HospitalInspections.org

Based on staff interview, it was determined the Hospital failed to ensure there was an operational Governing Body. Findings include:

1. On 4/23/13 at approximately 11:30AM, the Chief Nursing Officer (CNO) was interviewed. The CNO stated the Hospital did not have a Governing Body or Board of Directors in place as of 4/16/13. Refer to A049.

2. The Hospital failed to ensure a Psychiatrist evaluated seven (7) OF seven (7) patients admitted to the DTU. patient. Refer to A068

3. The Hospital failed to ensure the Governing Body prepared and approved an institutional plan. Refer to A077

4. The Hospital failed to ensure there was a Governing Body to review Hospital services provided by contracts. Refer to A083

5 The Hospital failed to ensure evaluation of contracted services. Refer to A084.

Based on document review and interview, it was determined the Hospital failed to maintain a Hospital wide, ongoing, integrated, comprehensive Quality Assessment Program. As a result, the Hospital cannot ensure integration of services and patient safety. Findings include:

1. The Hospital failed to ensure medication errors were identified and reported
Refer to A266.

2. The Hospital failed to ensure development of Hospital wide performance improvement measures and reported to the Performance Improvement Team in accordance with policy.
Refer to A273.

3. The Hospital failed to ensure there was a performance improvement team.
Refer to A309.

Based on document review and interviews, it was determined, the Hospital failed to ensure the CNO was licensed in the State of Illinois. The cumulative effect of this systemic practice resulted in the Hospital's inability to adequately provide supervision to the approximately 100 patient care staff employed for the Hospital as of on 3/25/13 and failed to ensure proper and safe nursing care to the patients. Therefore, the Hospital failed to comply with the Condition of Nursing Services. Findings include:

1. The Hospital failed to ensure the CNO maintained licensure in the State of Illinois. Refer to A 386.

2. The Hospital failed to ensure all physicians' orders were followed. Refer to A395A.

3. The Hospital failed ensure Deep Vein Thrombosis (DVT) prophylaxis was implemented according to protocols. Refer to A395B

4. The Hospital failed to ensure proper care of Intravenous (IV) access. Refer to A395C.

5. The Hospital failed to ensure the nursing staff developed and maintained current nursing care plans. Refer to A396.

6. The Hospital failed to ensure nursing staff nursing staff ensured daily labs were drawn for 3 of 3 patients. Refer to A405.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on April 23 - 24, 2013, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on document review and interviews, it was determined for 1 of 1 Infection Control Coordinator (E#15), the Hospital failed to ensure the ICC was qualified, developed policies and procedures regarding TB exposure, and failed to ensure TB patients were appropriately isolated. The cumulative effect of these systemic practices resulted in the Hospital's inability to adequately provide Infection Control guidance. This placed all patients and staff at risk. Therefore, the Hospital failed to comply with the Condition of Infection Control. Findings include:

1. The Hospital failed to ensure the Infection Control Coordinator was qualified for the job.
Refer to A748A.

2. The Hospital failed to ensure an TB exposure control policy was available.
Refer to A748B.

3. The Hospital failed to ensure TB patients are appropriately isolated.
Refer to A748C.

4. The Hospital failed to ensure Hospital patient care providers were instructed and certified in the use of the N 95 respirator. Refer to A748D.

5. The Hospital failed to ensure the evaluation of nosocomial infections of surgical patients. Refer to A749A.

6. The Hospital failed to ensure the Infection Control Coordinator maintained a log related to infections. Refer to A750.

Based on document review and interviews, it was determined that for 6 of 6 patients (Pt #2, 19, 21, 22, 23, 24) requiring Physical Therapy Assessments, the Hospital failed to ensure a Physical Therapist was available to assess the patients . The cumulative effect of this systemic practice resulted in the Hospital's inability to adequately provide therapy services. Therefore, the Hospital failed to comply with the Condition of Rehabilitation Services.

1. The Hospital failed to ensure a qualified physical therapist was available to provide required services. Refer to A1126.

A. Based on interview, it was determined the Hospital failed to ensure the evaluation of patient quality and safety Governing Body. Thus placing all patients on census (18) at risk.
Findings include:

1. On 4/24/13 at approximately 11:30AM, the Chief Nursing Officer (CNO) was interviewed. The CNO (E#8) stated that the Hospital did not have a Board of Directors, Governing Body or Chief Operating Officer since 4/16/13.


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B. Based on document review, observational tour, and interview, it was determined for all seven (7) patients on the DTU, the Hospital failed to ensure a comprehensive detoxification program was in place. Findings include:

1. On 4/23/13 at 3:00 PM, the "Practice Guideline for the Treatment of Patients with Substance Disorders", second edition was reviewed. The 180 page reference manual was found on the Detoxification Unit. The Guidelines included, "I. Executive Summary... B. General Treatment Principles - Individuals with substance abuse use disorders... [have] a number of clinically important features and domains of functioning. Consequently, a multimodal approach to treatment is typically required... 1. Assessment - A comprehensive psychiatric evaluation is essential to guide the treatment of a patient with a substance use disorder... 2. Psychiatric management - Psychiatric management is the foundation of treatment for patients with substance use disorders... 3. Specific treatments... a) Pharmacological treatments... b) Psychosocial treatments... Evidence-based psychosocial treatments include cognitive-behavioral therapies (CBTs, e.g., relapse prevention, social skills training), motivational enhancement therapy (MET), behavioral therapies (e.g., community reinforcement, contingency management), 12-step facilitation (TSF), psychodynamic therapy/ interpersonal therapy (IPT), self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies..."

2. On 4/23/13 between 9:45 AM and 11:40 AM and again on 4/23/13 between 2:15 PM and 3:30 PM, observational tours were conducted on the DTU. There were 2 female and 5 male patients being cared for by 1 RN (E #7), 1 LPN (E #9), and 1 CNA (E #A). A Physician (E #16) was meeting with each patient individually. However, there were no other patient activities seen during the tour. At 10:15 AM, 3 men were asleep (Rm. 319, 323, & 324A), 1 man was walking in the hall (Rm. 325), and the fifth man was watching television (Rm. 324B). At 3:30 PM, 2 men were asleep (Rm. 319 & 324A), 1 man was walking in the hall (Rm. 325), and 3 men were watching television (Rm. 323 & 324B).

3. On 4/23/13 at 2:00 PM, an interview was conducted with the DTU's Attending Physician (E #16). E #16 stated he is an Internal Medicine Physician and manages all the patients on the DTU. The Unit uses the "Practice Guideline for the Treatment of Patients with Substance Disorders" as a reference for patient care.

4. E #16 stated the Unit has a Mental Health Counselor (E #17), who supervised therapeutic activities for the patients. However, E #17 has been off duty since 4/18/13 with a serious illness and may not be able to return to work.

5. E #16 stated the Hospital has 1 Psychiatrist (E #10) who was available for the patients. However, E #10 has not been coming to the DTU because he has a disagreement with the Mental Health Counselor (E #17). This has been going on for about 2 months.

6. On 4/25/13 at approximately 9:00 AM, an interview was conducted with the Acting Administrator. The Acting Administrator stated he was new to the position (4/17/13), but the previous Administrator was aware E #10 was not providing care for the DTU patients but had not found a solution. The Acting Administrator was unaware of the serious illness of the Mental Health Counselor (E #17).

Based on document review and interview, it was determined for 1 of 1 patients (Pt. #9) with a psychiatric diagnosis, the Hospital failed to ensure a Psychiatrist responded to a consultation request on the DTU. Findings include:

1. The clinical record for Pt. #9 was reviewed on 4/23/13 at 1:10 PM. Pt. #9 was a 24 year old male, admitted on 3/8/13, with diagnoses of headache and bipolar I disorder. Pt. #9 was placed on the Telemetry Unit.

-A consultation dated 3/9/13 and a progress note dated 3/9/13 at 6:53 AM, included Pt. #9 was "evaluated" by a Psychiatrist (E #10), who wrote orders for psychiatric medication for Pt. #9. Progress notes on 3/10/13 at 8:30 AM, included, "Patient has orders to be transferred to third floor [Detoxification Unit] because ...is having Hallucinations and needs one to one monitoring...Transferred...to third floor."

-A progress note dated 3/10/13 at 9:00 AM, included, "... Patient has Bipolar and is very restless and agitated. Has so many reasons for wandering... Paged Doctor [E #10]... Still waiting for a call back..." There is no progress note to indicate E # 10 returned the call.

- A progress note dated 3/10/13 at 12:00 PM, included, " Patient uncontrollable... Paged Doctor [E #10]... for more psyche evaluation. No response yet..." There is no progress note to indicate E #10 returned the call.

- A progress note dated 3/11/13 at 12:00 AM, included, "... Patient becoming increasingly agitated and combative... Increase elopement risk... Doctor [E #10]... repaged for psych evaluation. Awaiting response. Restraints applied..." There is no progress note to indicate E #10 returned the call.

-A progress note dated 3/11/13 at 6:00 AM, included, "... Doctor [E #10]... paged again for psych evaluation." Pt. #9 was still in restraints. There is no progress note to indicate E #10 returned the call.

- Progress notes included Pt. #9 was released from restraints on 3/11/13 at 7:00 AM and was transferred to another Hospital for psychiatric treatment on that date some time after 12:28 PM (the last progress note entry). There is no documentation a psychiatrist assessed Pt. #9 after E #10 was paged at least 4 times.

2. On 4/23/13 at 2:00 PM, an interview was conducted with Pt. #9's Attending Physician (E #16). E #16 stated he is an Internal Medicine Physician and manages all the patients on the DTU. When a patient needs a psychiatric evaluation, the Hospital has one Psychiatrist (E #10). However, E #10 has not been responding to pages from the DTU because he has a disagreement with the Mental Health Counselor (E #17) which has been going on for about 2 months. Administration is aware of the problem, but has failed to address it.

3. On 4/25/13 at approximately 9:00 AM, a request to interview E #10 was made to the Acting Administrator. E #10 did not make himself available for interview.

Based on staff interview, it was determined the Hospital did not have available an institutional plan or operating budget. Findings include:

On 4/25/13 at approximately 11:40 AM, the Hospital's operating budget was requested.
At that time, the CNO was interviewed. The CNO stated the Hospital does not have an operating budget at this time.

Based on interview it was determined the Hospital failed to ensure the Governing Body prepared and approved an institutional plan. Findings include:

On 4/25/13 at approximately 11:40 AM, the Hospital's operating budget was requested.
At that time, the CNO was interviewed; the CNO stated the Governing Body had not approved an operational plan at this time.

Based on interview, it was determined the Hospital failed to ensure there was a Governing Body to review Hospital services provided by contracts. Findings include:

On 4/24/13 the Hospital's list of Governing Body approved and reviewed contractual services was requested. On that date at approximately 11:30 AM, the CNO was interviewed. The CNO verified the Hospital has not had a Governing Body since 4/16/13.

Based on document review and interview, it was determined the Hospital failed to ensure there was an evaluation of contracted services for 3 of 3 contracts. Findings include:

1. On 4/24/13 at approximately 1:15 PM a list of contracted services was requested from the CNO. The list contained approximately 28 direct patient care contracted services. As of 4/24/13, three of the 28 contracted services were provided: A Plus Therapy, LLC and Maxim staffing Solutions and Rush University. Per the CNO, none of the contracted services had been evaluated.

2. On 4/23/13 at approximately 1:15 PM, the CNO stated that to his knowledge none of the remaining contracts were evaluated through the Quality Committee.

Based on document review and interview, it was determined for 1 of 1 patients (Pt. #9) restrained for behavioral reasons, the Hospital failed to ensure the care plan included restraints when used. Findings include:

1. Hospital policy No 38.018.1, titled "Use of Restraints", revised 1/09, was reviewed on 4/25/13 at 11:35 AM. The policy required, (pg. 4) "6. Care Plan: The patient's care plan shall be modified to indicate the type of restraint, the rationale for restraint use, frequency of patient assessments, and readiness for release for restraint... The care plan will be modified upon discontinuation of restraint."

2. The clinical record for Pt. #9 was reviewed on 4/23/13 at 1:10 PM. Pt. #9 was a 24 year old male, admitted on 3/8/13, with diagnoses of headache and bipolar I disorder. Pt. #9's progress note dated 3/11/13 at 12:00 AM, indicated Pt. #9 was placed in restraints on 3/10/13 at 11:00 PM. A progress note on 3/11/13 at 7:00 AM, included Pt. #9 was released from restraints at 7:00 AM.

3. Pt. #9's care plan dated 3/8/13, did not include include the use of restraints.

4. On 4/25/13 at 1:25 AM, an interview was conducted with the Manager of DTU. The Manager stated there was no revision in Pt. #9's care plan to include restraints.

Based on document review and interview, it was determined, for 1 of 1 patients (Pt. #9) restrained for violent behavior, the Hospital failed to ensure restraint orders included a length of time restriction. Findings include:

1. Hospital policy No 38.018.1, titled "Use of Restraints", revised 1/09, was reviewed on 4/25/13 at 11:35 AM. The policy required, (pg. 3) "2. Physician Orders: a. Restraint must be ordered by a physician on staff...b. The order shall specify the method of restraint to be used and the indication for restraint usage..." The policy did not include the length of time a patient may be restrained before the order must be renewed must be included in the order.

2. The clinical record for Pt. #9 was reviewed on 4/23/13 at 1:10 PM. Pt. #9 was a 24 year old male, admitted on 3/8/13, with diagnoses of headache and bipolar I disorder. An unsigned physician's telephone order dated 3/10/13 included, "Vest jacket restraint. Soft limb restraint... all four limbs... prevent harm to self... Called Doctor... at 10:22 PM... Restraints applied at 11:00 PM." The order did not indicate how long the restraints were to remain on.

3. Pt. #9's progress note dated 3/11/13 at 12:00 AM, indicated Pt. #9 was placed in restraints on 3/10/13 at 11:00 PM, "becoming increasingly agitated and combative". Progress notes at 2:00 AM, 4:00 AM, and 6:00 AM indicated Pt.#9 remained in restraints. A progress note on 3/11/13 at 7:00 AM, included the restraints were removed (after 8 hours) because Pt. #9 was less agitated.

4. On 4/25/13 at 11:30 AM, an interview was conducted with the Manager of the DTU. The Manager stated there was no time limit for the restraint.

Based on document review and interview, it was determined for 1 of 1 patients (Pt. #9) restrained for violent behavior, the Hospital failed to ensure the patient was assessed by a physician within one hour of restraint application. Findings include:

1. Hospital policy No 38.018.1, titled "Use of Restraints", revised 1/09, was reviewed on 4/25/13 at 11:35 AM. The policy required, (pg. 7) "d. If the patient was restrained for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff, or others, the physician must perform a face-to-face assessment within 1 hour after initiation of restraints..."

2. The clinical record for Pt. #9 was reviewed on 4/23/13 at 1:10 PM. Pt. #9 was a 24 year old male, admitted on 3/8/13, with diagnoses of headache and bipolar I disorder. An unsigned physician's telephone order dated 3/10/13 included, "Vest jacket restraint. Soft limb restraint... all four limbs... prevent harm to self... Called Doctor... at 10:22 PM... Restraints applied at 11:00 PM."

3. Pt. #9's progress note dated 3/11/13 at 12:00 AM, indicated Pt. #9 was placed in restraints on 3/10/13 at 11:00 PM, "becoming increasingly agitated and combative". Progress notes at 2:00 AM, 4:00 AM, and 6:00 AM indicated Pt.#9 remained in restraints. A progress note on 3/11/13 at 7:00 AM, included Pt. #9's restraints were removed because Pt. #9 was less agitated. There was no progress note to indicate Pt. #9 was assessed by a physician during the 8 hours Pt.#9 was restrained.

4. On 4/25/13 at 11:30 AM, an interview was conducted with the Manager of the DTU. The Manager stated a physician did not conduct an assessment of Pt. #9 while Pt.#9 was restrained.

Based on document review and interview, it was determined the Hospital failed to ensure development of Hospital wide performance improvement measures that were to be reported to the Performance improvement team in accordance with policy. Findings include:

1. On 04/23/13 at approximately 9:45 AM, the "Performance Improvement/Patient Safety (PIP)"plan was reviewed. The plan included, "Performance Improvement is an organizational-wide program that studies functions and processes to achieve best practice in patient care outcomes...comprehensive performance measures...Obtain approval from the Medical PIPS Committee before starting a project. The Hospital's quality assessment and improvement program is a continuous, integrated activity within the facility. It is the responsibility and accountability of the PIP committee to coordinate and become the oversight for all performance improvement activities. "

2. On 4/23/13 at approximately 9:25 AM, an interview was conducted with the Dietary Manager (E #1). E #1 was unable to provide department performance improvement indicators and/or projects. E #1 stated, "We have no indicators."

3. On 4/25/13 at approximately 11:05 AM the above was verified with the CNO.

Based on document review and staff interview, it was determined the Hospital failed to ensure there was a performance improvement (PI) team. Findings include:

1. On 4/24/13 at approximately 12:30 PM the Performance Improvement (PI) Reporting Structure (revised 12/20/10) was reviewed with the CNO. The composition of the PI committee required a Governing Board and Chief Operating Officer.

2. On 4/24/13 at approximately 11:30 AM, the CNO was interviewed. The CNO verified the Hospital had neither a Governing Body or Chief Operating Officer since 4/16/13. As a result, the Hospital did not have the ability to review reports, draw conclusions, make recommendations and act upon and make improvements when necessary thus placing 20 patients on census at risk.

Based on interview and document review it was determined that the Hospital failed to ensure the CNO maintained licensure in the State of Illinois. Findings include:

1. An interview was conducted with the CNO on 4/25 13 at approximately 8:45 AM. the CNO stated that he does not have an Illinois Registered Professional Nurse license, but is currently licensed in the State of Michigan. The CNO also stated he has applied for Illinois licensure.

2. On 4/25/13 at approximately 11:00 AM, the CNO presented an Application for Licensure and/or Examination for the State of Illinois dated 11/30/12.

3. Verification that the CNO does not have an Illinois license was made through the Illinois Department of Financial and Professional Regulation Licenses-look up website as no license was found.

A. Based on document review and staff interview, it was determined for 6 of 20 patients (Pt #2, 5, 20, 21, 22 and 24), the Hospital failed to ensure all physicians' orders were followed. Findings include:

1. The Hospital policy titled, "Physician Orders" (revised 4/09), reviewed on 4/24/13, required, "Purpose: To establish nursing procedures for taking physician orders in addition to acknowledging and implementing physician orders in a safe, effective, and timely manner... The Registered Nurse is responsible for coordinating and implementing physician orders in accordance with the Nurse Practice Act of the State...."

2. The Hospital policy titled, "Physician Orders" (revised 4/09), reviewed on 4/24/13, required, "Purpose: To establish nursing procedures for taking physician orders in addition to acknowledging and implementing physician orders in a safe, effective, and timely manner...."

3. Pt #2 was a 57 year old male admitted from the ED on 4/19/13 with diagnoses of dehydration and sleep deprivation. Pt #2's clinical record contained a physician's order dated 4/19/13 for Pt #2's pulse oximetry (oxygenation) be monitored every shift. Pt #2's Graphic and I & O records (the sheet contained a section to document oxygenation) dated 4/19, 4/21, and 4/22/13 failed to document the patients's oxygenation status as required.

4. Pt #5 was an 87 year old female admitted from the ED on 3/30/13 with a diagnosis of acute congestive heart failure. Pt #5's clinical record contained a physician's order dated 3/30/13 that required "Strict I & O" (intake and output). Pt #5's Graphic and I & O records contained multiple dates and times when intake and output were not documented. Examples include: 4/11/13 and 4/12/13 lacked documentation of intake; 4/12/13 lacked documentation intake and output were not monitored; and 4/22/13 lacked documentation for output.


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5. The clinical record for E #24 was reviewed on 4/23/13. E #24 was a 56 year old female admitted on 4/16/13 with a diagnosis of altered mental status. The clinical record included the physician's order dated 4/17/13 at 11:45 PM: "Transfer Pt to ICU, with Neuro Checks, Q1H (every hour), and Glucose Q2H (every 2 hours)." Documentation indicated neuro checks were done hourly on 4/18/13 at 9:00 and 10:00 AM, however all other documentation indicated neuro checks were done every 2 hours from 2:00 AM on 4/18/13 -8:00 PM on 4/19/13, and every 8 hours thereafter, instead of every hour as ordered.
Glucose documentation included every two hour levels from midnight to 2:00 PM on 4/18/13, with subsequent glucose testing that ranged in intervals of 4 to 22 hours thereafter, instead of every two hours as ordered.

6. The clinical record of Pt. #22 was reviewed on 4/23/13. Pt. #22 was a 88 year old male admitted on 4/8/13 with diagnoses of gastrointestinal bleed and anemia. The DVT risk assessment score, utilizing the Hospital's DVT Admission Assessment Protocol, was 5 (2 points for ICU admission, and 3 for age greater than 75), indicating high risk. The MAR documented Heparin 5000 units subcutaneously, was given every 12 hours from 4/13/13 to 4/23/13. However the clinical record lacked a physician's order for Heparin. This finding was confirmed with the ICU Clinical Manager during an interview on 4/23/13 at approximately 3:00 PM, who stated that Heparin has to be ordered by a physician and documented on the record either on the electronic medical record (EMR) or written in the paper record and with the Telemetry Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

7. The clinical record for Pt #21 was reviewed on 4/23/13 at approximately 10:15 am. Pt #21 was a 92 year old female admitted on 4/11/13 with a diagnosis of atypical chest pain. The physician's order dated 4/15/13 at 6:17 PM required, "Regular Insulin Sliding Scale 150-200 2 units/ 201-250 4 units/ 251-300 6 units/ 301-350/ 351-400 10 units/ >400 call MD". The "Diabetic Flow Sheet" which included the point of care glucose checks and the type and dose of insulin administered. The "Diabetic Flow Sheet" lacked administration of insulin per the sliding scale on the following dates:
- 4/15/13 at 10:00 PM - blood sugar (BS) 164
- 4/17/13 at 5:00 am - BS 152; 12:00 PM - BS 215; 4:00 PM - BS 215
- 4/18/13 at 9:00 PM - BS 189
- 4/19/13 at 6:00 am - BS 247; 12:00 PM - BS 206; 5:00 PM - BS 212; 9:00 PM - BS 300
- 4/20/13 at 6:00 am - BS 188
- 4/21/13 at 4:00 PM - BS 168
- 4/22/13 at 6:00 am - BS 162; 12:00 PM 211
- 4/23/13 at 6:00 am - BS 270

8. The clinical record for Pt #20 was reviewed on 4/23/14 at approximately 2:30 PM. Pt #20 was a 92 year old male admitted on 4/19/13 with diagnoses of peripheral vascular disease and gangrene (left heel). The clinical record included a physician's order dated and timed 4/19/13 at 6:44 PM that required, "Aggressive wound care, turn patient every 2 hours; Air mattress, wound prevention." The nurses' notes lacked documentation of turning every 2 hours from 4/19/13 through 4/23/13. During an interview with the RN (E #12) who was assigned to care for Pt #20 on 4/23/13 from 7:00 am - 7:00 PM, E #12 stated the nurses complete patient turns every 2 hours on the even hours but do not document this in the chart. Therefore, there is no documentation of the patient's position or time of turns. During the observational tour of the Medical/Surgical Unit conducted on 4/23/13, it was observed at approximately 3:00 PM that there was no air mattress on Pt #20's bed. During an interview with the Medical/Surgical Nurse Manager on 4/23/13 at approximately 3:05 PM, the above findings were confirmed. The Medical/Surgical Nurse Manager stated the air mattresses have to be ordered from an outside company, and a mattress was ordered by the Unit Secretary on 4/23/13 at 3:00 PM.

B. Based on document review and interview, it was determined for 1 of 3 patients (Pt. #30) assessed for DVT risks, the Hospital failed ensure DVT prophylaxis was implemented according to protocols. Findings include:

1. The "DVT Prophylaxis Standing Order Protocol" (no date or review or revision, printed from electronic record), reviewed on 4/25/13, required, "select...Prophylaxis based on patients risk score...Moderate to high risk (total risk = 2-4) Medications: (Select one option) Heparin 5000 units subcutaneous..., Lovenox 40 mg subcutaneous every 24 hours...."

2. The clinical record of Pt #30 was reviewed on 4/25/13. Pt. #30 was a 80 year old male admitted on 4/10/13 with a diagnoses of gross hematuria and prostate cancer. The initial Nursing assessment on 4/10/13 at 4:44 AM included a DVT risk assessment of "3" (moderate risk) and a nursing note indicating: "patient currently anticoagulated." The clinical record lacked documentation that the DVT prophylaxis protocol was initiated and/or prophylactic medication order obtained.

3. The above findings were confirmed with the Nurse Manager during an interview on 4/25/13 at approximately 12:30 PM, who stated Pt. #30 should have been on prophylaxis but wasn't.


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C. Based on document review and interview, it was determined for 2 of 10 patients (Pt #5 and 6) with intravenous (IV) access, the Hospital failed to ensure proper care of IV access sites. Findings include:

1. Hospital policy entitled, "Catheter: Central Venous-Single, Multi, and Femoral," (revised 2/09) required, "C. Catheter Maintenance. 1. Dressing Change: a. The dressing will be changed every 3 days by the nurse..."

2. Hospital policy entitled, "Intravenous Therapy," (revised 2/09) required, "Guidelines: A. 2. Peripheral venous catheters should be routinely changed at least every 3 days unless, in the judgement of the nurse...The physician is to be notified and may elect to leave a peripheral venous catheter intact for longer than 3 days."

3. Pt #5 was an 87 year old female admitted from the ED on 3/30/13 with a diagnosis of acute congestive heart failure. Pt #5's clinical record contained documentation that a left subclavian central line was inserted on 4/9/13. The clinical record lacked documentation that Pt #5's central line dressing had been changed since insertion (14 days).

4. Pt #6 was a 63 year old male admitted on 3/31/13 with diagnoses of hypotension and septic shock. The clinical record of Pt #6 contained documentation that Pt #6 had a heparin lock (peripheral venous catheter) inserted on 4/14/13. The clinical record lacked documentation that Pt #6's heparin lock had been changed every 3 days or documentation of a physician's order to leave the catheter in place longer.

5. The findings were verified by the Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

Based on review of documents and staff interview, it was determined that in 13 of 20 patients (Pts # 1, 2, 3, 4, 5, 8, 11 - 16, & 37), the Hospital failed to ensure all patient's care plans were individualized and revised when necessary. Findings include:

1. Hospital policy entitled, "Patient Care Plan," (revised 10/11) required, "Policy: A. The Registered Nurse (RN) must formulate a care plan and problem list on admission within 8 hours of admission and review care plan for effectiveness at least every 24 hours for the duration of patient's hospitalization and update care plan accordingly...9. Care plan updates are triggered by reassessment findings related to patient system specific changes from baseline, responses to therapy, and/or other patient changes."

2. Pt #1 was a 75 year old male admitted to the Hospital on 4/9/13 from the EDt with a diagnosis of acute pancreatitis. Pt #1's care plan reviewed 4/23/13 dated 4/10/13 did not include pain either actual or potential. Pt #1's record reviewed 4/23/13 included a physician's order dated 4/20/13 that required "ambulate with walker BID (two times a day)." The care plan did not include Pt #'1's activity level and restrictions.

3. Pt #2 was a 57 year old male admitted from the ED on 4/19/13 with diagnoses of dehydration and sleep Deprivation. Pt #2's clinical record reviewed 4/23/13 contained a physician's order dated 4/19/13 that required Pt #2 be placed on fall precautions. Pt #2's care plan dated 4/19/13 failed to include Pt #2's precaution.

4. Pt #3 was a 52 year old female admitted from the ED on 4/10/13 with a diagnosis of soft tissue infection of left knee. The clinical record of Pt #3 reviewed 4/23/13 contained a physician's order dated 4/10/13 that required Pt #3 be placed on Contact Precautions. Pt # 3's care plan dated dated 4/10/13 did not include isolation status.

5. Pt #4 was a 77 year old male admitted from the ED on 4/21/13 with a diagnosis of hypoglycemia. Pt #4's Care Plan reviewed 4/23/13 dated 4/21/13 did not include Pt #4's hypoglycemia or glucose monitoring.

6. Pt #5 was an 87 year old female admitted from the Hospital's ED on 3/30/13 with a diagnosis of acute congestive heart failure. Pt #5's clinical record reviewed 4/23/13 did not address Pt #5's fluid volume status.

7. The findings for Pt.#s 1, 2, 3, 4, and 5 were verified by the Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.


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8. Pt #8 was a 60 year old male admitted to the DTU on 4/20/13 with a diagnosis of withdrawal symptoms. Pt. #8's Care Plan dated 4/20/13, included a Nursing Diagnosis - "Substance Abuse, Drugs". The Goals included, "The patient will recover from the drug overdose and withdrawal period; will be free from complications such as fluid and electrolyte imbalance, nutritional imbalance, respiratory failure, shock, and toxic psychosis." However, Pt. #8 did not have fluid and electrolyte imbalance, nutritional imbalance, respiratory failure, shock, or toxic psychosis. Pt. #8's Care Plan included 8 interventions for Substance Abuse:

a) "If abused substance is unknown, treat patient symptomatically." Pt. #8's substance abuse (Heroin) was known.

b) "Avoid jumping to conclusion, moralizing, or making accusations..."

c) "Assess and chart LOC [Level of Consciousness] and report changes to physician..." The frequency of LOC monitoring was not written. Pt. #8's nursing notes and flow sheets did not include assessment of LOC.

d) "Check vital signs every ____ minutes; until full consciousness returns..." Pt. #8 did not loose consciousness.

e) "Monitor for any abnormal respiratory patterns..."

f) "Keep accurate intake and output [I&O]..." Pt. #8's I&O was not monitored.

g) "Offer oral fluids and diet when permitted..." Pt. #8 was on a regular diet without fluid restrictions.

h) "Administer drugs... as ordered..."

9. The clinical record for Pt. #11 was reviewed on 4/23/13 at 3:00 PM. Pt. #11 was a 42 year old male, admitted on 4/22/13, with a diagnosis of withdrawal symptoms from heroin. Pt. #11's care plan was not in the clinical record. When a Licensed Practical Nurse (E #9) was asked if a care plan had been prepared, E #9 printed Pt. #11's Care Plan. The care plan did not include time completed nor the identity of the person who wrote the care plan. Pt. #11's care plan was exactly the same as Pt. #8's. Fluid and electrolyte imbalance, nutritional imbalance, respiratory failure, shock, or toxic psychosis were included in the care plan. Pt. #11's substance abuse (Heroin) was known. Nursing notes did not include monitoring of loss of consciousness, I&O, or any dietary restrictions, as included in the care plan.


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10. The care plan dated 4/21/13 for Pt. #12 was reviewed on 4/23/13 at 10:00 AM. Pt. #12 was a 75 year old male admitted to the DTU on 4/21/13 with a diagnosis of polysubstance abuse. The POC dated 4/20/13 for Pt.#14 reviewed on 4/23/13 at 10:15AM. Pt. #14 was a 58 year old male admitted on 4/20/13 to the DTU with a diagnosis of polysubstance abuse. The POC dated 4/19/13 for Pt. #15 was reviewed on 4/23/13 at 10:20 AM. Pt. #15 was a 64 year old male admitted on 4/19/13 to the DTU with a diagnosis of polysubstance abuse. The care plan dated 4/22/13 for Pt. #13 was reviewed on 4/23/13 at 10:30 AM. Pt. #13 was a 75 year old male admitted to the DTU with a diagnosis of polysubstance abuse. . The POC dated 4/21/13 for Pt. #16 was reviewed 4/23/13 at 10:45 AM . Pt. #16 was a 43 year old male admitted with to the DTU a diagnosis of polysubstance abuse. None of the care plans were patient specific and lacked individual goals, interventions, evaluations, and discharge planning, based on the patients' admission assessments. An interview was conducted with a Registered Nurse (E #7) on 4/23/13 at 3:30 PM. E #7 stated that all the DTU's patient's "Controlled Substance, Drugs" care plans were the same.

11. The care plan dated 4/25/13 for Pt. #37 was reviewed on 4/26/13 at 10:10 AM. Pt. #37 was a 58 year old female admitted with a diagnosis of severe decogenic low pack pain and a history of ulcerative colitis, pneumonia, mitral valve prolapse, and a laminectomy twenty years ago. Pt. #37 had a lumbar laminectomy performed on 4/25/13. The care plan lacked patient specific goals, interventions, evaluations and discharge planning related to Pt. #37's admission assessment, medical history or recent procedure.

Based on review of documents and interview, it was determined that for 3 of 3 patients (Pt #5, 6, and 24), the Hospital failed to ensure laboratory values (PTT/INRs) were monitored as required. Findings include:

1. Pt #5 was an 87 year old female admitted from the ED on 3/30/13 with a diagnosis of acute congestive heart failure. Pt #5's clinical record contained a physician's order dated 4/5/13 that required Pt #5 receive Heparin (anticoagulant) and to check PTT/INR daily. Since the order date, the clinical record lacked documentation that Pt #5's PTT/INR was monitored daily.

2. Pt #6 was a 63 year old male admitted on 3/31/13 with diagnoses of hypotension and septic shock. Pt #6's clinical record contained a physician's order dated 4/14/13 that required Pt #6 receive Heparin and to check PTT/INR daily. Since the order dated 4/14/13 the clinical record lacked documentation that Pt #5's PTT/INR was monitored daily.


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3. E #24 was a 56 year old female admitted on 4/16/13 with a diagnosis of altered mental status. The clinical record included a physician's order dated 4/16/13 at 5:38 PM, for Heparin and "check PTT/INR daily." The MAR indicated Pt. #24 received the Heparin as ordered however, as of 4/23/13, PTT/INR had only been done once, on 4/16/13.

4. These findings were confirmed with the ICU Manager during an interview on 4/23/13 at approximately 3:00 PM and by the Telemetry Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

.

Based on review of documents and interviews it was determined that for 1 of 4 patients (Pt #5), it was determined the Hospital failed to ensure blood was transfused as required. Findings include:

1. Hospital policy entitled, "Blood Administration," (revised 3/06) required, "Policy: C. Infusion must begin prior to expiration time listed on the label of the blood unit and be completed within 4 hours."

2. Pt #5 was an 87 year old female admitted from the Hospital's ED on 3/30/13 with a diagnosis of acute congestive heart. Pt #5's clinical record contained a physician's order dated 4/12/13 that required Pt #5 receive 2 units of packed red blood cells. Pt #5's second unit dated W285413001822 was initiated at 5:30 PM on 4/12/13 and completed at 10:25 PM on 4/12/13 (4 hours 55 minutes).

3. The finding was verified by the Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

Based on document review and staff interview, it was determined that for 7 of 20 patients (Pt #1, 2, 3, 4, 5, 6, 18) the Hospital failed to ensure all telephone orders are signed as required. Findings include:

1. Hospital Medical Staff Rules and Regulations dated 12/11, page 20 required, "Orders: ...A telephone order must be dated, timed and authenticated promptly but not later than 24 hours after dictating the order by the ordering practitioner or the practitioner responsible for the patient's care."

2. Pt #1 was a 75 year old male admitted to the Hospital on 4/9/13 from the ED with a diagnosis of acute pancreatitis. Pt #1's clinical record contained multiple unsigned physicians' telephone orders. Examples include: 4/20/13 (blood draws and activity order) and 4/21/13 (blood draws and medication).

3. Pt #2 was a 57 year old male admitted from the ED on 4/19/13 with diagnoses of dehydration and sleep Deprivation. Pt #2's clinical record contained multiple unsigned physician telephone orders. Examples include: 4/19/13 (precautions, medications) and 4/20/13 (medications).

4. Pt #3 was a 52 year old female admitted from the Hospital's ED on 4/10/13 with a diagnosis of soft tissue infection (left knee). Pt 3's clinical record contained multiple unsigned physician telephone orders. Examples include: 4/10/13 (medications, diet) and 4/14/13 (medications) and 4/21/13 (diet, central line insertion).

5. Pt #4 was a 77 year old male admitted from the ED on 4/21/13 with a diagnosis of hypoglycemia. Pt#4's clinical record contained multiple unsigned physician telephone orders. Examples include: 4/21/13 (blood sugar monitoring, medications, consultations).

6. Pt #5 was an 87 year old female admitted from the ED on 3/30/13 with a diagnosis of acute congestive heart failure. Pt 4's clinical record contained multiple unsigned physician telephone orders. Examples include: 3/30/13 (blood sugar monitoring, medications), 4/5/13 (medications, diet), and 4/17/13 (medications, fluid restriction) .

7. Pt #6 was a 63 year old male admitted on 3/31/13 with diagnoses of hypotension and septic shock Pt 6's clinical record contained multiple unsigned physician telephone orders. Examples include: 4/14/13 (medications, heparin lock, chest x ray).

8. The clinical record for Pt #18 was reviewed on 4/23/13 at approximately 10:45 am. Pt #18 was a 60 year old male admitted on 4/12/13 with diagnoses of left lower lobe pneumonia and leg edema. The clinical record contained 14 telephone orders from 4/13/13 - 4/21/13 that had not been signed by the ordering physician to indicate verification.

9. These findings were verified by the Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

Based on review of documents and staff interview, it was determined for 2 of 10 patients (Pt #2 and 6), the Hospital failed to ensure all clinical records contained a patient history and physical as required. Findings include:

1. 1. Hospital Medical Staff Rules and Regulations dated 12/11, page 1, dated 12/2011 required, "Section 1. Admission Prerogatives...H. Physical examinations and a medical history shall be done no more than seven(&) days before or 24 hours after an admission of a patient..."

2. Pt #2 was a 57 year old male admitted from the ED on 4/19/13 with diagnoses of dehydration and sleep Deprivation. On 4/23/13 (4 days after admission) the clinical record of Pt #2 lacked a physician's history and physical.

3. Pt #6 was a 63 year old male admitted on 3/31/13 with diagnoses of hypotension and septic shock. The clinical record lacked a physician's history and physical.

4. The findings were verified by the Unit Manager during an interview on 4/23/13 at approximately 2:30 PM.

Based on document review and staff interview, it was determined that the Hospital failed to ensure medical records were complete within 30 days. Findings include:

1. The Hospital's "Medical Staff Rules and Regulations" (revised 12/11) required, "The patient's medical record, including progress notes, final diagnosis and (dictated) discharge summary must be completed within 30 days".

2. The Director of Health Information presented the surveyor with a letter of attestation on 4/24/13 that included, "as of 4/24/13 203 charts are delinquent/deficient".

3. The above findings were confirmed with the Director of Health Information on 4/24/13 at 2:10 pm.

A.Based on document review and staff interview, it was determined the Hospital failed to ensure the DTU's crash cart was checked daily for 3 of 23 days in April 2013, potentially affecting all 7 patients on census. Finding include:

1. The Crash Cart check list for the DTU was reviewed on 4/23/13 at 10:10 AM. The Crash Cart check list stated, "All items on the crash cart are checked daily, including firing the defibrillator, inspecting the monitor and ensuring the seal is not broken on the medication drawer."

2. The Crash Cart check list on the DTU was not checked on April 16, 18, or 20, 2013.

3. An interview was conducted with a Registered Nurse (E #7) on 4/23/13 at 10:15 AM. E #7 reviewed the crash cart check list and shook her head when asked if the check list was missing checks on 3 days. E #7 did not comment about the missing crash cart checks.

B. Based on observations and staff interview, it was determined the Hospital failed to ensure crash cart supplies had not expired potentially affecting all patients on the DTU. Findings include:

1. The contents of the DTU Crash Cart were reviewed on 4/23/13 at 10:20 AM, during a Unit Tour. The Crash Cart contained expired supplies including:

- Dobutamine, 2000 mcg/ml, in 5% Dextrose, 500 ml, expired 2/1/13.

- .4% Lidocaine, 4 mg/ml, in 5% Dextrose, 500 ml, expired Oct. 2012.

2. An interview was conducted with E #7 on 4/23/13 at 10:15 AM. E #7 asked an LPN (E #9) to contact the Pharmacy to resupply the crash cart.

Based on document review and staff interview, it was determined that the Hospital failed to ensure 2 of 2 dietary sanitation policies were developed. Findings include:

1. On 4/24/13 at approximately 10:00AM, the Dietary policy and procedure manual (approval date 2011) was reviewed. The manual failed to contain a procedure for the sanitation of food thermometers and preparation of sanitizers.

2. The Dietary Manager (E#1) and Dietitian (E#6) both stated the manual was missing the two policies.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on April 23 - 24, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 24, 2013.

A. Based on observational tour and interview, it was determined, for 1 of 1 blanket warmer, 2 of 4 steam sterilizers, and 1 of 1 Endoscope Disinfection units in the Perioperative (OR) and Reprocessing Area, potentially affecting all 3 patients on the the OR schedule on 4/24/13, the Facility failed to ensure OR equipment was functioning. Findings include:

1. An observational tour was conducted in the OR on 4/24/13 at 7:30 AM to 10:00 AM. This was found:

- In the OR Clean Utility Room, the blanket warmer (Biomed # 055) was not functional.

- In the OR Clean Utility Room, the Steam Sterilizer(Biomed # 054) was not functional.

- In the OR Dirty Utility Room, the Endoscopic Disinfection Unit (Biomed # 27875) was not functional.

- In the Reprocessing Area, Steam Sterilizer #2 (Biomed # 002) was not functional.

- In the Reprocessing Area, there was no eye wash station.

2. An interview was conducted with the Manager of Perioperative Services on 4/24/13 at 9:00 AM. The Manager stated that they use the blanket warmer for storage and do not provide warm blankets for the patients. The Manager stated that they can not do flash sterilization at this time and are not doing endoscopic procedures at this time."


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B. Based on observation and interview it was determined for 1 of 1 operating room (OR) suite, the Hospital failed to ensure supplies were not expired and safe for patient use. This potentially affected all 3 surgical patients on the surgical schedule.

Findings include:

1. An observational tour was conducted in the operating room (OR) suites on 4/24/13 at approximately 7:30 AM. OR #1, OR #3 (storage room), and the OR hallway storage cabinets, contained expired items as follows:

a. In OR #1:

-1 box (5pcs) 4.0 vicryl sutures, expired 1/13
-1 box (8pcs) 2.0 ethibond sutures, expired 7/11
-1 box (24pcs) 5.0 ethilon sutures, expired 7/12
-1 box (36pcs) 4.0 silk sutures, expired 1/10

b. In OR #3's storage cabinets:

-1 box of (2 dozen) K8318 black silk sutures, expired 1/2013
-1 box (6 pcs) TA30 auto-sutures, expired 5/2011
-1 box (5pcs) 4.0 vicryl sutures, expired 1/13
-1 box (8pcs) 2.0 ethibond sutures, expired 7/11
-1 box (24pcs) 5.0 ethilon sutures, expired 7/12
-1 box (36pcs) 4.0 silk sutures, expired 1/10

c. In the OR hallway storage cabinets:

-4 EO Lens Implants:
(1) SN60WS/28.OD, expired 2/2013
(1) SN60WS/14.5D, expired 1/2013
(1) SN6OWS/12.OD, expired 2/2013
(1)SN6OWS/11.OD, expired 3/2013

-2 intra-Ocular Lens:
(1) MTA4UO/17.OD, expired 3/2013
(1) MTA4UO/24.5D, expired 9/2012
-1 box (2 dozen) Cardiovascular Prolene monofilament sutures, expired 7/2011
-1 box of (10 pcs) CH117 Vascular Loops, expired 10/2012

2. These findings were confirmed by the Manager of Perioperative Services on 4/24/13, during the observational tour.

3. The OR Nurse Manager (E #11) stated during an interview on 4/24/13 at 2:15 PM, "we look for outdated supplies. There is no organized schedule, individuals are assigned as possible, and when we find outdated supplies we call the supplier, especially for the Lens, for replacements."

C. Based on observation, and interview it was determined for 5 of 5 ventilators, 1 of 1 Arterial Blood Gas Machine, 1 of 1 Pulmonary Function test machine, and 1 of 1 Electronic Encephalogram machine, the Hospital failed to ensure the required annual preventative maintenance was completed as required.

Findings include:

1. On 4/25/13 during an observation tour of the Respiratory Therapy department the the following machines were observed with expired inspection stickers.

-1 ventilator SN (serial number) A 01807- dated 12/10
-4 ventilators SN (A 01457, A 01259, A 03223, A 01349)- dated 3/13
-Arterial Blood Gas machine -dated 3/13
-pulmonary function test machine -dated 3/13
-electronic encephalogram machine -dated 3/13

2. During inspection of the equipment accompanied by the respiratory therapist (RT) on 4/25/13 at approximately 2:00 PM, the RT stated that there are sticker on the machines with numbers on them, but she did not know why they were there, or what they meant.

3. These findings were confirmed by the RT department Administrative Assistant during the tour on 4/25/13 at approximately 2:30 PM, who attempted to obtain the information from the Biomedical department.

4. On 4/26/13 approximately 10:30 AM during an interview, the Director of Material Management stated it is normal practice to do preventative maintenance on all equipment annually; he does not believe there is a policy.

D. Based on document review, observation and staff interview, it was determined for 1 of 1 pediatric crash cart, the Hospital failed to ensure the cart contained standard doses of medication for pediatric patients. Findings include:

1. The Hospital policy, titled, "Pediatric Emergencies" (revised 2/09), reviewed on 4/25/13 at 3:00 PM, required, "Pediatric supplies and equipment: b. Standard doses of medication for the pediatric patient is located on the Crash Cart. RN's must be familiar and use when necessary. c. It will be the responsibility of the nurse on each shift to check the contents of the cart at the beginning of the shift... At the beginning of each month each crash cart is to be checked for expired medications."

2. An observational tour of the ED was conducted on 4/25/13 at approximately 11:45 AM. The pediatric crash cart was found unlocked and lacked a comprehensive list of emergency medication. The medication drawer divided in to smaller compartments each labeled with a medication name, were missing the following medication from their respective labeled compartments: Narcan, Decadron, Mannitol and Lasix.

3. The ED Manager interviewed during the tour on 4/25/13 between 11:45 and 12:30 PM confirmed the finding and stated that the crash cart should have been locked, medication list included in the log book or the emergency medication drawer, and all medication should be in the compartments.

A. Based on document review and interview it was determined for 1 of 1 Infection Care Coordinator (E#15), the Hospital failed to ensure she was qualified for the job.
Findings include:

1. The Hospital's job description entitled, "Infection Control Coordinator," (undated) required, "Job Qualifications:2. At least two years experience in infection control, prefer national certification in Infection Control."

2. The Infection Control Coordinator (E #15) was interviewed on 4/26/13 at approximately 10:30 AM. E #15 stated she started in October 2012. E#15 stated she is currently taking classes and has a consultant that she works with once a week. E #15 further stated she was assigned as the Hospital's Employee Health Nurse 11/12 and has been and still is the Surgery Intake Coordinator.

B. Based on document review and interview, it was determined the Hospital failed to ensure a TB exposure control policy was available. Findings include:

1. Hospital job description entitled, "Infection Control Coordinator'" (undated) required, "Job Duties: 2. Develops infection control policies, procedures and guidelines on prevention, surveillance and control that maintains community standards and adhere to CDC guidelines. 15. Conducts appropriate investigative research on identified control issues..."

2. On 4/25/13 at approximately 1:00 PM and again on 4/26/13 at 10:30 AM the Hospital's Exposure Control policy was requested. The Infection Control Practitioner stated that the Hospital does not have a policy regarding exposure control.

C. Based on document review and interview, it was determined that for 1 of 1 patients (Pt # 36) the Hospital failed to ensure a patient was appropriately isolated. Findings include:

1. Hospital policy entitled, "Guidelines for Prevention of TB Transmission," (reviewed 7/10) required, "Policy: To ensure an effective Infection Control Program for early detection, isolation and treatment for patients with active or suspect TB, the following guidelines are to be adhered to: B. Medical/Surgical Units: 2. those identified as active or suspect TB cases will be placed on a negative pressure room under Airborne Precautions."

2. Hospital policy entitled, "Isolation Precaution Authority," (reviewed 7/10) required, "Procedure: A. Registered Nurse. 1. Isolate the patient if assessment of condition warrants according to guidelines stated in the Hospital's Infection Control Manual."

3. Hospital Quick Guide to Infection Control Isolation Precautions (undated) required that Droplet precautions used for Meningitis, Pertussis, Mumps Influenza, Rubella, Group A Strep, Pharyngitis or Scarlet Fever, and Parvovirus B19. Airborne precautions used for TB, suspect or confirmed.

4. Hospital Rooming Criteria For Patients on Precautions required the use of a N95 respirator.

5. Pt #36 was a 41 year old male admitted on 4/3/13 from the ED. Pt #36 was admitted with diagnoses of hyperglycemia and right upper lobe mass. Pt #36's clinical record contained a physician's order dated 4/3/13 at 2:30 PM that required Acid Fast Bacillus (sputum specimen for AFB). The clinical record of Pt #36 included laboratory reports dated 4/3/13, 4/4/13 and 4/5/13 that indicated Mycobacteria with Fluorochrome Smear (AFB) that indicated "Few (2+) acid - fast bacilli seen using the fluorochrome method". Pt #36's clinical record contained nursing documentation that Pt #36 was placed in Droplet Precautions on 4/4/13. Nursing documentation dated 4/4/13 at 8:00 PM included, "On droplet precautions due to possible TB." Nursing documentation does not indicate Pt #36 was placed on Airborne Precautions until 4/5/13 at 8:00 PM.

6. The findings were verified by the E#15 during an interview on 4/26/13 at approximately 10:00 AM.

D. Based on document review and interview , it was determined for approximately 97 out of 100 patient care providers in the Hospital, the Hospital failed to ensure the providers were instructed and certified in the use of the N 95 respirator. Findings include:

1. Hospital policy entitled, "Transmission - Based Precautions/Isolation IC-6A," (reviewed 7/10) required, "A. Airborne Precautions/Isolation. 2. Respiratory Protection. Wear N 95 Respirator protection when entering room of a patient with known or suspected pulmonary tuberculosis..."

2. The Hospital's 3M Fit Tester Training Record dated 2/19/13 included, "Individuals listed below were trained on fit testing in compliance with OSHA Standard 1910.134(F)." The list contained the names of only 4 Hospital employees out of the approximately 100.

3. The Infection Control Practitioner stated during an interview on 4/16/13 at approximately 10:30 AM that there are not any other employees in the Hospital that were currently trained at the Hospital on the N 95 respirator.


E. Based on observation and staff interview, it was determined for 1 of 1 dietary staff (E#2), the Hospital failed to ensure staff sanitize food temperature thermometers in accordance with acceptable standards of practice. Findings include:

1. On 4/24/13 at approximately 7:30AM, the dietary cook (E#2) was observed obtaining a food temperature. After checking the temperature of the oatmeal, E#2 wiped the thermometer with a wet towel that was on a counter. There was no policy in place for this practice.

2. E#2 was interviewed on 4/24/13 at approximately 7:35AM. E#2 stated the towel contained a sanitizing solution.

3. The Dietitian (E#3) was interviewed on 4/24/13 at approximately 8:30AM. E#3 stated the thermometer should be sanitized with an alcohol wipe.


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A. Based on document review and staff interview it was determined for 1 of 3 patients (Pt#38), the Hospital failed to ensure evaluation of nosocomial infections and post operative complications. Findings include:

1. The clinical record for Pt. #38 was reviewed on 4/26/13. Pt. #38, a 47 year old female was admitted on 7/27/12 for a laminectomy to be performed on that date. Pt. #38 was discharged in stable condition on 8/1/12. Pt. #38 was readmitted 08/9/12 with a diagnosis of "Mersilene infection post status post lumbar laminectomy and spinal fluid leak.". Pt. #38 required surgery on 8/23/12 for a wound debridement. On 8/30/12 Pt. #38 was treated with antibiotics and discharged home. The discharge summary by the primary care physician included "the prognosis is good".

2. On 4/26/13 surgical site infections for 2012 were provided by E#15. The document included surgical site infections in January 2012 (one) and one in September 2012. There was not documentation of a nosocomial infection for Pt#38 as part of the infection control data for August, 2012.

3. The Surgical site infection document included a section titled,"Plan for Improvement". The plan included," All potential surgical site infections are assessed for any following that may place the patient at increased risk. inappropriate use of antimicrobial prophylaxis, infection at remote site not treated prior to surgery,shaving the site verses clipping, improper skin preparation, improper surgical team hand preparation, drapes..." There was no documentation available for review for evaluation of a post operative nosocomial infection for Pt. #38.

4. E#15 was interviewed on 4/26/13. E#15 stated she had no knowledge of the nosocomial infection for Pt. #38 because she began employment in October, 2012.


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B. Based on document review, observation and staff interview, it was determined the Hospital failed to ensure staff adhered to the hand washing/hand hygiene policy.
Findings include:

1. The Hospital policy titled, " Hand Washing /Hand Hygiene" (revised 2/09), reviewed on 4/23/13 required, " Hand washing/Hand Hygiene must be performed: ...3. After contact with a source of microorganisms( body fluid and substances...) 4. After removing gloves...."

2. During an observational tour of the ICU on 4/23/13 at approximately 9:55 AM, E #3 was observed removing her gloves, after handling an a used feeding tube from a patient, and proceeded to the nursing desk without performing hand hygiene.

3. The above finding was discussed with the Nurse Manager during an interview on 4/23/13 at approximately 3:30 PM.

Based on document review and interview it was determined the Hospital failed to ensure the Infection Control Coordinator (E#15) maintained a log related to infections. Findings include:

1. Hospital policy entitled "Surveillance Activities," (Reviewed 7/10) required, "The Infection Control systematically collects, tabulates and analyzes data..."

2. Hospital job description entitled, "Infection Control Coordinator," (undated) required, "Position Summary: Responsible for the surveillance, analysis, and reporting..."

3. On 4/25/13 at approximately 12:45 PM E#15 was interviewed. E #15 stated she does not make rounds on the nursing units and does not keep a log of patients on isolation. The Unit Managers are responsible for keeping a log in the Nursing Unit. The last log was dated 3/21/13.

4. The findings were verified by E #15 during an interview on 4/25/13 at 1:45 PM.

A. Based on document review, observations and interview, it was determined, for 2 of approximately 50 sterile instruments potentially affecting all 3 patients on the the OR schedule on 4/24/13, the Hospital failed to ensure sterile instruments packaging was labeled and intact. Findings include:

1. Policy No. 39.016.6, titled, "Shelf Life of Commercially Prepared Products", revised 2/09, was reviewed on 4/24/13 at 10:25 AM. The policy required, "3. All sterile items or shelves will be inspected daily. If anytime there is a question about the integrity of the sterility of the packaging... said item will be removed immediately from the shelves."

2. An observational tour was conducted in the OR on 4/24/13 between 7:30 AM and 10:00 AM. The following was found in the Clean Utility Room:

a) A sterilized instrument labeled, "belongs to knee instrument" was in a wrapper that did not include a sterilizer label.

b) A sterilized cup was in a torn package.

3. An interview was conducted with the Manager of Perioperative Services (E#11) on 4/24/13 at 9:00 AM. E#11 observed the instrument packets but did not make a statement.

B. Based on document review, observation and staff interview, it was determined for 2 of 5 operating room staff (E #4, E#5), the Hospital failed to ensure staff adhered to appropriate surgical attire as required by policy. Findings include:

1. The Hospital policy titled, "Operating Room Attire" (reviewed 6/12) and reviewed on 4/24/13, required, "Policy: All... entering the restricted and semi-restricted areas of the Operating Room will be appropriately attired... Appropriate Attire: Proper attire in the restricted areas will include hospital supplied: 1 disposable bouffant cap 2. Disposable hood for personnel with facial hair."

2. During observational tour of Surgical Services on 4/24/13 between 7:30 and 10:00 AM the following was observed:

a) At 7:30 AM, E #4, was observed in OR 1 wearing a bouffant cap, however his facial hair (beard, mustache, sideburns) was not covered with the disposable hood.

b) At 9:10 AM, E#5, was observed entering OR 1 wearing a bouffant cap, however 3 inches of hair, under the left ear, was exposed.

3. The above findings were discussed with E#11 during an interview on 10:00 AM


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C.. Based on document review, observations and interview, it was determined for 3 of 3 days when cataract procedures were done, the Hospital failed to ensure flash sterilization was not routinely performed, but only on an emergent basis. Findings include:

1. Policy No. 39.008.2, titled, "Hi-Speed Sterilization", revised 1/09, was reviewed on 4/24/13 at 1:25 PM. The policy required, "This method is used when there is an immediate need for a certain instrument or equipment in a surgical procedure when no other sterile instruments or equipment are available in an emergency sterilization process."

2. An observational tour was conducted in the OR on 4/24/13 between 7:30 AM and 10:00 AM. There were 2 cataract procedures scheduled (Pts. #26 & 27). The Surgeon (E #5) brought a single cataract instrument tray to use for both procedures. The tray was taken to the Reprocessing Area at 8:30 AM for steam sterilization, not for flash sterilization.

3. The flash sterilizer log for 2012 and 2013 was reviewed on 4/24/13 at 2:00 PM. The log included dates (1/5/12, 2/1/12, 5/9/12) when cataract instruments were flash sterilized.

4. An interview was conducted with E#11 on 4/24/13 at 7:45 AM. E#11 stated the Hospital has only 1 cataract tray and the tray is usually flashed sterilized between cases. However, the flash sterilizer has not been working since 4/18/13.

Based on review of documents and staff interview, it was determined that for 6 of 6 (Pt #2, 19, 21, 22, 23, and 24 ) patients with Physical Therapy (PT) orders, the Hospital failed to ensure a qualified PT was on staff to provide patient evaluations. Findings include:

1. Hospital job description entitled, "Director of Physical Therapy," (revised 2012) required, "Position summary: Oversees day-to-day department operational and clinical activities. Qualifications: B.S. in Physical Therapy...Clinical: Screens patients to determine appropriateness of skilled PT services. Evaluates patients for Physical Therapy treatment including ..."

2. Hospital policy entitled, "Staff Qualifications of the Physical Therapist," (revised April 2012) required, "Physical Therapy must be planned and initiated by a licensed Physical Therapist.

3. Hospital job description entitled, "Physical Therapy Assistant," (revised April 2012) required, "Job Function: Employees in this job, functions under direction of a registered, licensed Physical Therapist. The physical therapist must maintain continual contact with the physical therapist assistant including periodic personal supervision."

4. On 4/24/13 at approximately 2:30 PM a tour was conducted in the Hospital's PT Department. During the tour a Physical Therapy Assistant (PTA) and Speech Therapist (ST) were on duty.

5. The PTA presented six (6) PT inpatient referrals that have not been completed as of 4/24/13. Examples: Pt #2 referral dated 4/19/13 reason Parkinson Disease; Pt #19 referral dated 4/22/13 reason Pelvic Pain; Pt #21 referral dated 4/19/13 reason Muscle Weakness; Pt #22 referral dated 4/19/13 reason Muscle Weakness; and Pt #24 referral dated 4/19/13 reason Muscle Weakness.

6. On 4/24/13 at approximately 2:00 PM the PTA stated the six referrals have not been completed because the physical therapist who was "agency", left on 4/19/13.

7. The findings were verified with the Hospital's Speech/ Language Therapist and Physician Therapy Assistant during an interview on 4/24/13 at approximately 2:30 PM.

Based on document review and interview, it was determined the Hospital failed to ensure a qualified Physical Therapist was available to provide required services. Findings include:

1. Hospital policy entitled, "Staff Qualifications of the Physical Therapist," (revised April 2012) required, "Physical Therapy must be planned and initiated by a licensed Physical Therapist.

2. On 4/24/13 at approximately 2:30 PM a tour was conducted in the Hospital's PT Department. During the tour a Physical Therapy Assistant (PTA) and Speech Therapist (ST) were on duty.

3. The PTA presented six (6) PT inpatient referrals that had not been completed as of 4/24/13. Examples: Pt #2 referral dated 4/19/13 reason Parkinson disease; Pt #19 referral dated 4/22/13 reason pelvic pain; Pt #21 referral dated 4/19/13 reason muscle weakness; Pt #22 referral dated 4/19/13 reason muscle weakness; and Pt #24 referral dated 4/19/13 reason muscle weakness.

4. On 4/24/13 at approximately 2:00 PM, the PTA stated the six referrals had not been completed because the physical therapist, who was "agency", left on 4/19/13.

5. The findings were verified with the Hospital's Speech Language Therapist and Physician Therapy Assistant during an interview on 4/24/13 at approximately 2:30 PM.

Based on review of documents and staff interview, it was determined that for 6 of 6 patients (Pt #2, 19, 21, 22, 23, and 24) the Hospital failed to ensure physical therapy assessments were completed as required. Findings include:

1. Hospital policy entitled, "Staff Qualifications of the Physical Therapist," (revised April 2012) required, "Physical Therapy must be planned and initiated by a licensed Physical Therapist."

2. Hospital policy entitled, "Assessment/Referral Procedure," (revised 2/09) required, "Procedure: Physical Therapy Services will be rendered upon the written request of a physician who is a member of the Medical Staff to Sacred Heart Hospital. A. In-Patient: 4. The patient is seen for evaluation within 24 hours of receipt of the physicians order for therapy..."

3. The Physical Therapy Assistant (PTA) presented six (6) PT inpatient referrals that have not been completed as of 4/24/13. Examples: Pt #2 referral dated 4/19/13 reason Parkinson disease (5 days); Pt #19 referral dated 4/22/13 reason pelvic pain (2 days); Pt #21 referral dated 4/19/13 reason muscle weakness (5 days); Pt #22 referral dated 4/19/13 reason muscle weakness (5 days); and Pt #24 referral dated 4/19/13 reason muscle weakness (5 days).

4. The findings were verified with the Hospital's Speech Language Therapist and the PTA during an interview on 4/24/13 at approximately 2:30 PM.

Based on document review and staff interview, it was determined the Hospital failed to ensure medication errors were identified and reported. Findings include:

1. On 4/26/13 the Pharmacy &Therapeutic Committee minutes dated 8/14/12 were reviewed. There was no documentation that facility wide medication errors were reviewed. The Hospital was unable to produce a current evaluation for medication errors.
This was verified with the CNO during an interview on 4/26/13 at approximately 3:00 PM.

2. On 04/23/13 at approximately 9:45 AM, the "Performance Improvement/Patient Safety (PIP)"plan was reviewed. The plan included, "Performance Improvement is an organizational-wide program that studies functions and processes to achieve best practice in patient care outcomes...comprehensive performance measures...Obtain approval from the Medical PIPS Committee before starting a project. The Hospital's quality assessment and improvement program is a continuous, integrated activity within the facility. It is the responsibility and accountability of the PIP committee to coordinate and become the oversight for all performance improvement activities " At approximately 3:00 PM, a document titled. "Performance Improvement 2012" was provided. The document listed 100% compliance for May, June and July 2012 for 9 pharmacy topics (medication inspection, sample drug inspection, antibiotic review, coumadin review, total parental nutrition, culture and sensitivity, vancomycin/aminoglycoside monitoring, creatinine clearance review and daily narcotic count). No further data was documented for 2012 or 2013.