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A. Based on document/record review and staff interview, it was determined in 1 of 1 (Pt #20) the Hospital failed to ensure a consent for treatment was obtained prior to providing patient care.

Findings include:

1. The "Release of Information/Assignment/Agreement to Pay" form was reviewed 3/5/15. The form stated "the person(s) signing this form below ("Undersigned") agree(s) as follows:... hereby consents to emergency and/or routine treatment rendered by the Hospital....I understand the scope of my consent...1. Release of Information...2. Assignment of Benefits...3. Payment...4. Goods and Services...5. Miscellaneous/Guaranty... The undersigned promises to pay all costs... 6. Personal Belongings...7. Patient Rights and Responsibilities/Advanced Directives... 8. Out of Network Provider... Notice to Undersigned... 3. I acknowledge.... the terms contained..."

2. Pt #20's clinical record was reviewed on 3/5/15 at approximately 3:30 PM. Pt #20 presented to the emergency department on 3/3/15 from a nursing home with a diagnosis of aspiration pneumonia. Pt #20 was non verbal, disoriented and completely dependant on others for all cares. The clinical record noted 2 names under the "contacts" tab and Pt #20 did have a power of attorney although no documents were found. Pt #20 was married and spouse was identified as living. The consent for treatment form titled "Release of Information/Assignment/Agreement to Pay" dated 3/3/15 was signed by E#18, a registration clerk. The record lacked documentation the "contacts" or spouse verbalized consent for treatment.

3. During an interview on 3/5/15 at approximately 3:45 PM, E#3 (Manager Medical/Surgical Unit) stated "I called registration and they said if a representative is not with a patient they initial or sign the consent. They said they do not call the family to obtain consent... they also said they have no policy regarding the process... A nurse would think the consent was taken care of if it was signed..." E#3 provided a copy of a nursing home "Consent For Treatment', signed by Pt #20's spouse on 11/23/09 which stated in an emergency authorization was granted to "the facility's physician to make the decision necessary to properly care for me."

4. During an interview on 3/6/15 at approximately 9:00 AM, E#2 (Vice President of Nursing Services) verbally confirmed registration should not sign a patients consent for treatment. E#2 stated "the family or power of attorney should always be informed and a verbal consent obtained...verbal consents should be witnessed and documented that way" E#2 was unable to find a policy for obtaining a consent for treatment.

B. Based on document/record review and interview, it was determined in 1 of 1 (Pt #21) patients who had a surgical procedure at the bedside, the Hospital failed to ensure an informed consent was obtained.

Findings include:

1. The policy titled "Informed Consent for Procedures" (issued 1/5/01) was reviewed on 3/6/15. The policy stated "The medical record shall contain evidence of a patient's informed consent for any procedure or treatment.."

2. The clinical record of Pt #21 was reviewed on 3/5/15 at approximately 12:00 PM. Pt #21 was admitted on 1/5/15 with a stage 4 sacral decubitus. An operative note dated 1/6/15 stated a debridement of the sacral wound was conducted. The clinical record lacked an informed consent.

3. During an interview on 3/5/15 at approximately 2:00 PM, E#3 verbalized after checking with the medical records department and nursing staff a surgical consent could not be found.

4. During an interview on 3/6/15 at approximately 9:00 AM, E#2 stated an informed consent should be obtained prior to any bedside procedure and was not.

Based on document review, observational tour and interview, it was determined for 1 of 1 (Pt. #9) psychiatric patients observed on the Intensive Care unit, the Hospital failed to ensure safety checks were performed every 30 minutes as required by policy.

Findings include:

1. The policy titled "Suicide Precautions" was reviewed on 3/3/2015 at 3:00 PM. The policy indicated "IV. Procedure; c. Patients under suicide precautions will be monitored minimally every 30 minutes."

2. On 3/2/2015 at approximately 1:45 PM an observational tour was conducted on the Intensive Care unit. A physician order dated 3/2/2015 was written for suicide precautions. The "Care Activity Interventions" dated 3/2/15 indicated hourly rounding was performed on 3/2/2015 at 01:00, 02:00, 03:00, 04:00 and 05:00 AM, thus not meeting the every 30 minute requirement.

3. An interview was conducted on 3/2/2014 at approximately 1:50 PM, E#5 (Intensive Care Unit Manager) verbally agreed that the 30 minute checks were not completed per policy and should have been.

A. Based on document review and staff interview, it was determined the Hospital failed to utilize a risk assessment process to prioritize infection control quality indicators. This has the potential to affect all patients receiving services at the Hospital.

Findings include:

1. During a review of the Infection Control Program (policies and minutes 1/2014- 1/2015) on 3/3/15 at approximately 3:15 PM, the program lacked documentation that a risk assessment was performed or a policy of the risk assessment process.

2. During an interview on 3/4/15 at approximately 9:15 AM, E#7 (Infection Control Coordinator) stated a risk assessment had not previously been completed and will be added to the March 2015 Infection Control Committee meeting agenda. E#7 stated "I don't think it is included in a policy but when I took this position 8 months ago, I did identify a risk assessment had not been conducted and we need to add the process to our policy."

B. Based on interview and document review, it was determined the Hospital failed to ensure surgical site infections were tracked and monitored. This has the potential to affect all patients receiving surgical services.

Findings include:

1. During an interview on 3/4/15 at approximately 9:15 AM, E#7 (Infection Control Coordinator) stated "Infection Control is not involved in the reprocessing or the sterilization process...I don't do rounds or monitor those processes. We don't have surgical site infections so it's been a non issue I guess... We have a form that is sent to the surgeons for all surgical cases performed. The surgeon is expected to complete the form and tell us if there has been an infection diagnosed for that patient...I don't track the compliance rate with returning the forms...I have a stack of them I haven't even reviewed.."

2. During an interview on 3/6/15 at approximately 2:15 PM, E#6 (Vice President Quality and Community Services) stated "The Infection Control (IC) Coordinator just started reporting to Quality Council. The previous IC reported to Quality Council but E#7 has only been in this position for 8 months or so." E#6 verbally agreed the process for assessing surgical site infections could be skewing the surgical site infection rate.

3. The Quality Council meeting minutes were reviewed 3/6/15. The meeting minutes dated August 20, 2014, October 20, 2014 and December 15, 2015 lacked infection control data. The meeting minutes dated 2/20/15 stated the surgical site infection rates: 1/2012, 3/2013 and 0/2014.

Based on document review and staff interview, it was determined the Hospitals Quality program did not involve all departments and services. This has the potential to affect all patients and staff served by the Hospital.

Findings include:

1. The policy titled "Performance Improvement Plan" (issued 7/17/12) was reviewed 3/6/15. The quality council facilitates performance improvement by developing performance indicators, monitoring performance measures and developing action plans, overseeing and directing compliance with policies and procedures and sets priorities at all levels of the organization annually and as needed.

2. A review of the Quality Council Meeting Minutes were reviewed from June 2014 through February 2015. The meeting minutes lacked data analysis and performance improvement projects for the ancillary departments such as radiology, dietary and laboratory.

3. During an interview on 3/5/15 at approximately 4:00 PM, E#6 (Vice President of Quality and Community Services) verbally agreed the quality council does not have established performance indicators which are monitored for the ancillary departments. E#6 stated the laboratory had a CLIA survey last year and the survey results and corrective action plan was discussed at quality but not monitored.

4. During an interview on 3/4/15 at approximately 3:00 PM, E#17 (Vice President of Ancillary Services) verbalized that safety rounds and infection control monitoring had not been completed in the dietary department. E#17 stated data had not been collected by the radiology, laboratory or dietary department other than peer review.

Based on observation and interview, it was determined the hospital failed to secure medications. This has the potential to affect all patients and visitors.
Findings include:
1. An observational tour was conducted on 3/4/2015 at approximately 1:50 PM through 2:20 PM on the Obstetric Unit with the Obstetric Unit Manager (E #9). It was observed in the Obstetric operating room a neonatal crash cart (red box) did not have a lock securing the following medication.

4 (four) Epinephrine 1:10,000 one (1) ml (milligram) syringes
2 (two) Sodium Bicarbonate 5 meq (miliequlivent) (0.5 meq/ml) 10 milligram syringes
4 (four) Infant 25% Dextrose 2.5 (250 mg/ml) 10 milligram syringes

2. During an interview on 3/4/2015 at approximately 3:30 PM,E #2 stated the medications were not secured and should have been. E#2 stated "any medication, no matter if it's high risk or not should be secured.'

A. Based on document review, observation and interview, it was determined in 7 of 7 dietary department employees observed in the food preparation area, the Hospital failed to ensure policies were followed.

Findings include:

1. The policy titled "Personal Appearance Policy/Dress Code" (issued 6/12/14) was reviewed on 3/4/15. The policy stated dietary "employees shall use effective hair restraints...(beard restraints)...that are designed and worn to effectively keep hair from contacting exposed food..."

2. During an observational tour of the dietary department on 3/4/15 at approximately 11:40 AM, 7 employees including the dietary manager (E#16) were observed in the food preparation area with the following non compliance:
1 employee was observed with a beard and mustache restraint hanging around neck thus leaving mustache and beard exposed, 1 employee with a visor and no hair restraint, 6 employees were observed with a hair restraint worn on back of head leaving hair exposed in front and around ears.

3. During an interview on 3/4/15 at approximately 12:30 PM, E#16 verbally agreed hair restraints were not appropriately worn on the seven employees who were preparing food or her/himself. E#16 stated that although the employee with the visor was a hostess and the visor was part of the uniform, that employee should not have been in the food preparation area without a hair restraint.

4. During an interview on 3/4/15 at approximately 12:45 PM, E#7 (Infection Control Coordinator) who was present during the tour and interview, verbally agreed the observations and stated "I saw it (inappropriate use of hair restraint) right away. I think I'll start making rounds down here."

B. Based on document review, observation and interview, it was determined the Hospital failed to ensure food was stored per policy. This has the potential to affect all patients, staff and visitors who consume food prepared in the dietary department.

Findings include:

1. The policy titled "Food Storage" (superseded 12/20/2000) was reviewed on 3/4/15. The policy stated all dry staples received for storage are dated, foods no longer in the original package will be labeled and dated and an example of a date is written as mo/day/year.

2. During an observational tour of the dietary department on 3/4/15 at approximately 11:40 AM, the following non compliance was observed:

a) Dry Food Storage area: The dated items were identified with the month although it was unable to be determined if the second number was the day or year. Examples include boxed food dated as 7/14, canned goods as 1/14... It was unable to be determined if the date represented July 14 th or July 2014, January 14 th or January 2014; 4 boxes of dry food items and an opened bag of marshmallows had illegible dates.
b) Food Storage Cabinet near food line: An opened package of a dry powdered substance was unlabeled and not dated; 2 cans of opened chicken base covered with foil were undated.
c) Walk in Freezer: 32 ounce bag of diced onions, opened bag of chicken breast, opened bag of sausage links, opened bag of beef fritters were not dated; 2 opened bags of pre cut beef had an expiration date of 2/29 and 1 opened bag of pre cut beef had an expiration date of 2/28.

3. During an interview on 3/4/15 at approximately 12:30 PM, E#16 stated the dates "probably mean the month and day...I assume all dry goods should be discarded after a year... I can see how you wouldn't know if the date meant July 14 of 2013 or 2014 or January could be last year which would now be expired or this year... I don't know except this storage area is for the more frequently used items so I don't think it's been that long." E#16 verbally agreed the 4 boxes of dry food items and marshmallows were illegible, the items in the food storage cabinet were not appropriately labeled and the walk in freezer items were undated and/or expired.

4. During an interview on 3/4/15 at approximately 12:45 PM, E#7 who was present during the tour and interview, verbally agreed with the above findings and stated a better labeling process needs to be implemented immediately.

A. Based on document review, observation and interview, it was determined the Hospital failed to ensure mechanical and electrical equipment available for patient use, was inspected and had routine maintenance. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. The policy titled "General Equipment Guidelines" (issued 12/15/1999) was reviewed on 3/3/2015 at 10:00 AM. The policy stated "II. Policy; Non-medical equipment will be kept in inventory and on a preventive maintenance schedule by the Director of Facilities Management... III. Procedure... b. The manager of the user department will assure safety check has been completed before placing the equipment into use."

2. During a tour of the clean utility room on the Medical-Surgical unit on 3/2/2015 at approximately 11:50 AM with the Medical-Surgical Clinical Manager (E#3), one (1) Conair hairdryer and one (1) Conair instant heat curling iron did not have a maintenance sticker or an inspection sticker to indicate an electrical safety check was conducted.

3. An interview was conducted during the tour on 3/2/2015 at approximately 11:50 AM with E#3. E#3 verbally stated there had not been a safety check conducted on the hair dryer or curling iron and should have.

4. During an interview on 3/2/2014 at approximately 1:00 PM, E#4 (Director of Maintenance and Environmental Services) stated "I was not aware of a hairdryer or a curling iron on the unit."

B. Based on document review, observation and interview, it was determined the Hospital failed to ensure patient owned equipment was checked for safety. This has the potential to affect all patients, staff and visitors.

Findings include:

1. The policy titled "Personal Equipment" (issued: 12/16/2009) was reviewed on 3/4/2015 at 10:50 AM. The policy stated "II. Policy: Patient owned equipment will only be allowed in the hospital after it has been checked by the Maintenance Department for defects in wiring and fire hazard potential."

2. Pt #14 was admitted on 2/24/15 for an incision and drainage of an infected finger and intravenous antibiotics. During an interview on 3/4/2014 at approximately 10:55 AM, Pt #14 stated the c-pap (continuous positive airway pressure) machine was a personal device, brought from home on the day of admission. There was no documentation/evidence the c-pap had an electrical safety check prior to use.

3. During an interview on 3/4/2015 at 10:30, E #3 stated the c-pap should have had an electrical check done by maintenance and had not.


C. Based on observation and interview, it was determined the Hospital failed to ensure expired biological's were available for use in the dietary department. This has the potential to affect all patients, staff and visitors who consume food prepared in the dietary department.

Findings include:

1. During an observational tour of the dietary department on 3/4/15 at approximately 11:40 AM with the Dietary Manager (E#16) and the Infection Control Coordinator (E#7), E#16 demonstrated how to test the sanitizing solution with the available Hydron Papers QT-10 sanitizing test strips (multi use roll) which were labeled as having a manufacturers expiration date of 3/1/14; at the food line preparation sink, a Microchlorine test strips (multi use roll) available for use had a worn off label and was sticky and water stained. The test strip storage area held 2 Hydron Papers QT-10 sanitizing strips (multi use roll) with an expiration date of 3/1/14 and 1 unknown date; 3 Microchlorine test strips (multi use roll) with an expiration date of 11/19/01 and 2 unknown; 3 Microchlorine test strips (multiple strips per container) with an expiration date of 1/2011.

2. During an interview on 3/4/15 at approximately 12:15 PM, E#16 stated "the test strips are used with each bucket of solution made... multiple buckets are made throughout the day..." E#16 and E#7 verbally agreed the test strips were expired, available for use, and should not have been.

A. Based on observational tour and interview, it was determined the Hospital failed to ensure equipment was thoroughly disinfected prior to patient use. This has the potential to affect all patients on the medical surgical unit.

Findings include:

1. On 3/2/2015 at approximately 11:50 AM an observational tour was conducted on the Medical-Surgical unit. In room 216A both arm rests of a bariatric chair was observed to be ripped with exposed foam through torn outer covering.

2. During an interview on 3/2/2015 at approximately 12:12 PM, E#3 (Medical-Surgical Unit manager) stated the chair could not be appropriately disinfected and should not be available for patient use until repaired.

B. Based on document review, observation and interview it was determined the hospital failed to ensure infection control techniques were being followed. This has the potential to affect all patients receiving medications.

Findings include:

1. On 3/4/2015 the policy titled "Multiple Dose Vials" (Issued 2/21/2011) was reviewed at 12:00 PM. The policy stated "IV. Procedure... D. The rubber stopper of the vial MUST be wiped with an alcohol swab prior to entry, including the first entry."

2. On 3/4/2015 at approximately 9:30 AM an observational tour of the medical surgical unit was conducted with E#3. A registered nurse (E#8) was observed to open a vial of medication, insert the needle and draw the medication into the syringe. E#8 failed to disinfect the rubber septum with alcohol prior to entry.

3. An interview was conducted with E#3 on 3/4/2015 at approximately 9:50 AM. E#3 stated the vial should have been wiped with an alcohol pad prior to accessing.


C. Based on observation and staff interview, it was determined the Hospital failed to ensure a sanitary environment in the dietary department. This has the potential to affect all patients, staff and visitors who consume food prepared by the dietary department.

Findings include:

1. During an observational tour of the dietary department on 3/4/15 at approximately 11:40 AM with the Dietary Manager (E#16) and the Infection Control Coordinator (E#7), E#16 was asked to demonstrate how the food line was sanitized and how often. E#16 demonstrated at the sink how to prepare and test the sanitizing solution with the available Hydron Papers QT-10 sanitizing test strips (multi use roll) which was labeled as having a manufacturers expiration date of 3/1/14. E#16 demonstrated a storage cabinet in the managers office where all the test strips (sanitizing and chlorine) are stored.

2. During an interview on 3/4/15 at approximately 12:15 PM, E#16 stated "the test strips are used with each bucket of solution made... multiple buckets are made throughout the day... I don't monitor the staff doing the test but they are suppose to do it each time... If the staff was doing it right, those strips should not have lasted this long...." E#16 replied as to who had a key to the office and how staff access the strips if the office was locked as the staff did not have access if the manager was unavailable.

3. During an interview on 3/4/15 at approximately 12:30 PM, E#7 verbally agreed the sanitizing solution and the chlorine concentration could not be tested accurately with expired test strips. E#7 stated "due to the strips being expired for the past year the staff could not be testing the solutions with each bucket prepared."