/15/07, showed direction for staff to obtain a physician's order for restraints.

Record review of the facility's policy for behavioral restraints titled "Restraint and Seclusion" revised 01/11, showed the following direction:
- Restraints shall be ordered by a physician or LIP primarily responsible for the patient's ongoing care authorized by the medical staff;
- The order shall specify the method of restraint and/or seclusion to be used.

2. Review of Patient #43's medical record showed:
- The patient was admitted to the facility on 12/29/11;
- A nursing progress note dated 12/30/11 at 7:00 PM which stated that wrist restraints were placed on the patient due to family's concern that the patient would remove oxygen mask;
- No physician order for the restraint;
- No further documentation regarding a restraint.

During an interview on 01/18/12 at 9:20 AM, Staff B, Registered Nurse (RN), confirmed there was not an order for a restraint for this patient.

During an interview on 01/18/12 at 3:00 PM, Staff A, Director of Nursing (DON), said that the RN (Staff CCC) who had applied the restraint to Patient #43 had received orientation, which included restraint training and had an extensive nursing background, and could not understand why Staff CCC would apply a restraint without a physician order.

3. Review of Patient #25's medical record showed:
- The patient was admitted to the facility to the Behavioral Health Unit on 03/17/11;
- Nursing progress notes dated 03/17/11 which stated the patient was placed in four-point restraints on 03/17/11 at 6:45 PM until 8:45 PM;
- A physician order for restraints dated 03/17/11 at 6:45 PM which does not include the type of restraint ordered.

During an interview on 01/12/11 at 3:15 PM, Staff P, DON Behavioral Health, confirmed the order did not include what type of restraint would be used for Patient #25.

Based on interview, restraint training review, personnel file review and policy review, the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to immediate interventions that would need to be rendered to a restrained or secluded patient who is in distress or injured while the patient is in restraints. This failure has the potential to affect all patients placed in restraints. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Restraints" dated 05/15/07, showed the following direction:
- In orientation, staff that come in contact with restraint usage will complete competency-based education within their scope of practice in assessment, alternatives in handling behavior, symptoms and situations that have traditionally been treated through the use of restraint/seclusion, initiation, application and removal of restraints, ongoing monitoring, documentation, taking vital signs, physical safety, recognizing nutritional hydration, hygiene and elimination needs, assessing circulation, range of motion, physical and psychological status and comfort of the patient;
- Direct care staff that come in contact with restraint usage will receive competency-based education in correct application and removal, monitoring, care of the patient, and documentation.

2. Review of four personnel files of Registered Nurses (RNs) Staff B, C, U, and Z showed no evidence of first aide training related to restraints.

3. Review of the skills checklist for nursing staff included restraint training, but did not specify first aide training.

4. During an interview on 01/18/12 at 3:15 PM, Staff A, Director of Nursing (DON) stated that staff are not trained in first aid as related to restraints because she was not aware of this requirement. Staff A stated that she does the training to nursing staff, and first aid training is not included.

Based on observation, interview, record review, and policy review the facility failed to individualize and/or update the care plan for 13 patients (#1, #2, #4, #9, #10, #14, #35, #36, #45 #46, #47, #48 and #49) of 17 reviewed. The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Care Plans," dated 03/19/09, showed the following direction:
- The three most important problems will be addressed.
- Care needs will be reassessed every shift or 12 hours.

Record review of the facility's policy titled, "Fall: Scoring, Precautions and Occurrence Reporting," dated 01/31/08, showed the following direction:
- If patient is a fall risk, instruct patients not to get out of bed without assistance.
- Inpatient fall assessment:
Initiate care plan.

2. Observation on 01/09/12 at 3:50 PM showed Patient #1's room with a sign posted showing the patient to be high risk for falls.

During an interview on 01/09/12 at 3:50 PM, Patient #1 and a family member stated that he had not seen the sign and had not been told he was high risk for falls. Patient #1 stated that no one had instructed him as to the precautions needed when high risk for falls, such as asking for help when getting out of bed. Patient #1 stated that he was admitted that day around 11:30 AM.

Review of Patient #1's medical record on 01/10/12 showed the care plan did not include the patient being high risk for falls. A fall assessment was completed on 01/09/12 at 3:07 PM and the nurse noted, "Remind patient/significant other to call for help to get out of bed." The fall assessment showed Patient #1 to be an extreme high risk for falls.

During an interview on 01/10/12 at 2:10 PM, Staff C, Registered Nurse (RN), Rehabilitation Manager, stated that she would expect Patient #1's care plan to include being high risk for falls.

3. Review of Patient #2's medical record showed the patient had difficulty swallowing and had a swallow study (test to determine if food/liquid is swallowed correctly). The care plan did not include any problem related to the patient having difficulty swallowing.

During an interview on 01/10/12 at 2:55 PM, Staff C stated that she would expect Patient #2's care plan to include the patient's difficulty swallowing.

4. Review of Patient #10's medical record showed the patient had been assessed to be an extreme high risk for falls. The care plan did not include the patient being high risk for falls. In addition, the nurse failed to review the care plan on 01/09/12 night shift (12 hour shifts).

During an interview on 01/10/12 at 2:55 PM, Staff C stated that she would expect Patient #10's care plan to include being high risk for falls. Staff C stated that the nurse is to review the care plan every shift (12 hour shifts).

5. Observation on 01/10/12 at 9:25 AM showed Patient #14 was in reverse isolation. During an interview upon the observation, the patient stated that he/she did not know why he/she was in reverse isolation (a method to protect a patient from infectious organisms that might be carried by the staff, other patients, or visitors).

Record review on 01/10/12 at 10:30 AM of the patient's medical record showed the patient was in reverse isolation due to low white blood count. Staff failed to include low white blood count and reverse isolation and interventions in the plan of care.

Record review of the patient's medical record showed he/she was diabetic and the physician ordered a diabetic diet, glucose (blood sugar) testing before meals and at bedtime, and insulin administration. Staff failed to include diabetes in the plan of care.

During an interview on 01/10/12 at 10:45 AM Staff C, RN Rehabilitation Manager stated that staff failed to include a plan of care for diabetes and reverse isolation. Staff C stated that staff should have included these issues in care plans.

6. Record review on 01/10/12 at 11:00 AM of Patient #9's medical record showed the patient refused multiple medications on multiple days, was on a pureed diet, had poor oral intake and staff were adding protein powder to the patient's juice, additionally the patient had a fall after admission. Staff failed to include a plan of care for these problems and failed to implement interventions in the plan of care to address the problems.

During an interview on 01/10/12 at 11:30 AM Staff C, RN Rehabilitation Manager stated that she would have expected these problems to be addressed in the care plan.

7. Observation on 01/10/12 at 10:00 AM showed Patient #4 with a tegaderm (clear) dressing on his/her coccyx (tailbone area).

Review of Patient #4's medical record showed nursing notes dated 01/08/12 that stated the patient had a small open area on the coccyx, a wound care consult dated 01/09/12 at 1:40 PM for an open area on the patient's coccyx, nursing notes dated 01/09/12 at 9:00 PM and 01/10/12 at 1:15 PM that stated the patient had an open area on the coccyx and the dressing on the patient's coccyx was intact. Staff failed to include skin breakdown in the patient's treatment plan/care plan.

During an interview on 01/11/12 at 2:30 PM, Staff P, Director of Nursing, Behavioral Health Unit, stated that the treatment plan should have included the patient's skin breakdown.

8. Record review of Patient #45's History and Physical (H&P) dated 01/01/12 showed the patient had a history of Parkinson's disease with dementia, psychosis and agitation, and had traumatic blindness. Review of a procedure report dated 01/07/12 showed the patient underwent insertion of a feeding tube (a flexible tube inserted into the stomach used to provide all nutrition, fluids and medications to the patient) on 01/07/12. Staff failed to include a plan of care for these problems and failed to implement interventions in the plan of care to address these problems.

During an interview on 01/18/12 at 10:00 AM, Staff C, RN, Rehabilitation Unit Manager, stated that she would expect the plan of care to include these problems.

9. Record review of Patient #35's H&P dated 12/25/11 showed the patient was admitted to the facility's inpatient rehabilitation unit on 12/24/11 for therapy and stabilization following recent back surgery and a stroke. Review of the record showed the patient had right-sided weakness, an indwelling urinary catheter for incontinence, speech difficulty (stereotypical, responds "doing good" and "doing well" every time asked) and jerking movements and poor coordination secondary to the stroke. Review of the patient's computerized general nursing care plans showed the patient was a high risk for fall/injury, stroke and weakness but did not show specific interventions and updates regarding the right sided weakness, urinary catheter being discontinued, speech difficulty and/or jerking movements.

10. Record review of Patient #36's H&P dated 01/03/12 showed the patient was admitted to the facility's inpatient rehabilitation unit on 01/02/12 for gait balance training following right hip fracture surgery. Review of the record showed the patient was very hard of hearing, his diet was advanced to regular with thin liquids per swallow study, required right hip surgical incision care and was taking Lovenox (blood thinning medication to prevent blood clots). Review of the patient's computerized general nursing care plans showed the patient was a risk for fall/injury, fracture and weakness but did not show specific interventions and updates regarding the patient being hard of hearing, diet, surgical incision care and risk of bruising from blood thinning medication.

11. Record review of Patient #46's H&P dated 12/07/11 showed the patient was admitted to the facility's inpatient rehabilitation unit on 12/08/11 for gait balance training following left total hip replacement surgery. The patient's history included a left foot and right below the knee amputation. The patient had left sided pain and weakness, continued on Lovenox and ambulated with a walker and stand-by assistance. The patient was discharged to home with home health on 12/15/11. Review of the patient's computerized general nursing care plans showed the patient was a high risk for fall/injury, post-op surgical hip replacement and weakness but did not show specific interventions and updates regarding the patient's left foot and right leg amputations and/or taking blood thinning medication with risk of bruising, and did not show whether goals were met prior to discharge.

12. Record review of Patient #47's H&P dated 12/17/11 showed the patient was admitted to the facility's inpatient rehabilitation unit on 12/18/11 following a motor vehicle accident for intensive physical and occupational therapy. The patient suffered multiple fractures, had severe pain, poor appetite and nausea, surgical dressings changes every 48 hours, was non-weight bearing in the right lower extremity and continued on Lovenox to help prevent blood clots following surgery. The patient was discharged to home with home health on 12/23/11. Review of the patient's nursing care plans showed the computerized general care plans were initiated for impaired skin integrity, pain, self-care deficit and fracture comfort but did not show specific interventions and updates regarding the pain, non-weight bearing in right lower extremity, decreased appetite and nausea and/or taking blood thinning medication with risk of bruising, and did not show whether goals were met prior to discharge.

13. Record review of Patient #48's H&P dated 12/17/11 showed the patient was admitted to the facility's inpatient rehabilitation unit on 12/18/11 following a motor vehicle accident. The patient suffered multiple fractures and contusions with multiple surgeries. The patient had decreased range of motion and back pain, was in an immobilizer (a device to help limit movement), had breathing difficulties due to fluid in right lung, continued on Lovenox to help prevent blood clots following surgery and was standby to independent with bed mobility and transfers. The patient was discharged to home on 12/22/11 and refused home health. Review of the patient's nursing care plans showed the computerized general care plans were initiated for impaired skin integrity, pain, self-care deficit and fracture comfort but did not show specific interventions and updates regarding the immobilizer, decreased range of motion, back pain, breathing difficulty and/or taking blood thinning medication with risk of bruising, and did not show whether goals were met prior to discharge.

14. Record review of Patient #49's H&P dated 12/13/11 showed the patient was admitted to the facility's inpatient rehabilitation unit on 12/14/11 following a seizure and stroke with right sided weakness. The patient was evaluated and placed on a regimen of exercise and therapy for strengthening. The patient had a history of retinal detachment and was blind in the left eye, suffered migraine headaches and depression. The patient's bed rails were padded for safety due to seizures. The patient was discharged to home on 12/30/11. Review of the patient's nursing care plans showed the computerized general care plans were initiated for stroke, seizures and fall/injury risk but did not show specific interventions and updates regarding the right sided weakness, left eye blindness, headaches and/or specific seizure precautions to include padded side rails, and did not show whether goals were met prior to discharge.

During an interview on 01/16/12 at 9:50 AM, Staff C, Rehabilitation Manager, confirmed the nursing care plans for the sampled patients were not individualized and/or updated as required and were not acceptable. Staff C stated that until recently, the care plans were handwritten but the new computerized care plans were not individualized and did not allow updates with interventions. She stated that the nursing care plan policy for the inpatient rehabilitation unit was the same policy that was used hospital-wide and nurses were required to initiate specific care plans, individualize with interventions and to address whether the patients met goals prior to discharge.

During an interview on 01/17/12 at 10:45 AM, Staff A, Director of Nursing, stated that the care plan policy needed revised to be clearer and should state that the nurse needs to have at least three problems identified, not be limited to just three problems identified. Staff A stated that she would expect to see high risk for falls included in the care plan.



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18075

Based on interview, record and policy review, the facility failed to ensure verbal and telephone orders were used infrequently and were not a common practice for two of two medical patient's (#9 and #14) and five of five inpatient rehabilitation patient's (#36, #46. #47, #48 and #49) records reviewed. The facility census was 37.

Findings included:

1. Review of the facility policies and procedures showed there was no policy that addressed frequency of verbal and telephone orders.

2. Record review conducted 01/10/12 at 10:30 AM showed the following:
-Patient #9's medical record showed 14 of 35 orders were telephone or verbal orders.
-Patient #14's medical record showed seven of 12 orders were telephone or verbal orders.

Record review conducted on 01/16/12 from 2:00 PM to 3:45 PM showed the following:
-Patient #36's medical record showed nine of 16 orders were telephone or verbal orders.
-Patient #46's medical record showed six of 10 orders were telephone or verbal orders.
-Patient #47's medical record showed nine of 17 orders were telephone or verbal orders.
-Patient #48's medical record showed three of six orders were telephone or verbal orders.
-Patient #49's medical record showed 19 of 24 orders were telephone or verbal orders.

During an interview on 01/18/12 at 12:45 PM, Staff A, Registered Nurse, Director of Nursing stated that:
-The facility did not have a policy for verbal orders to be used infrequently.



18075

Based on observation, interview, and policy review, the facility failed to demonstrate compliance with the requirements under 42 CFR Part 482.24, Condition of Participation: Medical Records Services due to the following:
- Failure to store medical records in a secure location that would protect them from fire, water damage or other threats;
- Failure to prevent unauthorized staff access to confidential patient medical records.

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the safety and confidentiality of all patient's medical records from 2002 through 2012. The facility admissions from the fiscal year beginning 10/1/10 and ending 09/30/11 was 2,155 patients.

Based on observation, interview and policy review, the facility failed to store medical records in a secure location that would protect them from fire, water damage or other threats. This has the potential to affect medical records located in a storage shed from years 2002 through 2012. The facility census was 37.

Findings included:

1. Record review of the facility's undated policy titled, "Storage of Medical Records", provided by Staff MM, Medical Records Director on 01/26/12, showed the following direction:
- Medical records are taken for storage for two reasons;
- Current medical records are taken to off-site storage when additional space is needed;
- Death records are stored in off-site storage after all records have been completed;
- When transporting medical records to off-site storage, they are transported by the Maintenance Department, accompanied by a Medical Record Clerk;
- Access of these records is by key, which is kept by the Maintenance Staff, a Medical Record Clerk, and a Nursing Supervisor.

2. Observation on 01/17/12 at 2:00 PM showed a large metal building with a metal garage door and one entrance door with wooden shelves from floor to ceiling which contained medical records. Other items stored in the shed included one truck, two lawn tractors, containers of paint, bags of salt used to melt ice and snow, aerosols used for cleaning, and two five gallon gas containers.

During an interview on 01/17/12 at 2:30 PM, Staff MM, Medical Records Director, stated that the shed contains closed patient records (patient record which had been completed by all providers, i.e., dictations complete, signatures complete), death records (a closed record of a deceased patient), and active records (patient records that are still alive and may be re-admitted to the facility, not yet completed by all providers). Staff MM stated that these records were from the years 2002 through 2012. She stated that staff had nowhere else available to store the medical records.

During an interview on 01/18/12 at 9:00 AM, Staff H, Maintenance Director, confirmed that the shed is used by maintenance staff, and confirmed the contents of the shed. Staff H stated that there are no alarm systems to alert if someone broke into the shed, no smoke alarms, no smoke detection system tied into the facility's fire alarm system, and no sprinkler system in the shed.

During an interview on 01/18/12 at 3:30 PM, Staff FFF, Chief Fiancial Officer, stated the facility admissions from the fiscal year beginning 10/1/10 and ending 09/30/11 was 2,155 patients.

Based on observation, interview, and policy review, the facility failed to prevent unauthorized staff access to confidential patient medical records. This has the potential to affect confidentiality of all medical records stored in a storage shed from years 2002 through 2012. The facility census was 37.

Findings included:

1. Record review of the facility's undated policy titled, "Security of Medical Records", provided by Staff MM, Medical Records Director on 01/26/12 showed the following direction:
- When medical records are stored off-site, they are taken by Maintenance accompanied by Medical Record personnel;
- No other individual or employee will have access to records in the Medical Record Department or in storage at off-site storage;
- The storage facility will be locked by Maintenance;
- Keys are kept by Maintenance, Medical Records, and nursing House Supervisors.

2. Observation on 01/17/12 at 2:00 PM showed a large metal building with a metal garage door and one other entrance door. The shed contained wooden shelves from floor to ceiling which contained medical records.

During an interview on 01/17/12 at 2:30 PM, Staff MM, Medical Records Director, stated that the shed contains closed patient records (patient records which had been completed by all providers, i.e., dictations complete, signatures complete), death records (a closed record of a deceased patient), and active records (patient records that are still alive and may be re-admitted to the facility, not yet completed by all providers). Staff MM stated that these records were from the years 2002 through 2012. She stated that staff had nowhere else available to store the medical records.

During an interview on 01/18/12 at 9:00 AM, Staff H, Maintenance Director, stated that the two maintenance staff and Medical Record Staff have access to the shed. The doors are kept locked when no one is in the building accessing medical records, or when maintenance staff are not working in the shed. The garage door would be open when supplies or equipment needed to be removed from the shed.

During an interview on 01/17/12 at 3:30 PM, Staff FFF, Chief Financial Officer, stated:
- The level of access to computerized medical records is based on the employee job description. Maintenance staff would not require access to patient medical records, unless required to move medical records for the Medical Records Department;
- The facility admissions from the fiscal year beginning 10/1/10 and ending 09/30/11 was 2,155 patients.

Based on interview, record review and review of Medical Staff Rules and Regulations, the facility failed to ensure medical record entries had dated and timed signatures for three (Patients #39, #40 and #41) of six current patient medical records reviewed for complete medical records entries. The facility census was 37.

Findings included:

1. Review of the Medical Staff Rules and Regulations, approved 11/14/05 showed they did not contain specific direction for physician's to date and time medical record entries.

Record review on 01/17/12 at 9:50 AM of Patient #41's medical record showed the physician failed to time the History and Physical (H&P) dated 01/11/12 and failed to time the post operative note dated 01/11/12.

During an interview upon the record review, Staff Y, Registered Nurse (RN) Director of Surgery confirmed the physician failed to document a time on the H&P and the post operative note.

2. Record review on 01/17/12 at 10:05 AM of Patient #40's medical record showed the physician failed to time the progress note dated 01/10/12.

During an interview upon the record review, Staff Y, RN Director of Surgery confirmed the physician failed to document a time on the progress note.

3. Record review on 01/17/12 at 10:20 AM of Patient #39's medical record showed the physician failed to date and time the H&P.

During an interview upon the record review, Staff Y, RN Director of Surgery confirmed the physician failed to date and time the H&P.

During an interview on 01/18/12 at 1:10 PM Staff MM Medical Records Director stated that the facility did not have a specific policy for physician's to sign and date H&P's and Progress Notes.

Based on interview, record review and review of the Medical Staff Rules and Regulations, the facility failed to ensure physician's orders were dated, timed and/or signed for nine (#2, #10, #14, #36, #40, #42, #47, #48 and #49) of nine patient medical records reviewed for complete physician's orders. The facility census was 37.

Findings included:

1. Review of the Medical Staff Rules and Regulations, approved 11/16/11, Amendment to Pages 5 & 6, #12 showed:
- All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a licensed practical nurse or registered nurse, certified respiratory therapist, registered pharmacist within their scope of practice and signed by the attending physician. At the next visit or within 24 hours, whichever comes first, the attending physician shall sign such orders. The Rules and Regulations did not give specific direction for dating and timing physician orders.

2. Record review on 01/10/12 at 10:30 AM of Patient #14's medical record showed:
-An unsigned order dated 01/06/12 for sliding scale insulin and blood glucose testing before meals and at bedtime;
-An unsigned order clarification dated 01/06/12 and;
-An unsigned verbal order dated 01/08/12.

During an interview upon the record review Staff C, Registered Nurse (RN) Rehabilitation Manager confirmed the orders were not signed and stated that the physician should have signed the orders.

Record review on 01/17/12 at 10:05 AM of Patient #40's medical record showed an unsigned order dated 01/13/12 and an untimed order dated 01/13/12. During an interview upon the record review, Staff Y, RN, Director of Surgery, confirmed the physician failed to sign the order.

Record review of Patient #42's medical record on 01/17/12 at 9:30 AM showed an unsigned order dated 01/05/12. During an interview upon the record review, Staff Y, RN, Director of Surgery, confirmed the physician failed to sign the order.

Review of Patient #2's medical record on 01/10/12 showed physician orders. The physician failed to date and time the order entry to show when it was written. In addition, they physician wrote orders on 01/04/12 but failed to document what time the orders were written.

During an interview on 01/10/12 at 9:20 AM, Staff C, RN, Rehabilitation Manager, stated that the physician failed to complete the orders as required.

Review of Patient #10's medical record on 01/10/12 showed physician orders written on 01/07/12. The physician failed to document what time the orders were written.

During an interview on 01/17/12 at 10:45 AM, Staff A, Director of Nursing, stated that physicians were expected to date and time each medical record entry.

Record review on 01/16/12 from 3:00 PM to 4:20 PM showed Patient #36 was admitted to the facility's inpatient rehabilitation unit on 01/02/12 for gait balance training following right hip fracture surgery. Record review of the patient's physician's orders showed the following:
- Four page admission standing order set dated 01/02/12 and timed at 5:00 PM by the nurse but showed no date or time of the physician's signature;
- One page verbal orders of multiple medications dated 01/02/12 and timed at 5:00 PM by the nurse but showed no date or time of the physician's signature; and
-Six occasions of various verbal orders dated and timed from 01/03/12 at 8:50 AM to 01/11/12 at 2:30 PM by the nurse but showed no date or time of the physician's signature.

Record review on 01/16/12 from 3:00 PM to 4:20 PM showed Patient #47's was admitted to the facility's inpatient rehabilitation unit on 12/11/11 following a motor vehicle accident for intensive physical and occupational therapy. Record review of the patient's physician's orders showed the following:
- Four page admission standing order set dated 12/11/11 and timed at 1:37 PM by the nurse but showed no date or time of the physician's signature;
- One page verbal orders of multiple medications dated 12/11/11 with no time by the nurse and showed no date or time of the physician's signature; and
-Nine occasions of various verbal orders dated and timed from 12/12/11 at 12:15 PM to 12/25/11 at 8:50 AM by the nurse but showed no date or time of the physician's signature.

Record review on 01/16/12 from 3:00 PM to 4:20 PM showed Patient #48's was admitted to the facility's inpatient rehabilitation unit on 12/18/11 following a motor vehicle accident. The patient suffered multiple fractures and contusions with multiple surgeries.
- Four page admission standing order set dated 12/18/11 with no time by the nurse and showed no date or time of the physician's signature.

Record review on 01/16/12 from 3:00 PM to 4:20 PM showed Patient #49's was admitted to the facility's inpatient rehabilitation unit on 12/14/11 following a seizure and stroke with right sided weakness. The patient was evaluated and placed on a regimen of exercise and therapy for strengthening.
- Four page admission standing order set dated 12/14/11 and timed at 2:40 PM by the nurse but showed no date or time of the physician's signature;
- One page verbal orders of multiple medications dated 12/14/11 and timed at 2:40 PM by the nurse but showed no date or time of the physician's signature; and
-Six occasions of various verbal orders dated and timed from 12/15/11 at 6:12 PM to 12/29/11 at 8:10 AM by the nurse but showed no date or time of the physician's signature.

During an interview on 01/16/11 at approximately 1:45 PM, Staff VV, RN, confirmed the physician's orders noted above were not dated or timed and therefore, could not show the timeliness of the physician's signature.









18075





27724

Based on interview, record review, policy review, and review of Medical Staff Bylaws and Rules and Regulations, the facility failed to ensure physicians' verbal and/or telephone orders were authenticated (signed, dated and timed) by the physician within 24 hours for current patients (#2, #10) and discharged patients (#44, #43) of eight records reviewed for physician orders. The facility census was 37.

Findings included:

1. Record review of the facility's Bylaws and Rules and Regulations dated 11/16/11, showed the following direction:
- All orders for treatment shall be in writing;
- An order shall be considered to be in writing if dictated to a licensed practical or register nurse, certified respiratory therapist, registered pharmacist within their scope of practice and signed by the attending physician;
- Orders dictated over the telephone shall be documented and signed by the person placing the order with the name of the physician;
- At the next visit, or within 24 hours, (48 hours in the case of geriatric psychiatric patients in the Behavioral Health Unit) whichever comes first, the attending physician shall sign such orders.

Record review of the facility's policy titled "Taking Verbal and Telephone Orders RNs/LPNs", revised 07/10, showed the following direction:
- The physician giving a telephone or verbal order will be responsible for signing the order within 24 hours of giving the order. When the physician signs the order, he or she will also write the time and date of signing.

2. Review of current Patient #2's medical record on 01/10/12 showed:
- Telephone order dated 01/04/12 at 12:40 AM for intravenous fluid (fluid administered through a vein) and lab tests. The physician signed the telephone order but failed to date and time his/her signature to show when it was signed.
- Verbal order dated 01/04/12 at 2:00 AM for insulin (lowers and helps control blood sugar levels) coverage, parameters for notifying the physician, diet and blood sugar test frequency. The physician failed to authenticate the order.
- Verbal order dated 01/04/12 at 8:40 AM for medication. The physician failed to authenticate the order.

During an interview on 01/10/12 at 9:35 AM, Staff C, Registered Nurse (RN), Rehabilitation Manager, stated that the verbal orders on Patient #2 had not been signed. Staff C stated that the physician has 24 hours to sign telephone orders.

3. Review of current Patient #10's medical record on 01/10/12 showed:
-Verbal order dated 01/04/12 at 3:20 PM for a special diet. The physician failed to authenticate the order.
- Telephone order dated 01/07/12 at 4:05 PM for lab tests. The physician signed the telephone order but failed to date and time his/her signature to show when it was signed.
- Telephone order dated 01/08/12 at 11:50 AM to remove an indwelling urinary catheter. The physician signed the telephone order but failed to date and time his/her signature to show when it was signed.

4. Review of discharged Patient #44's medical record on 01/18/12 showed a telephone order dated 01/03/12 at 7:00 PM for bilateral wrist restraints. The physician failed to authenticate the order.

5. Review of discharged Patient #43's medical record on 01/17/12 showed a telephone order dated 12/30/11 at 4:20 PM for medication. The physician failed to authenticate the order.




27724

Based on observation, interview and policy review, the facility failed to ensure expired medications were not available for patient use; failed to label opened multi-dose medications/vials with the date opened and the initials of the staff member that opened the medication, failed to dispose of open single use medications and the facility policy failed to reflect current standards for open, multi-use medications to be disposed of after 28 days. The facility census was 37.

Findings included:

1. Review of the Centers for Disease Control (CDC) and Prevention recommendations for multi-dose vials, dated 02/09/11 showed:
- Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
- If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
- If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date.
The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date.

Review of the Joint Commission Online, dated 06/09/2011 showed, Joint Commission Online published a clarification on multi-dose vials, reinforcing the 28-day rule.
MM.03.01.01, element of performance 7, requires facilities to store all medications labeled with an expiration date, which is defined as the last date the product can be used. Therefore, facilities need to re-label the expiration date once the vial is punctured in order to reflect the 28-day rule.

Review of the facility's Anesthesia Department policy titled, "Infection Control", updated 04/27/11 showed multi-mode (dose) vials should be dated when opened and discarded after 30 days. Staff failed to update the policy to reflect current standards.

Review of the facility's policy titled, "Multi Dose Medication Vials in Clinical Areas" dated 01/07/08 showed:
-Place the open date on the vial upon opening (date, time and initial). The expiration date should be 30 days after the vial is opened or the manufacturer's recommended expiration date (whichever comes first). Staff failed to update the policy to reflect current standards.

Record review of the facility's policy titled "Single Use and Multi-Use Vials of Medications, Single Use Ampules", dated reviewed 12/12/11 showed directions included:
- If labeled "Single Use", be sure to discard any medication left in the vial after appropriate dosage has been withdrawn.
- Multi-dose vials must be dated when opened and then discarded in one month.
- All ampules are single-use, and the remaining solution should be discarded after the appropriate dosage had been withdrawn.

Review of the facility's Post Anesthesia Care Unit (PACU) policy titled, "Use of Multi-Dose Vials", dated 05/02/06 showed the expiration date for multi-dose vials will be the manufacturer's recommended date on the vial, providing there is no obvious contamination. Staff failed to update the policy to reflect current standards.

2. Observation on 01/09/12 at 2:25 PM of the medical/surgical crash cart showed:
-Four-expired 10 (ml) milliliter multi-dose vials of 0.9% sodium chloride (normal saline), expiration 01, Nov 2010, lot 71-158DK.

Observation on 01/09/12 at 3:00 PM of the Intensive Care Unit crash cart #1 showed:
-One expired 50ml 50% vial of Dextrose (used to restore blood glucose levels) with an expiration date of 12/01/11.

Observation on 01/09/12 at 3:30 PM of the medical/surgical medication room showed an open 50 milliliter multi-dose vial of Lidocaine 1% (numbing medication). Staff failed to document the date opened and failed to initial the vial with the staff member's initials. Failure to document the date opened gives no way to determine if the medication is beyond the 28 day expiration. During an interview upon the observation Staff C Registered Nurse (RN) Director of Surgery stated that facility policy is for staff to initial, date and time when staff opened/punctured a multi-dose vial of medication.

Observation on 01/10/12 at 2:30 PM of the surgical department medication refrigerator showed four reconstituted vials of Bacitracin (anti-bacterial medication) dated 01/09/12. Staff failed to document their initials on the vials of medications. During an interview upon the observation, Staff C RN Director of Surgery stated that staff should document the date, the time and their initials on the medication vials.

Observation on 01/12/12 at 8:30 AM of the Anesthesia supply cart in Operating Room (OR) #1 showed:
-An open, dated, multi-dose vial of Lidocaine 2% (numbing medication);
-An open, dated, multi-dose vial of Neostigmine (medication used to reverse the effect of anesthesia) and;
-An open, dated, multi-dose vial of Zantac (medication given to minimize nausea after anesthesia) 25 mg.
Staff dated the vials but failed to document their initials on the vials to show who opened/punctured the vials.

Observation on 01/12/12 at 8:35 AM of the anesthesia lock box (locked box containing medications) in OR #1 showed:
-An opened, dated and initialed, single dose vial of Duradon, 10 ml (medication used for epidural injection). Staff dated the vial as opened 01/10/12.
-An opened, dated and initialed, single dose vial of Xylocaine (numbing medication).
Staff dated the vial as opened 01/10/12. Staff failed to dispose of the single dose vials after single patient use.

3. During an interview on 01/17/12 at 2:45 PM, Staff HH, Assistant Pharmacist stated that the multi-dose vials were good for 30 days, staff should date and time multi-dose vials when punctured and he expected staff to dispose of single use vials after use.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN, Infection Control Nurse stated that:
- The facility followed CDC and APIC (Association for Professionals in Infection Control) guidelines.
-She did not look at medications, pharmacy staff were responsible and;
-She was not aware open multi-dose medications needed to be discarded after 28 days.

4. Record review of the facility's policy titled, "Outdates," dated 11/29/01, showed the following direction:
- All departments and areas within the hospital that contain medications will be reviewed on a sixty day basis to verify that all such medications are "in date".
- Each area, crash cart, and department will be reviewed during each sixty day period. Those medications that will become outdated within the next sixty days will be replaced with medications that carry a proper expiration date. This process may be undertaken by any person in the pharmacy department.
- Nursing staff are requested to help police their areas as possible. They are requested to notify pharmacy when any areas have been checked for outdates.

5. Observation on 01/11/12 at 10:15 AM of the Mammography (breast imaging) room in radiology showed:
- Omnipaque (contrast agent), 50 ml vial, expired 11/05/10;
- Methylene Blue (used as a dye in diagnostic studies) 1%, 1 ml vial, expired 06/00;
- An open 5 ml vial of Xylocaine MPF (used to numb tissue) 1%. Staff failed to date and initial the bottle when opened.

Observation on 01/11/12 at 10:35 AM of the Ultrasound (diagnostic test) room in radiology showed:
- An open 5 ml vial of Xylocaine 1%. Staff failed to date and initial the bottle when opened.

Observation on 01/11/12 at 10:35 AM of the Pain Clinic Cart (mobile cart used to store medication and supplies used in the treatment of pain) showed:
- Betamethasone Sodium Phosphate & Betamethasone Acetate (anti-inflammatory), 5 ml vial, expired 08/11.

6. During an interview on 01/11/12 at 11:50 AM, Staff BBB, Director of Pharmacy, stated that all drugs were under lock and key - no exceptions and that medications should not be in radiology. Staff BBB stated that he was not aware that medications were stored outside of emergency boxes. He stated that he had no idea why the Methylene Blue would be in the Mammography room. Staff BBB stated that vials were not allowed to be opened without dating when opened.

During an interview on 01/11/12 at 12:00 PM, Staff BBB, Director of Pharmacy, stated that pharmacy staff is responsible for any expired medications in the crash/emergency carts.























14331




27724

Based on interview and policy review, the Nuclear Medicine department failed to ensure there were policies in place regarding safe transportation of hazardous (radioactive) materials within the hospital and access to the hot lab (area for storage, preparation, and dispensing of hazardous materials used in nuclear medicine's diagnostic tests). The facility census was 37.

Findings included:

1. Record review of the radiology/nuclear medicine department's policies showed no policy on the safe transportation of hazardous material within the hospital. There was no policy on who had access to the hot lab.

2. During an interview on 01/11/12 at 8:00 AM, Staff T, Manager of Diagnostic Imaging, stated that they did not have a policy on transporting hazardous material within the hospital but that they do carry radioactive material to the patient's bedside. Staff T stated that they did not have a policy on access to the hot lab but that it was only himself and one technician.

Based on observation, interview, and policy review, the facility failed to ensure supplies beyond manufacturers expiration date were removed from patient care areas in the obstetrical (OB) unit, nursery, radiology department, Medical Unit, Intensive Care Unit, Surgery Department and the Post Anesthesia Care Unit (PACU). The facility census was 37.

Findings included:

1. Record review of the facility's policy titled, "Crash Carts, (mobile cart with a set of trays/drawers/shelves with emergency medication/equipment which is used to potentially save someone's life) dated 03/18/09, showed the following direction:
- An exchange system will be used to immediately replace the used Cart.

The policy did not address who was responsible for checking the crash cart for outdated supplies and how the inventory would be checked.

Review of the facility's policy titled, "Crash Carts", Department of Nursing, dated 12/11/01 showed the following direction:
-Crash carts will be checked by nursing personnel on a regular basis.
-Crash carts will be kept in the Emergency Room, Intensive Care Unit, South Nurses Station, Cardiac Rehab, Behavioral Health Unit and the Treadmill Room. An extra cart will be stored in the ICU for use on an exchange basis.
-At the time routine checks of the Crash Carts are made, any deficiencies will be reported to the appropriate department immediately.
-Nursing will be responsible to replace supplies from drawer #2 with the exception of IV supplies and medications after a code blue (an emergency situation indicating a patient requires immediate resuscitation).
-Respiratory Therapy will be responsible for restocking and locking Drawer #3 after a code blue.
-Pharmacy will restock supplies in Drawer #1, including, the butterfly needles (a short, small diameter needle attached to a thin, flexible tube used to obtain a blood sample) angiocaths (a tubular, flexible surgical instrument that is inserted into a cavity of the body to withdraw or introduce fluid) subclavian catheter (a small, flexible plastic tube inserted into the large vein above the heart, usually the subclavian vein, through which access to the blood stream can be made. This allows drugs and blood products to be given and blood samples withdrawn) and IV tubing.

Record review of the facility's policy titled, "Code Carts," dated 10/01/05, provided by Staff UU, Registered Nurse (RN) on the OB unit on 01/09/12 showed no direction as to who was responsible for checking the crash cart for outdated supplies or how the inventory would be checked.

2. Observation on 01/09/12 at 2:20 PM showed one crash cart in the nursery with the following expired crash cart supplies:

Drawer 1:
- Endotracheal tube (tube inserted into the airway for delivering breaths), 4.0 millimeters (mm), two of two required by policy, expired 08/09;
- Endotracheal tube, 2.5 mm, two of two required by policy, expired 06/10;
- Suction catheter, one of two required by policy, expired 05/09;
- Suction catheter, one of two required by policy, expired 09/11.
Drawer 2:
- Connecting tubing (used for connecting oxygen source), count of one, expired 06/11.
Drawer 3:
- Lubricant 0.1 milliliters (ml), count of one, expired 07/07;
- Normal Saline pellets, numerous, expired 10/11.
Drawer 4:
- Sterile gauze, count of five packs, expired 10/10;
- Tuberculin (TB) (small size) syringe, count of one, expired 05/10;
- Syringe, 1 ml, count of one, expired 10/10.
Drawer 5:
- Silk Suture (needle and thread-like material used for sewing tissue), 2-0 (size), count of one, expired 07/08;
- Silk Suture, 2-0, count of one, expired 01/09;
- Silk Suture, 2-0, count of one, expired 07/09;
- Silk Suture, 2-0, count of one, expired 01/10;
- Silk Suture, 2-0, count of one, expired 01/11;
- Chromic Suture (needle and thread-like material used for sewing tissue), 3-0 (size), count of two, expired 01/10;
- Chromic Suture, 3-0, count of one, expired 07/10;
- Umbilical tape (used to tie off the cord that attaches the mother to the newborn), count of one, expired 07/09;
- Umbilical tape, count of one, expired 07/11;
- Povidone Iodine (antiseptic) swab, count of three, expired 10/06.

During an interview on 01/09/12 at 2:25 PM, Staff VV, Registered Nurse (RN) stated that the crash cart in the nursery was taken to all deliveries (births).

3. Observation on 01/09/12 at approximately 3:00 PM showed one crash cart on the OB unit with the following expired crash cart supplies:
Drawer 4:
- IV (intravenous - small catheter inserted into the vein for administering medications and fluid) catheter, 18 gauge (size), count of 14, expired 06/08;
- IV catheter, 20 gauge, count of two, expired 04/11;
- IV catheter, 22 gauge, count of two, expired 03/11.
Drawer 5:
- Connecting tubing, count of three, expired 06/10;
- Connecting tubing, count of two, expired 07/10.

Observation on 01/09/12 at approximately 3:05 PM showed an emergency respiratory kit on top of the OB crash cart with the following expired supply:
- Lubricating jelly 0.1 oz (ounce) expired 07/07.

During an interview on 01/09/12 at approximately 3:05 PM, Staff VV stated that pharmacy checked the medications on the crash cart, respiratory checked the respiratory supplies but she did not know who checked the other supplies.

Observation on 01/09/12 from 2:00 PM to 3:25 PM in the OB unit and nursery showed the following expired supplies:
- IV catheter, 22 gauge, expired 10/10;
- Peroxide (antiseptic), one partially filled bottle, not dated when opened;
- Suction catheter, count of 12, expired 09/11;
- Normal saline (sterile salt water) pellet (small amount used for instilling in the airway), expired 01/07;
- Normal saline pellet, expired 09/11;
- Epi-clens hand cleaner, one bottle, expired 01/07;
- Glucose water (for newborn consumption), count of two, expired 05/01/11;
- Premature nipple, expired 04/01/10.

During an interview on 01/09/12 from 2:00 PM to 3:25 PM, Staff VV stated the above items were expired and should be thrown away. Staff VV stated that many of these supplies were for use on newborns.

4. Observation on 01/11/12 from 9:30 AM to 10:55 AM throughout the radiology department showed the following expired supplies:
- Sialography set (used for x-raying the salivary glands - glands found in and around the mouth), expired 05/06;
- Iodophor PVP (antimicrobial), expired 10/06;
- Saf T needles (for starting IV), box of 50, expired 12/06;
- IV administration sets, count of five, expired 12/10;
- Hibiclens, 4 oz bottle, expired 02/11;
- Hibiclens (antimicrobial skin cleanser) 4 oz bottle, almost empty, expired 05/11;
- Hand sanitizer, 4 oz bottle, expired 08/05;
- Alcare Plus hand foam, count of one can, expired 01/11;
- Alcare Plus hand foam, count of one can, expired 02/11;
- IV catheter, 22 gauge, count of three, expired 12/11;
- Povidone iodine swabsticks, expired 07/10;
- Red top lab tube (for blood collection for lab tests), expired 01/11;
- IV catheter, 20 gauge, expired 07/10;
- Pack of sterile gauze, opened (no longer sterile).

During interviews on 01/11/12 from 9:30 AM to 10:55 AM, Staff T, Manager of Diagnostic Imaging, Staff V, Radiology Technician, Staff W, Radiology Technician, and Staff X, Radiology Technician stated that the above items were expired.

5. Observation of the medical nursing unit medication room on 01/09/12 at 3:10 PM showed:
-Expired surgical gloves, lot 0307201221, expiration 07/2008;
-An expired IV administration set, lot 060705864, expiration 08/2009;
-Expired sutures, lot XAM649, expiration 01/2011;
-Four expired microorganism collection and transport sets (used to collect and transport microorganism samples); various lot numbers with expiration dates ranging from 12/2010 through 07/2011;
-Multiple expired IV catheter needles various lot numbers with expiration dates ranging from 09/2002 through 03/2008;
-One occult blood testing kit for stool samples, lot 19608L, expiration 07/2009;
-20 expired blue top blood collection tubes, expiration 12/2011 and;
-Four expired purple top blood collection tubes, expiration 10/2010.

Observation on 01/09/12 from 3:30 PM to 3:45 PM, in the medication room on the medical nursing unit, showed the following expired supplies:
- Epi-clenz instant hand antiseptic lot # 28350, expired 07/11;
- Portex pro-vent arterial blood sampling kit with dry lithium Heparin for gases and electrolytes, lot # 1083129, expired 09/2010; and
- a plastic basket approximately 4 inches by 6 inches with odds and ends of unpackaged supplies that were opened and lying in the basket, to include sterile gauze, tape (with red colored fuzz type material on edges), Huber needle set in opened sterile package and blood colleting tubes with a clear liquid residue.

During an interview on 01/09/12 at 3:45 PM, Staff A, Director of Nursing, stated that the items found in the basket were not being used and just needed to be thrown away. Staff A also stated that many of the supplies in the medication room were not being used and needed to be thrown away and the room cleaned.

Observation on 01/09/2012 at 3:35 PM of the medication room for patient rooms 150-165 on the medical nursing unit showed:
-29 expired purple top blood collection tubes, expiration 11/2010;
-One expired red top blood collection tube, expiration 09/2009;
-Six expired blue top blood collection tubes, expiration 04/2006;
-Five expired green top blood collection tubes, expiration 01/2007
-Four expired culture swab sets (a swab and tube used to obtain and transport culture specimens), various lots, with expiration dates ranging from 04/2006 through 10/2010 and;
-Multiple expired IV catheter needles, various lot numbers, with expiration dates ranging from 03/2007 through 08/2010. During an interview upon the observation, Staff C, Registered Nurse stated that staff used the supplies.

Observation on 01/09/12 at 2:25 PM of the medical nursing unit crash cart showed:
-Nine various sized expired intravenous (IV) catheter needles with expiration dates ranging from 09/2007 to 10/2010;
-Two expired safety syringes with expiration dates of 01/2010 and 12/2010 and;
-An expired multi-lumen central venous catheter kit (a catheter inserted into a large vein to administer medications, fluids and/or obtain blood samples), expiration 07/2003, lot RF0088328,

Observation on 01/09/12 at 2:55 PM of the gray respiratory supply box (box containing emergency respiratory supplies) located on top of the medical nursing unit crash cart showed:
-Five expired angio catheter needles (a catheter through which a contrast medium is injected for visualization of the vascular system of an organ), lot 106051, expiration 06/2006;
-Five expired IV catheter needles, lot 3255991, expiration 06/2006;
-One expired arterial blood sampling kit; lot K218397, expiration 08/2006;
-Three expired iodine swabsticks, lot 3J765, expiration 09/06 and;
-Three expired individual packets of lubricating jelly, expiration 03/2005.

Observation on 01/09/12 at 3:00 PM of the red emergency respiratory supply box on top of the medical nursing unit crash cart showed multiple expired packets of lubricating jelly, expiration 12/2009.

6. Observation on 01/09/12 at 3:00 PM in the Intensive Care Unit (ICU) showed #3 crash cart with the following expired crash cart supplies:
- Three 18 gauge intravenous catheters with an expiration date of 09/2002;
- One 20 gauge intravenous catheter with an expiration date of 04/2006;
- One 20 gauge intravenous catheter with an expiration date of 10/2009;
- One 18 gauge intravenous catheter with an expiration date of 04/2009;
- Three 20 gauge intravenous catheters with expiration dates of 01/2010.

Observation on 01/09/12 at 3:15 PM in the ICU showed #1 crash cart with the following expired crash cart supplies:
- One 18 gauge intravenous catheter dated 09/2002;
- One 18 gauge intravenous catheter dated 06/2004;
- Two 22 gauge intravenous catheters dated 10/2010;
- Two 18 gauge intravenous catheters dated 02/2011;
- Two 20 gauge intravenous catheters dated 04/2011.

Observation on 01/09/12 at 4:20 PM of the ICU supply cabinet showed the following expired supplies:
- Temporary pacing electrode Heparin bonded (included syringe, needle cannula and safety adapter) lot # GFSE 1711, expired 08/2010.
-An open endotracheal tube
-Five expired stoma skin barriers (part of the ostomy pouching system. It protects the peristomal skin, holds the ostomy pouch in place, and provides a level pouching surface), lot 6K132, expiration 11/2011;
-Seven expired stoma skin barriers, lot 6H222, expiration 08/2011 and;
-Five expired drainage pouches (attaches to the skin barrier and used to collect stool or drainage), lot 4F282, expiration 06/2009.

During an interview on 01/09/12 at 4:25 PM, Staff F, ICU Charge Nurse, stated that Central Supply was responsible for checking their inventory and replaced used items but was not sure they realized that some of the items had expiration dates.

During an interview on 01/10/12 at 8:30 AM, Staff R, RN, ICU Manager, stated that nursing is responsible for checking for expired supplies in the crash cart, but there is no routine for checking expired items.

During an interview on 01/18/12 at 12:45 PM, Staff A, Director of Nursing stated that the facility did not have a policy for monitoring supplies for expiration.

7. Observation on 01/10/12 at 1:30 PM of Operating Room (OR) #2 showed:
-Three expired purple top blood collection tubes, various lot numbers, expiration dates ranged from 01/2011 through 10/2011;
-20 expired Silver Nitrate applicators (wooden applicator stick tipped with 75% Silver Nitrate/25% Potassium Nitrate, for precise placement) lot 111207, expiration 11/10;
-Three expired Osteonics (orthopedic surgical device) various lot numbers, with expiration dates ranging from 04/2009 through 12/2009.
-Five expired cement bowls (used to mix bone cement), lot AA1464, expiration 10/2010. During an interview upon the observation Staff Y RN Director of Surgery stated that they had not used the cement bowls in the past two years.
-Five expired sterile drapes, expiration, 11/2002. During an interview upon the observation Staff Y Registered Nurse Director of Surgery stated that staff occasionally used the drapes.
-An expired unopened bag of EKG electrode pads, expiration 11/2002.

During an interview upon the observation of expired EKG pads, Staff Y, RN, Director of Surgery stated that the EKG pads went to a crash cart that was not located in the OR.

Observation on 01/12/12 at 8:40 AM of the Operating Room (OR) #1 Anesthesia Cart showed:
-An expired fixed wing needle, lot 62265433, expiration 08/2011;
-An expired spinal needle, lot 4106057, expiration 05/2008;
-One expired IV catheter needle, lot 2539K50, expiration 09/2002;
-One expired IV catheter needle, lot 34H02MU09, expiration 03/2008 and;
-One expired IV catheter needle, lot 0704607, expiration 04/2010.

Observation on 01/12/12 at 8:40 AM of the OR #1 Anesthesia machine drawer showed one expired skin temperature probe (a device used to measure skin surface temperature), expiration 12/2007.

Observation on 01/12/12 at 8:40 AM of the Ear/Nose & Throat (ENT) Cart in OR #1 showed:
-39 assorted ENT burs and blades various lots with expiration dates ranging from 01/2010 through 10/2011. During an interview upon the observation, Staff Y, RN Director of Surgery stated that they had not used the burs and ENT blades in four years.

8. Review of the facility's policy titled, "Emergency Equipment", Post Anesthesia Care Unit (PACU), dated 05/02/06 showed, Post Anesthesia Care Unit (PACU) personnel are responsible for the maintenance and inventory of the emergency crash carts in the PACU.

Review of the facility's policy titled, "Environment of Care", PACU, dated 05/02/06 showed all drugs, equipment and supplies shall be checked and rotated at least every 30 days to ensure they are current and an adequate supply is on hand.

Observation on 01/10/12 at 2:05 PM of the Post Anesthesia Care Unit (PACU) crash cart showed an expired Thoracic catheter, (a tube used to drain fluid from the space between the lungs and chest wall) unreadable lot number, expiration 02/2010.

Observation on 01/10/12 at 2:15 PM of a supply cart in the PACU showed:
-Nine assorted IV catheter needles, various lots, expiration dates ranging from 12/2003 through 06/2011 and;
-CO2 detectors (used to verify endotracheal tube placement), lot 5119004, expiration 02/2008.
During an interview upon the observations Staff UU RN stated that staff used supplies from the supply cart.

Observation on 01/10/12 at 2:30 PM of the Airway Cart (cart with emergency airway supplies) in the Surgery department showed:
-An expired disposable tracheostomy tube (a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe (Trachea)), expiration 12/2011;
-Five expired tongue depressors, various lots, with expiration dates ranging from 11/2004 through 05/2009;
-One, expired emergency airway, lot 204664678, expiration 02/2011;
-Three, expired emergency cricothyrotomy catheter sets (equipment/supplies used for emergency airway access), various lots, with expiration dates ranging from 02/2011 through 03/2011.

During an interview on 01/18/12, at 12:45 PM Staff A, Registered Nurse, Director of Nursing stated that:
-The facility did not have a policy for monitoring supplies.







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18075

Based on interview, record review and facility policy, the facility failed to ensure daily temperature and humidity checks were documented. Temperature and humidity control help provide an electrically safe environment and could impact any patient having surgery. The facility failed to monitor temperature in food, medication storage and breast milk refrigerators in nursing areas. The facility census was 37.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated May 2009, Recommendation V showed:
V.b. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.
V.b.2 Humidity should be monitored and recorded daily using a log format or documentation provided by the heating, ventilation and air conditioning (HVAC) system.
V.c. Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

Review of the facility's policy titled, "Surgical Services Safety" effective 05/02/06, showed the policy did not include directions to document the humidity and temperature readings.

During an interview on 01/10/12 at 2:45 Staff Y, Registered Nurse (RN) Director of Surgery stated that staff do not document the Operating Room (OR) temperature and humidity. Staff Y stated that they have some trouble with the humidity in the summer.

2. Observation on 01/09/12 at 2:20 PM in the Obstetrical (OB) unit showed a large refrigerator that contained a Styrofoam box holding food with a patient's identification label attached to the top.

During an interview on 01/09/12 at 2:20 PM, Staff VV, RN, stated that the refrigerator was used to store breast milk. Staff VV stated they did not monitor the temperature of the refrigerator.

Observation on 01/09/12 at approximately 2:30 PM in the OB unit showed a small refrigerator containing drinks and snacks. The small freezer compartment had a layer of ice approximately three to four inches thick (the thick ice would make it difficult to maintain acceptable temperature levels).

During an interview on 01/09/12 at approximately 2:30 PM, Staff VV stated that the small refrigerator was used to hold drinks and snacks for the patients as well as small amounts of breast milk. Staff VV stated that the small refrigerator held a thermometer but they did not monitor the temperature. Staff VV stated that the refrigerator needed defrosted.

3. Observation on 01/10/12 at 2:25 PM of the medication refrigerator in the Post Anesthesia Care Unit (PACU) showed there was no temperature log available for review. During an interview upon the observation, Staffy Y RN Director of Surgery stated that they did not document refrigerator temperatures.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that:
-She did not monitor food or medication refrigerators.
-The dietary manager monitored food refrigerators.

During an interview on 01/18/12 at 1:25 PM Staff M, Dietary Manager stated that she:
-Only monitored refrigerators in the dietary department;
-Did not monitor medication, food or breast milk refrigerator temperatures or cleanliness in the nursing units and;
-Her policies were specific to the dietary department and nursing staff should have their own policies.




27724

Based on observation, interview and record review, the facility failed to ensure that there was an active program for the prevention and control of infections and communicable diseases as evidenced by:
-Failure to follow manufacturers recommendations and acceptable standards of practice, prior to sterilization and decontamination of surgical instruments;
-The use of expired sterilization supplies;
-Failure of the Infection Control Professional to monitor sterilization processes;
-Failure to appoint a professional with experience and training to supervise the sterile processing department (SPD);
-Failure of infection control staff to provide safe, sanitary conditions in the facility food service department to prevent cross contamination of food and possible food borne illness for patients, staff and visitors (Refer to A749).

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe environment and has the potential to affect all patient's in the hospital. As a result the hospital was found to be out of compliance with 42 CFR Part 482.42, Condition of Participation-Infection Control.

Based on observation and interview, the facility:
-Failed to ensure a sanitary environment where food is prepared and served in accordance with 19 CSR 20-010(4)(I) and (J);
-Failed to keep floors, equipment, and supplies in clean, serviceable condition for examination and treatment rooms in the Operating Rooms (OR's), Nuclear Medicine and Radiology;
-Failed to keep surfaces free from dust in the laboratory;
-Failed to follow manufacturers recommendations and acceptable standards of practice for sterilization,
-Failed to ensure a sanitary environment is preserved by failure to maintain damaged wall surfaces in two of two OR'sand failed to replace worn, rusted or deteriorating equipment in the OR with functional easily cleanable surfaces that will not harbor and transmit infections,
in two of two OR's,
-Failed to maintain a daily record of the temperature and humidity readings for each OR,
-Failed to ensure a sanitary environment is preserved in food and medication refrigerators in the nursing units, and
-Failed to ensure a sanitary environment is preserved in two of two patient rooms (Patient #8 & 9) observed with box fans.The facility census was 37.

Findings included:

1. Review of the facility, "Infection Control Overview" dated 05/18/05 showed the Infection Control Committee is responsible to:
-Conduct periodic review of cleaning procedures, agents, and schedules;
-Supervison of Infection Control in all phases of the hospital activities including: Nursing service and all nursing units, food and nutritional services, environmental services, Operating Room, sterile processing department, anesthesia, and radiology.

Duties and responsibilities of the Infection Control Nurse included:
-Evaluates cleaning methods and products used in cleaning as related to infection control for effectiveness of decontamination and cleaning procedures throughout the hospital and;
-Advises on standards of environmental cleanliness.

2. Observation of the kitchen on 01/9/12 at 1:50 PM through 01/10/12 at 10:00 AM showed the following:
-Blackened areas of dirt and built-up wax debris formed four inch diameter halos around the legs and base of a steam table, a plate warmer, reach-in refrigerator and a dessert cooler. A dark gray line of soil extended along the cove base around the perimeter of the cafeteria's serving area, under the front edge of the steam table, and across the threshold of the entrance to the kitchen.
-Dark brown food residue embedded in grooves and cuts of a rubber bumper on a large prep table in the back of the kitchen, next to the pot/pan wash area.
-Bowls (21 of 21 checked at random on three tiers of trays) coming off the dishwasher were being stacked wet on food trays in preparation for their next use, before they had ample time to air dry.
-White soap residue on the floor behind the wash line under the dishwasher.
-Dust and minute fuzzy-cobweb remnants clung to the caps of the range hood's fire suppression system above food prepared on the stove top.
-Scoops left inside of bulk flour and sugar bins with handles in contact with the product.
-Unidentifiable carbonized spills down the side of equipment, pooled and dried between the single convection oven and the double (over-under) convection oven.

3. Record review of facility's polity titled "Procedure for Daily Cleaning of Kitchen" does not address buffing the floor, just "wet mop with germicidal solution" and "use de-greaser if necessary." An attached handwritten 17 item checklist used by Housekeepers when cleaning the kitchen gave directives to "sweep," "mop," "clean," and "wash" in specific locations. Nothing in the procedure addressed how to contend with problem areas such as dried spills or hardened wax deposits around the legs of equipment. Nothing in the procedure specifically addressed division of labors between housekeeping and dietary staff (who cleans what).

During an interview on 01/10/11 at 10:00 AM, Staff M, Dietary Supervisor stated that kitchen staff is responsible for cleaning up after themselves, but housekeeping is responsible for cleaning the floors in the kitchen, food service and cafeteria areas. She stated that Housekeeping comes in to do a "swipe and wipe" nightly but she did not know how thorough a job they did. She stated she thought housekeeping was supposed to be cleaning the floors but they had not cleaned the dark dried spill between the convection ovens, so she was not sure how good of a job they were doing.

During an interview on 01/10/11 at 3:15 PM, Staff I, Housekeeping and Laundry Department Manager said that once a week, housekeeping staff clean the kitchen hood, filters and wash trash cans out with bleach. She stated and showed procedures titled for "Daily Cleaning of the Kitchen, last reviewed 04/30/91 and Responsibility of Housekeeping in X-Ray, dated 04/29/91. She stated the procedure and cleaning schedule are what is used and that no other formal policies exist. She stated her staff has been wet buffing the kitchen floors once a week, using a floor buffer with an abrasive pad, but now are supposed to use another floor buffer and abrasive pad with a special stripping compound that contains a degreaser. She stated that the kitchen staff are generally expected to clean up after themselves between meals, and were supposed to clean and mop the floors beneath the convection ovens because the equipment is on fixed piping and cannot easily be moved. She stated that housekeeping does a mop down by her night person who normally cleans the kitchen with whatever product the kitchen supplies them with. She said the alternate person she assigns is not as experienced or attentive to detail.

During an interview on 01/17/12 at 1:30 PM, Staff B, Registered Nurse (RN), Infection Control Nurse stated that she depends on the dietary staff to monitor cleanliness in the kitchen.

4. Observation on 01/11/12 at approximately 9:40 AM in Diagnostic Imaging, showed six large containers of Barium Sulfate (contrast agent that patients drink for a diagnostic test) solution sitting on the floor below shelves of supplies located in a hallway used by staff to get between exam rooms. When one of the containers was lifted, clumps of dust fell from the bottom of the container. There was an outline on the floor from where the container had been sitting, surrounded by clumps of dust.

During an interview on 01/11/12 at approximately 9:40 AM, Staff T, Manager, Diagnostic Imaging, stated they didn't normally store the Barium Sulfate there.

5. Observation on 01/11/12 at approximately 9:45 AM of the Radiology Room #2 showed all supplies very dusty with brown flecks at bottom of a storage tray. The radiology equipment was covered with dust. Two pieces of tape were adhered to the x-ray control module. The tape had dark edges.

During an interview on 01/11/12 at approximately 9:45 AM, Staff T stated that no one cleaned and the whole hospital was very dusty.

6. Observation on 01/11/12 at 10:05 AM showed dense gray deposits of accumulated dust, balls of fuzz and lint residue around the base of a CT scanner (Computerized Tomography-a medical diagnostic imaging scanner). Large fuzzy deposits of dust and lint had accumulated on the bulky bundle of wiring and control cables where they exited the wall and connected to the CT scanner. Red stains, said by Staff X, Radiology Technician, to be rust from the old machine, formed along one edge of the CT scanner base. Several black, dime-sized spots that looked like dried ink spots were scattered around the floor near the base of the CT scanner. Copious amounts of dust and lint on horizontal surfaces of the power unit (a large metal box the size of a file cabinet that houses a power generator for boosting power to the CT scanner), emergency medical kit and infectious waste kick bucket caused them to appear to be a dull, fuzzy gray color. Excessive dust and lint accumulated in the corners and recesses of equipment in Radiology rooms #1 and #2. Yellow stains along the cove base where it met the vinyl tile floor appeared to be an attractant to dust and lint sticking to it.

During an interview on 01/11/12 at 10:50 AM, Staff T stated that the yellow stain is from the contrast material used in some X-Ray procedures, and is very sticky so it easily attracts dust and lint to wherever there is merely a drop. He stated housekeepers probably cannot tell when they are not busy because the room is used almost all the time. "It's our most frequently used room."

Observation on 01/11/12 at 10:55 AM in the CT room showed a plastic covering over the part where the patient lays. The plastic cover had strips of tape. The tape was clear but had dark edges. The table pad under the plastic cover also had several pieces of tape over ripped areas in the patient pad (mattress type pad for the equipment).

During an interview on 01/11/12 at 10:55 AM, Staff X, Radiology Technician, stated that she sprays over the plastic and tape to clean.

During an interview on 01/11/12 at 11:20 AM, Staff T stated that the patient pad and plastic covering needed replaced.

7. Record review of facility's polity titled "Responsibility of Housekeeping in X-Ray," last reviewed on 04/29/91 showed direction for housekeeping staff to clean all three bathrooms daily, clean the office and office furniture, empty trash, dust and wet mop. A special note on the procedure instructed that "X-Ray employees clean their own equipment."

During an interview on 01/11/12 at 11:00 AM, Staff I Housekeeping and Laundry Department Manager stated that they try to clean the area every night, when they can get in without interfering with patient care. She was unaware of the amount of accumulated dust on equipment and yellow stains on the floor. She admitted that it was difficult for housekeeping to get into the rooms but they could gain access at night, when not all the rooms were in use and have enough time to complete their tasks. She stated that she was just going to have to begin going into each room and each area to check on details to ensure housekeepers are doing their jobs thoroughly.

8. Observation on 01/11/12 at 10:25 AM in the Magnetic Resonance Imaging (MRI) room showed a wedge-shaped positioner (used to help position patients) with a rip in the outer covering approximately 1-inch in length, exposing the inner core leaving an surface that could not be cleaned.

During an interview on 01/11/12 at 10:25 AM, Staff W, Radiology Technician, confirmed the rip in the positioner.

9. Observation on 01/11/12 at 10:50 AM in the radiology department showed an ultrasound (equipment that uses sound waves for diagnostic tests) machine in the hallway covered with dust and hair.

During an interview on 01/11/12 at 10:50 AM, Staff T, Manager, Diagnostic Imaging stated that the ultrasound machine was a back-up.

10. Observation on 01/12/12 at 9:10 AM showed visible dust on top of the specimen freezer, and visible dust on an office scanner located on the counter in the laboratory.

During an interview on 01/12/12 at 11:00 AM, Staff DDD, Laboratory Manager, stated that laboratory staff are responsible for cleaning the laboratory area.

11. Record review of the ANSI/AAMI ST 79" (American National Standards Institute/Association for the Advancement of Medical Instrumentation) Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities", dated 2010 showed:
-The Bowie-Dick test [equivalent to the DART test which is a commercially available disposable Bowie-Dick type test pack] should be performed each day the sterilizer is used. The test is conducted every day, before the first processed load because it is a sensitive and rapid means of detecting air leaks, inadequate air removal, inadequate steam penetration and noncondensable gases. Insufficient air removal can defeat sterilization and may result in nonsterile supplies if undetected.
-Effective removal of air is critical to predictable steam penetration and the resultant sterilization.
-If there is insufficient air removal, steam will subsequently drive the available air back into the load, air pockets will occur, and sterilizing conditions will not be attained.

Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated 2009, XVI.h.8. Dynamic air -removal steam sterilizers recommended guidelines showed:
-A Bowie-Dick air removal test should be routinely performed daily in an empty chamber.
-The air removal test is designed to detect residual air in the sterilizer chamber.
-The test should be run in accordance with the test manufacturer's instructions.
Whenever a dynamic air-removal sterilizer is installed, relocated, malfunctions, undergoes a major repair, or has a process failure, three consecutive cycles in an empty chamber should be tested with a biological indicator followed by three consecutive cycles in an empty chamber with a Bowie-Dick test.
Review of the manufacturer's guidelines for the sterilizer showed directions included:
-5.1 Before Operating the Sterilizer
Note that a Dart (Bowie-Dick) test should be run each day the sterilizer is used.

12. During an interview on 01/12/12 at 9:45 AM Staff FF, Certified Surgical Technician (CST) stated that staff performed the DART (Daily Air Removal Test).

Record review of the DART (Daily Air Removal Test) log showed one current test documented on 01/12/12. Further review showed staff documented performing the test one time on 12/19/2006. There were no tests documented as being performed between the two dates.

Observation on 01/12/12 at 9:50 AM of the DART testing supplies showed the 36 available DART tests expired 06/01/2007. During an interview upon the observation Staff FF, CST (certified sterile technician) stated that she had performed the DART test today using the expired supplies

During an interview on 01/12/12 at 9:50 after reviewing the DART log, Staff FF, CST stated that she had not been performing the DART test as she was not aware it needed to be done until today, when the sterilizer representative informed her.

During an interview on 01/12/12 at 9:55 AM, the sterilizer representative stated that the DART test should be performed daily.

During an interview on 01/12/12 at 10:40 AM, the sterilizer representative stated that failure of a DART test meant the failure to remove air and could indicate a leak and the possibility of contamination and there was no way to guarantee instrument sterility. The representative stated that he performed a DART test today using the (expired) facility DART test.

During an inteview on 01/12/12 at 10:30 AM Staff A Registered Nurse (RN) stated that she called the company that the facility purchased the sterilizer from and the company stated the facility should have been performing the DART test on the days the sterilizer was in use.

During an interview on 01/12/12 at 11:30 AM, Staff A, Registered Nurse (RN) Director of Nursing stated that the facility did not have a policy directing staff to perform the DART test.

During an interview on 01/12/12 at 12:45 PM Staff A, RN Director of Nursing stated that the facility had been using the sterilizer since April 2009 and it had replaced the same type of sterilizer which would have required a DART test be completed. Staff A stated staff would have received training with the purchase of the original sterilizer but there was no training documented.

During an interview on 01/12/12 at 1:00 PM Staff Y, RN Director of Surgery stated she was responsible for the sterile processing department (SPD), had minimal knowledge regarding the SPD and was not aware a DART test needed to be performed.

During an interview on 01/12/12 at 1:10 PM Staff ZZ, Medical Director of Surgical Services stated;
- Was aware the facility uses two steam sterilizers to sterilize instruments;
- Did not know what a DART test was and/or the significance of the test;
- Was not aware of the consequences of not using the DART testing;
- Thought the biological tests were adequate for testing that the sterilizers were operating properly.

During an interview on 01/16/12 at 1:15 PM Staff JJ, Sterile Technician (ST) stated that he was aware the DART test needed to be performed but had been on extended leave in 2006 and when he returned to work, he, "just forgot about it".

During an interview on 01/16/12 at 1:40 PM, Staff KK, Certified Sterile Technician (CST) stated that she had worked at the facility two years and was aware a DART test should be performed. Staff KK stated that upon hire, she had asked about performing the DART test but had been told DART testing did not have to be done. Staff KK stated that the response did not make sense to her but she did not question it further. She could not recall who told her the DART test did not need to be done.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that:
-She did not monitor the autoclave room or monitor sterility of surgical instruments until the problem with DART testing was identified. She depended on the OR manager to monitor.

13. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated May 2009, Recommendation V showed:
V.b. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.
V.b.2 Humidity should be monitored and recorded daily using a log format or documentation provided by the heating, ventilation and air conditioning (HVAC) system.
V.c. Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

Review of the facility's policy titled, "Surgical Services Safety" effective 05/02/06, showed the policy did not include directions to document the humidity and temperature.

During an interview on 01/10/12 at 2:45 Staff Y, RN Director of Surgery stated that staff do not document the Operating Room (OR) temperature and humidity. Staff Y stated that they have some trouble with the humidity in the summer.

14. Record review of Patient #8's medical record showed the patient had a diagnosis of pneumonia and exacerbation of chronic obstructive pulmonary disease (COPD).

Observation on 01/09/12 at 2:20 PM of Patient's 8's room showed the patient laid in his/her bed. There was a box fan in use in the patient's room. There was a heavy layer of dirt on the fan blades and the grill covers of the box fan. During an interview upon the observation, the patient stated that he/she wanted the fan on because he/she was short of breath.

Observation on 01/10/12 at 8:15 AM showed the dirty fan remained in the patient's room.

Record Review of Patient #9's History & Physical showed the patient was admitted on 12/28/11 with a diagnosis of pneumonia and congestive heart failure.

Observation on 01/09/12 at 1:55 PM showed a box fan in Patient #9's room. There was a heavy layer of dirt on the fan blades and the grill covers of the box fan.

Observation on 01/10/12 at 8:15 AM showed the dirty fan remained in the patient's room.

During an interview on 01/17/12 at 1:05 PM, Staff B, Registered Nurse (RN) Infection Control Nurse stated that:
-When staff observed a dirty box fan they should send it to maintenance for cleaning. There is no routine cleaning schedule for the box fan but maintenance staff are responsible if they are informed a fan needed to be cleaned.

During an interview on 01/17/12 at 3:00 PM, Staff PP, RN stated that when she found a dirty box fan she notified housekeeping staff as they are responsible to clean the box fans.

During an interview on 01/17/12 at 3:05 PM, Staff AAA, Licensed Practical Nurse (LPN) stated that when box fans were in patient rooms, housekeeping staff were responsible to clean them.

During an interview on 01/17/12 at 3:50 PM, Staff OO, Housekeeper stated that she thought maintenance staff were responsible to clean the box fan blades and grills but was not sure.

During an interview on 01/18/12 at 8:35 AM, Staff I, Housekeeping Supervisor stated that maintenance staff were responsible to clean the blades and grills of the box fans.

During an interview on 01/18/12 at 8:45 AM, Staff H, Maintenance Supervisor stated that he was not aware maintenance staff were responsible to clean the fans and he did not have a policy or a routine schedule to monitor and/or clean the fans.

15. Observation on 01/10/12 at 2:30 PM of the Airway Cart (cart containing emergency airway supplies) in the Surgery department showed the Airway Cart to be visibly dusty. When the airway supply items were moved in the drawers, a visible, heavy plume of dust and particles permeated the air.

Observation on 01/09/12 at 2:25 PM of the medical/surgical crash cart (cart containing emergency supplies) showed four of the drawers of the crash cart were dusty and the emergency supplies had a layer of dust on them. When the emergency supply items were moved in the drawers, a visible, heavy plume of dust and particles permeated the air.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that:
-She had been monitoring the dust situation and had discussed with maintenance staff recently about changing the filters.
-She was aware there was a problem with dust and had been in the Radiology Department the week before the survey and noticed the dust and the floors needed cleaning. She met with the housekeepers to work out a cleaning plan. Dust issues had been an ongoing problem since moving into the facility in 2002.

During an interview on 01/18/12 at 8:35 AM, Staff I, Housekeeping Supervisor stated that dust was an ongoing problem, part of the problem with keeping the radiology department clean was that housekeeping staff were afraid to move cords or equipment.

During an interview on 01/18/12, at 8:45 AM, Staff H, Maintenance Supervisor stated that no one had mentioned changing the filters recently and the filters were last changed around Halloween.

16. Observation on 01/09/12 at approximately 2:30 PM in the OB unit showed a small refrigerator containing drinks and snacks. The shelves and bottom of the refrigerator had flecks of food particles and/or dirt.

During an interview on 01/09/12 at approximately 2:30 PM, Staff VV, RN, Staff Nurse, stated that the small refrigerator was used to hold drinks and snacks for the patients as well as small amounts of breast milk. Staff VV stated that the refrigerator needed cleaned.

17. Observation on 01/09/11 at 3:30 PM of the medical /surgical medication refrigerator showed the shelf in the refrigerator door was dirty with dried debris and crumbly particles and there was dried crumbly residue on the bottom shelf inside the refrigerator.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that:
-She does not monitor food or medication refrigerators.
-The dietary manager monitored food refrigerators.

During an interview on 01/18/12 at 1:25 PM Staff M, Dietary Manager stated that she:
-Only monitored refrigerators in the dietary department;
-Did not monitor medication, food or breast milk refrigerator temperatures or cleanliness in the nursing units and;
-Her policies were specific to the dietary department and nursing staff should have their own policies.

18. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, May 2009, showed: "A safe, clean environment should be reestablished after each surgical procedure. Routine cleaning and disinfection reduces the amount of dust, organic debris and microbial load in the environment. Following scientifically based recommendations for cleaning and disinfection practice in health care organizations helps to reduce infections associated with contaminated items."

Paragraph 11.b. states, "Mattresses and padded positioning device surfaces (e.g. OR beds, arm boards, patient transport carts) should be moisture-resistant and intact," and 11.b.3. states, "damaged or worn coverings should be replaced."

Review of the facility's policy titled, "Traffic Patterns in the Surgical Suite" effective 05/02/06 showed directions for staff to damp-dust equipment such as compressed gas cylinders, brought from outside the surgical suite.

Review of the facility policy titled, "Infection Control in the PACU", dated 05/02/06 showed:
-Wheels and casters will be cleaned and will be free from debris at all times.

19. Observation on 01/10/12 at 1:30 PM of Operating Room (OR) #2 showed:
-The nitrous, oxygen and compressed air tanks were rusted leaving an un-cleanable surface;
-Two carbon dioxide (CO2) tanks were rusted leaving an uncleanable surface;
-Two IV poles, a suction canister pole, a rolling cart, the kick bucket, the biohazard box frame, the mayo stand, the back table where sterile surgical instruments are set up, had rusted castors, leaving an un-cleanable surface;
-Three of four step stools were heavily rusted leaving an uncleanable surface
-The top (head) portion of the three section OR bed mattress was worn and frayed in the corners and the velcro backing had pulled away from the bed allowing dust and debris to accumulate and;
-Two positioning devices had sticky residue with dirt and debris stuck into the residue.

Observation on 01/12/12 at 8:25 AM of OR #1 showed:
-A rusted CO2 tank with a peeling label. There was dirt and debris behind the label;
-A rusted oxygen tank and a rusted compressed air tank leaving an un-cleanable surface.
-The back table, the mayo stand (a metal table used to hold surgical instruments), and an IV pole had rusted castors leaving an un-cleanable surface;
-The linen frame cart and castors were rusted, leaving an un-cleanable surface.
-The lower section of the three section OR bed had a 1.5 cm hole on the back side and the velcro on the back side had pulled loose allowing dirt and debris to collect into the sticky residue leaving an uncleanable surface.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that:
-She had not been to the ORs for "a good month", and did not look at rusted items in the OR.

During an interview on 01/18/12, Staff A, RN, Director of Nursing stated that:
-The facility did not have a policy to monitor the OR for rusted equipment, torn and/or worn beds or positioning devices.

20. Review of the AORN Perioperative Standards and Recommended Practices, dated 2009, Recommendation IX showed: Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination.
IX.a. Flexible endoscopes should be stored in a closed cabinet.
Proper storage facilitates drying and decreases the potential for contamination.

21. Observation on 01/16/12 at 1:50 PM of the gastroenterology (GI) lab showed multiple endoscopes stored hanging in a cabinet. The upper and lower windows were missing from the cabinet doors. Further observation showed the windows were inside the cabinet. During an interview upon the observation, Staff J, RN stated that she was in charge of the GI lab, the tabs that hold the windows in the doors had broken off during "the summer" and she had not notified maintenance to replace them. Allowing the scopes to be exposed to the environment creates an infection control issue.

22. Review of the facility's policy titled, "Housekeeping Procedures" Surgical Services, effective 05/02/06 showed directions included: Walls are cleaned as necessary.

Review of the facility policy titled, "Infection Control in the PACU", dated 05/02/06 showed:
-Walls will be washed when grossly soiled.

23. Observation on 01/10/12 at 1:30 PM of OR #2 showed:
-A dirty adhesive residue on one wall where something had been posted. During an interview upon the observation Staff Y, RN Director of Surgery stated that there had been a white board posted there but it had fallen down approximately six weeks to two months prior.

Observation on 01/12/12 at 8:25 AM of OR #1 showed:
-The walls were scraped, dinged and marred with multiple small holes and/or gouges exposing the plaster in several areas, leaving an un-cleanable surface. One wall had an area approximately 3 inches wide by 7 inches long exposing the fiberboard below, leaving an un-cleanable surface. One wall had an area approximately 3 feet long where the paint was scraped off and there were multiple gouged areas exposing the fiberboard leaving an un-cleanable surface.
-The OR door had an area approximately 4-6 inches where the laminate on the door had broken off with multiple small chipped areas leaving an uncleanable surface.
-Multiple dark orange spots on the wall behind the anesthesia machine. During an interview upon the observation, Staff Y RN, Director of Surgical Services stated the spots were "betadine", (antiseptic).

During an interview on 01/18/12 at 8:45 Am, Staff H, Maintenance Director stated that he does environmental rounds looking for things that needed fixed but does not keep a record. Items are fixed based on severity of the problem. It had been over a year since any painting had been done in the OR.

During an interview on 01/17/12 at 1:05 PM, Staff B, RN Infection Control Nurse stated that she had not been to the OR's for "a good month", but had noticed there were holes in the OR walls.





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27724

Based on interview, record review, and policy review, the facility failed to ensure the Organ Procurement Organization (OPO) was notified timely after death of two (#28 and #32) of five deceased patients' record reviewed and failed to include any OPO Quality Assessment Performance Improvement (QAPI) in the hospital-wide QAPI program. The facility census was 37.

Findings included:

1. Record review of the facility's agreement with their OPO, dated 06/26/09 showed the following direction:
- Hospital shall notify (OPO) in a timely manner of every death that occurs at the hospital.
- Notification is "timely" if given:
Notice shall be deemed not timely if given later than one hour after cardiac death has occurred.

Record review of the facility's policy titled, "Requesting Organ and Tissue Donations," dated 01/03/08, showed the following direction:
- All deaths will be reported to (OPO) within 1 hour of the time of death.

2. Review of deceased Patient #28's medical record showed the patient died in the hospital on 11/18/11 at 6:07 PM. Staff failed to document the time when the OPO was notified for possible harvesting of donor organs/tissue.

During an interview on 01/12/12 at 11:45 AM, Staff B, Registered Nurse (RN), Infection Control and Employee Health, stated that staff did not document the time the OPO was notified and, therefore, it was not clear if the OPO was notified timely.

3. Review of deceased Patient #32's medical record showed the patient died in the hospital on 03/24/11 at 5:25 PM. Staff failed to document the time when the OPO was notified for possible harvesting of donor organs, tissue or eyes.

During an interview on 01/16/12 at 3:40 PM, Staff B stated that staff did not document the time the OPO was notified and, therefore, it was not clear if the OPO was notified timely.

4. During an interview on 01/16/12 at 3:42 PM, Staff A, Director of Nursing, stated that the OPO sends death chart audit results to her. She stated that she didn't believe the QAPI information went in the quarterly governing board report and was not included in the hospital QAPI report.

Based on interview, the facility failed to have a policy in place on maintaining a potential donor on life support to sustain viable donor organs, tissue or eye(s). The facility census was 37.

Findings included:

During an interview on 01/16/12 at 3:52 PM, Staff A, Director of Nursing, stated that they did not have a policy on maintaining a potential donor (on life support) while the testing for potential donation of organs, tissue, or eyes took place.

Based on interview, record and policy review, the facility failed to provide post anesthesia evaluations within 48 hours after receiving general anesthesia for two (Patient #41 and Patient #42) of six surgical patients sampled. The hospital census was 37.

Findings included:

1. Review of the medical staff rules and regulations, dated 11/14/05, Section 52 showed: Services included by a Certified Registered Nurse Anesthetist (CRNA) included: Postoperative visits of patients with documentation of anesthesia complications.

Review of the facility's policy, "Documenting the Standard of Care: The Anesthesia Record", dated 05/01/06 showed:
-The anesthesia provider supplies a post anesthesia evaluation of the patient encompassing recovery from anesthesia, evaluation, treatment and follow-up of possible anesthesia related complications. This evaluation is often made at the end of the day or on the following morning for inpatients and by telephone for outpatients.

The policy did not give specific timeframes for the post anesthesia evaluations to be completed.

2. Record review on 01/17/12 at 9:30 AM of Outpatient (home the same day)#42's medical record showed on 01/05/12 the patient had a surgical procedure with general anesthesia. Review of the anesthesia record (used to document pre-anesthesia evaluation, anesthesia administration and the post-operative anesthesia evaluation), showed the section for the post-operative anesthesia evaluation was blank.

Record review on 01/17/12 at 9:50 AM of Outpatient #41's medical record showed on 01/11/12 the patient had a surgical procedure with general anesthesia. Review of the anesthesia record showed the section for the post-operative anesthesia evaluation was blank.

During an joint interview on 01/17/12 at 9:40, with Staff LL, CRNA and Staff Y, Registered Nurse (RN) Director of Surgery, Staff LL, CRNA stated that anesthesia staff:
-Do not do a post anesthesia evaluation on patients who are outpatients;
-Only do a post anesthesia evaluation on inpatients;
-Do not document an assessment of heart and lungs on outpatients;
-Nursing staff do a post anesthesia evaluation the following day by telephone and this included asking the patient about nausea and pain.
Staff Y, RN stated that when the patient left the operating room the anesthesia provider transferred the patient's care to the post anesthesia care unit (PACU) nurse and the PACU nurse would assess the patient's vital signs, nausea and pain.

Based on interview, record and policy review, the facility failed to provide one Patient (#27) of three Swingbed patient records selected for review with a discharge notice that included all components required in the discharge letter. The Swingbed census was two. The facility census was 37.

Findings included:

1. Review of the facility policy titled, "Swingbed Policy and Procedure", dated August 2010 showed directions for staff did not include what information must be included in the written discharge notice.

Record review on 01/11/12 at 3:00 PM of Patient#27's medical record showed the patient was discharged from the facility Swingbed program on 12/19/11. Review of the facility form titled, "Medically Indicated Transfer", dated 12/19/11 at 12:55 PM, showed the transfer form did not include:
- The location to where the patient was being transferred to;
-A statement that the resident had the right to appeal the transfer to the state and;
-The name, address and telephone number of the state long term care Ombudsman.

During an interview on 01/11/12 at 3:15 PM Staff BB, Registered Nurse (RN) and Staff DD, Social Worker (MSW) confirmed the discharge letter did not include a statement that the resident has the right to appeal the transfer to the state and the name, address and telephone number of the state long term care Ombudsman.