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Based on Medical Record (MR) review, and staff interview, this facility failed to establish individualized goals for 14 out of a total of 25 Pt's who had an inpatient admission and required a care plan (Pt. #4, 14, 15, 16, 17, 18, 23, 24 25, 26, 27, 28, 29, 37). Failure to complete a nursing care plan specific to the needs of the patient has the potential to affect all 28 patients present during the survey.

Findings by Surveyor #26711 include:

An interview with Registered Nurse (RN) I was conducted on 3/7/2012 at 7:30 a.m. during MR reviews. RN I stated that the goals that nurses pick for patients and enter into the care plans are not able to be individualized to each patient. RN I stated that this would have to be brought to the provider of the software to enable staff to do this.
At 9:23 a.m. RN V clarified that the ability to add "evidenced by" statements to computer generated goals is possible, thereby enabling staff to individualize these goals to the patient's needs.

Pt. #14's closed surgical MR was reviewed on 3/6/2012 at 2:15 p.m. accompanied by RN Q.
Pt. #15, 16, 17, and 18's open inpatient MRs were reviewed on 3/7/2012 between 7:15 a.m. and 9:45 a.m. accompanied by RN T.
Pt. #37's closed surgical MR was reviewed on 3/7/2012 at 2:05 p.m. accompanied by RN V.

Pt.'s 14, 15, 16, 17, 18, and 37 had computer generated goals entered by nursing that were not altered to reflect the individualized needs of the patients.

These findings were confirmed by RN's Q, T, and V at the time of the MR reviews.



18816

Examples by surveyor 18816:

Per Pt (Patient) 4's MR (medical record) review by surveyor 18816 on 3/6/12 at 8:05 AM the nursing care plan does not have goals that are unique to the Pts needs. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.




29972

Findings by surveyor #29972

Per Pt #23 and Pt #24's medical record review on 3/7/12 at 9:30 am, the nursing care plans do not have individualized goals unique to the patients needs. These findings were confirmed with Staff A director of Quality on 3/7/12 at 1:25 pm.





29963



Findings by surveyor 29963 include:

Pt. # 25, 26, 27, 28, and 29 open medical record review on 3/7/2012 between 7:30 a.m. and 10:40 a.m. with RN V. All MR's had computer generated goals entered by nursing that were not altered to reflect the individual needs of the patients.

These findings were confirmed with RN V and RN R at the time of the MR review.

On 3/7/2012 at 7:30 a.m. open medical record review on pt. # 25 with RN V and RN R revealed a score of 2 on the falls risk which would place pt to be at risk for falls. No careplan addressing falls noted. Pt # 25 scored a 17/23 points on her Braden score which places pt. at risk for alteration in skin integrity. No careplan addressing potential for alteration in skin integrity.

On 3/7 2012 at 10:25 a.m. open medical record review on pt. # 29 with RN V and RN R revealed a score of 15/23 points on her Braden score which places pt. at risk for alteration in skin integrity. No careplan addressing potential for alteration in skin integrity.

These findings were confirmed with RN V and RN R at the time of the MR review.

Based on policy and procedure review, observations of care, and staff interview, this facility does not ensure that medications are prepared and administered in a safe manner in 2 of 2 observations made (Pt. #1 and #3). Failure to safely administer and prepare medications has the potential to affect all 28 patients present during the survey.

Findings by Surveyor #26711 include:

The facility's policy titled, "Safe Injection Practices and Multidose Vials," dated 12/2011 was reviewed on 3/7/2012 at 12:35 p.m. On page 2, C. Single-use/Multi-use Vials, #3. states, "The diaphragm of a vial shall be cleansed prior to accessing the medication using an alcohol wipe or alcohol spray and gauze. The diaphragm shall be dried completely before inserting any device into the vial."

The facility's policy titled, "Medication Administration," dated 09-2009 was reviewed on 3/7/2012 at 12:50 p.m. On page 7, .03 R. #3 states in part, "If you get nitroglycerine ointment on your hands, you could develop a headache. Use gloves when applying."

An observation of medication administration in the Intensive Care Unit was conducted on 3/5/2012 at 11:30 a.m. accompanied by Quality Specialist (QS) I. RN H was observed removing a paper patch with nitroglycerin ointment (a medication applied to the skin to manage chest pain) from Pt. #1's left back and re-applying the new patch with nitroglycerin ointment without wearing gloves. The old patch was discarded in the waste receptacle in Pt. #1's room. Gloves are to be worn for this procedure.

In an interview with Director Z on 3/7/2011 at 11:45 a.m. regarding the use of gloves to apply and remove nitroglycerine patches, Director Z confirmed that gloves should be worn.

A tour of the Surgery Suite and an observation of Pt. #3's surgical procedure was conducted on 3/6/2012 from 7:30 a.m.-11:45 a.m. accompanied by Dir. P and QS I.
Between 7:47 a.m. and 7:50 a.m. Medical Doctor (MD) N was observed to open 3 vials of medication and insert needled syringes into them to withdraw medication for surgery without swabbing the rubber septum with alcohol prior to inserting the needle on 5 separate occasions. MD N also dropped one of these syringes, with a needle cover on, on the floor and put it back on the table top with the rest of the medications.

These findings were discussed on 3/7/2011 at 2:30 p.m. in the presence of QS I and RN R

Based on MR (medical record) review, review of P&P (policy and procedures) and interview with staff, in 14 of 34 MR's the facility failed to ensure all entries are documented with a date and time, the MD (medical doctor) notification time is documented in ER (emergency room) records, discharge instructions are complete and in the record, and all dictations have a dictation and transcription time. This deficiency affects all 28 inpatients and 171 ER Pt (Patient) at the facility during survey.

Findings include:

Per Rules and Regulations for Medical Staff, reviewed 4/6/11, state, 3.5. Clinical Entries, 3.5.1 All clinical entries in the patients medical record shall be legible, complete, accurately dated, timed and authenticated.


Examples by surveyor 18816:

Pt #4's MR review by surveyor 18816 on 3/6/12 at 8:05 AM revealed the Pt arrived in the ER on 5/19/11 at 9:51 AM. There is no documented time the MD was notified of Pt #4's arrival. The H&P (History & Physical) and Death Summary do not have a time dictated nor a time transcribed. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #5's MR reviewed by surveyor 18816 on 3/7/12 at 12:50 PM revealed the Pt arrived in the ER on 3/15/11 at 5:51 PM. There is no documentation time the MD was notified of Pt #5's arrival, and no documented time the MD saw Pt #7. The Consent for Organ/Tissue Donation is not dated and timed when completed by the RN or Requestor. This is confirmed in interview with IS (Informatics Specialist) AA on 3/7/12 at 12:50 PM.

Pt #7's MR reviewed by surveyor 18816 on 3/6/12 at 10:00 AM revealed the Transfer Form does not have a time the MD completed the form. This is confirmed in interview with RN Q on 3/6/12 at 10:00 AM.

Pt #8's MR reviewed by surveyor 18816 on 3/6/12 at 10:30 AM revealed the Pt arrived in the ER on 11/2/11 at 3:41 PM. There is no time documentated when the MD was notified of Pt #8's arrival. There is no time documented on the Discharge Instructions. This is confirmed in interview with RN Q on 3/6/12 at 10:30 AM.

Pt #9's MR reviewed by surveyor 18816 on 3/6/12 at 10:55 AM revealed the Pt arrived in the ER on 1/5/11 at 2:33 PM. There is no time documentated when the MD was notified of Pt #9's arrival. There is no MD authentication of the PA (Physician Assistant) notes. The Discharge Instructions do not have a signature, date and time when completed with the Pt. This is confirmed in interview with RN Q on 3/6/12 at 10:55 AM.

Pt #10's MR reviewed by surveyor 18816 on 3/6/12 at 1:00 PM revealed the SANE (Sexual Assault Nurse Examiner) notes do not have dates and times when the examination documentation is completed. This is confirmed in interview with DQ (Director of Quality) A on 3/6/12 at 1:00 PM.

Pt #11's MR reviewed by surveyor 18816 on 3/6/12 at 1:00 PM revealed the SANE notes do not have dates and times when the examination documentation is completed. This is confirmed in interview with DQ A on 3/6/12 at 1:00 PM.

Pt #12's MR review by surveyor 18816 on 3/7/12 at 1:10 PM revealed the Medication Reconciliation forms are not signed with a date and/or time by the MD. Pt #12 had an epidural placed on 1/1/11 to relieve labor pain, there is no post anesthesia note to ensure complete recovery from the epidural anesthetic. The Delivery Summary is not timed when signed by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:10 PM.

Pt #13's MR review by surveyor 18816 on 3/7/12 at 1:40 PM revealed the Neonatal Examinations dated 1/1/12, 1/2/12 and 1/3/12 are not timed when completed by the MD. An MD progress note completed on 1/4/12 is not timed by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:40 PM.

Pt #32's MR review by surveyor 18816 on 3/7/12 at 10:40 PM revealed the Neonatal Examination completed on 3/7/12 is not timed by the MD. This is confirmed in interview with RN Z on 3/7/12 at 10:40 AM.


26711

Findings by Surveyor #26711:

An MR review was completed on Pt. #3's closed surgical MR on 3/6/2012 at 1:20 p.m. in the presence of RN Q. Pt. #3 had been discharged just prior to the MR review. The discharge instructions were not dated or timed by Pt. #3.

An MR review was completed on Pt. #14's closed surgical MR on 3/6/2012 at 2:15 p.m. in the presence of RN Q. The discharge instructions were not dated or timed by Pt. #14.

An MR review was completed on Pt. #16's open MR on 3/7/2012 at 7:55 a.m. in the presence of RN T and Quality Specialist (QS) U. There is a pre-printed order for Heparin in the MR dated 3/7/12 that does not include a time the MD signed it.

An MR review was completed on Pt. #37's closed surgical MR on 3/7/2012 at 2:05 p.m. in the presence of RN Q. The discharge instructions were not dated or timed by Pt. #37. The discharge summary, dictated by a physician assistant on 12/8/11, was not co-signed by the MD for more than 30 days (1/14/12). The operation report, dictated by a physician assistant on 12/5/11, was not co-signed by the MD for more than 30 days (1/14/12), and there are medication reconciliation forms (dated 12/8/11) and a post-operative order form (dated 12/5/11) completed by the physician assistant that were not co-signed by the MD for more than 30 days (1/14/12).

These findings were confirmed and verified at the time discovery with the staff members accompanying Surveyor #26711 at the times of the MR reviews.

Based on MR (medical record) review, review of rules and regulations and interview with staff, in 4 of 34 (Pt #4, 13, 23, 24) inpatient MR's the facility failed to ensure all verbal, standing and telephone orders are authenticated by the MD (Medical Doctor) with a signature, date and/or time within 48 hours of being written. This deficiency potentially affects all 28 inpatients at the facility during survey.

Findings include:

The facility's Medical Staff Rules and Regulations, dated 4/5/2011, were reviewed on 3/7/2012 at 1:05 p.m. On page 10, 4.1.3 states in part, "All verbal and telephone orders must be dated, timed and authenticated by the ordering Practitioner within forty-eight (48) hours."

Pt (patient) #4's MR reviewed by surveyor 18816 on 3/6/12 at 8:05 AM revealed there are verbal and telephone orders written between 5/19/11 and 5/21/11 that are not authenticated by the MD within 48 hours of when they were written. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #13's MR reviewed by surveyor 18816 on 3/7/12 at 1:40 PM revealed there are telephone orders written on 1/2/12 that are not authenticated with a time by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:40 PM.


29972

Finding by surveyor #29972:

Pt #23's MR's reviewed on 3/7/12 beginning at 9:30 AM revealed telephone orders written on 10/12/11 on the "ER Admission Order Form" that are not authenticated by physican until 10/18/12, 6 days after the orders were written. This is confirmed in interview with Information Specialist U on 3/7/12 at 9:30 am.

Pt #24's MR's reviewed on 3/7/12 beginning at 10:45 AM revealed telephone orders written on 1/10/12 that are not authenticated by physican until 1/16/12, 6 days after the orders were written. This is confirmed in interview with Information Specialist U on 3/7/12 at 11:00 am.

Based on Medical Record (MR) review, observation, and staff interview, this facility failed to obtain proper authentication on admission consents (dates, times, and/or signatures) for 6 of 25 patients (Pt. #1, 4, 5, 18, 35, 37); failed to obtain an admission consent on 1 out of 25 (Pt. #17); and failed to identify all surgical personnel who would be involved in manipulating tissue on the surgical consents in 3 out of 5 surgical MR reviewed (Pt. #3, 14, and 37). Failure to obtain a properly authenticated consent has the potential to affect all 28 present during the survey.

Findings by Surveyor #26711 include:

An MR review was completed on Pt. #1's open MR on 3/7/2012 at 7:15 a.m. in the presence of Registered Nurse (RN) T and Quality Specialist (QS) U. Pt. #1's admission consent for care is not signed, dated, or timed by Pt. #1.

An MR review was completed on Pt. #17's open MR on 3/7/2012 at 9:14 a.m. in the presence of RN T and QS U. Pt. #17 does not have an admission consent for care.

An MR review was completed on Pt. #18's open MR on 3/7/2012 at 9:24 a.m. in the presence of RN T and QS U. Pt. #18's admission consent for care is not dated or timed by Pt. #18.

An MR review was completed on Pt. #35's closed MR on 3/7/2012 at 1:27 p.m. in the presence of RN V. Pt. #35's surgical consent was signed on 10/11/11 in the MD office and was not re-signed and witnessed prior to surgery on 11/17/11. The consent was more than 30 days old.

An MR review was completed on Pt. #37's closed MR on 3/7/2012 at 2:05 p.m. in the presence of RN V. Pt. #37's admission consent for care is not dated or timed by Pt. #37.

In an interview with Director (Dir.) P on 3/6/2012 at 11:30 a.m., Dir. P stated that there are some physicians who have Physician Assistants (PA) and these PAs are privileged to assist with the surgery. The PAs can mark the skin for the surgical site and can close incisions for the physician. Dir. P stated that the PAs are not named on the surgical consent.

An MR review was completed on Pt. #3's closed surgical MR on 3/6/2012 at 1:20 p.m. in the presence of RN Q. Pt. #3 had a surgical procedure on 3/6/2012 (observed by Surveyor #26711) and PA FF was in the Operating Room (OR) with Medical Doctor (MD) O. PA FF is not named on the surgical consent.

An MR review was completed on Pt. #14's closed surgical MR on 3/6/2012 at 2:15 p.m. in the presence of RN Q. Pt. #14 had a surgical procedure on 11/8/11 and PA FF was in the OR with the MD. PA FF is not named on the surgical consent.

An MR review was completed on Pt. #37's closed surgical MR on 3/7/2012 at 2:05 p.m. in the presence of RN V. Pt. #37 had a surgical procedure on 12/5/11 and PA FF was in the OR with the MD O. PA FF is not named on the surgical consent.

These findings were verified and confirmed at the time of discovery with the staff members in attendance of the MR reviews.


18816

Examples by surveyor 18816:

Pt (Patient) #4's MR (medical record) review by surveyor 18816 on 3/6/12 at 8:05 AM revealed the Pt arrived in the ER (Emergency Room) on 5/19/12 at 9:51 AM. The consent on file is dated 5/18/12, no new consent is completed for the 5/19/12 admission. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #5's MR review by surveyor 18816 on 3/7/12 at 12:50 PM revealed the consent signed by two witnesses are not dated and timed by the witnesses. This is confirmed in interview with IS (Information Specialist) AA on 3/7/12 at 12:50 PM.

Based on MR (medical record) review, review of rules and regulations, and interview with staff, in 2 of 30 (Pt #9 and 12) inpatient MR's and 3 of 8 (MD BB, MD CC, MD DD) medical doctors reviewed, the facility failed to ensure MR's are complete within 30 days of discharge. This deficiency potentially affects all 28 inpatients at the facility during survey.

Findings include:

The Medical Staff Bylaws/Rules and Regulations, which are reviewed annually and were last reviewed in April of 2011, state:
On page 8 of the Rules and Regulations, 3.8.2 states, " The patents medical record shall be reasonably complete at the time of discharge. All remaining documents shall be completed and authenticated within fifteen (15 ) days following discharge. If any physician has failed to complete a patient's record within this time period, the physician shall be notified that s/he may be subject to corrective action if records are not timely completed. If the record is not completed within seven (7) calendar days after such notification, a second reminder letter will be sent to the physician. If the medical record is not completed within 30 days following discharge, the delinquent physician will be subject to action consistent with the Medical Staff Bylaws."

On page 39 of the Bylaws of the medical staff, #3 states, "A Practitioner will be considered to have voluntarily relinquished the privilege to admit new patients or schedule new procedures whenever he/she fails to complete medical records within time frames established by Medical Staff and/or Hospital policy, after received written notice of such deficiency. This relinquishment of privileges shall not apply to patients admitted at the time of relinquishment, or to imminent deliveries. The relinquished privileges will be automatically restored upon completion of the medical records and compliance with medical records policies."

Pt (patients) #9's MR reviewed by surveyor 18816 on 3/6/12 at 10:55 AM revealed the Pt was seen by a PA (Physician Assistant) in the Emergency Room on 1/5/12. There is no MD authentication of the PA notes. This is confirmed with RN Q on 3/6/12 at 10:55 AM.

Pt #12's MR review by surveyor 18816 on 3/7/12 at 1:10 PM revealed the Pt was discharged on 1/3/12. The Discharge Summary is not dated and timed by the MD. This is confirmed in interview with IS (Informatics Specialist) AA on 3/7/12 at 1:10 PM.


29963


Findings include:

During an interview of the Medical Records (MR) Dir. K on 3/5/2012 at 1:15 p.m. accompanied by CFO EE, it was discovered that several physicians had delinquent records past 30 days.

According to Dir. K, the expectation is that the record will be complete within 30 days. The physicians are called and reminded. No tracking of delinquent physicians has been done. Letter will be sent out starting in March and then staff will start reinforcing the policy.

Dir. K stated this information has been shared with physicians at Medical staff meetings on 11/17/11 and 12/15/11.

A sampling of MR's were reviewed. MD BB had 3 delinquent MRs dating back to 12/11 that needed completion. MD CC had 4 delinquent MRs dating back to 5/11. MD DD had 13 delinquent MRs dating back to 10/09. .

These findings were confirmed by Dir. K on 3/3/2012 at the time of the findings.

Based on observation and staff interviews the hospital failed to ensure 4 of 6 medication carts were properly secured from unauthorized access. This could potentially impact all 28 patients receiving care at this facility.

Findings Include:

Per observation, by surveyor #29963 while touring the Emergency Department (ED) on 3/5/12 at 2:55 p.m. with Dir. of ED J and Quality Specialist (QS) I, a crash cart which contained drugs and biologicals was sitting next to patient gurney's in trauma room B and D. The crash carts contained a break away locking device to alert staff if someone had accessed the cart for use. The carts do not have a permanent locking device to ensure unauthorized access by patients, families and visitors.

Per Dir ED J, patients, families and visitors are at times left unattended in the trauma bay with curtain drawn and out of continuous staff view. As a result, the cart which contains drugs, biological's and intravenous solutions could be accessed without staff knowledge resulting in tampering, destruction, or removal of the crash cart contents.


26711

Findings by Surveyor #26711:

During a tour of the Post Anesthesia Care Unit, accompanied by Dir. P and Quality Specialist (QS) I on 3/6/2012 at 9:45 a.m. an emergency cart (crash cart) which contained medications was noted to be in the hallway and was equipped with a break away lock.

Dir. P stated that this cart is placed in the Surgical suite after hours, however housekeeping would still have access to the medications in this cart when it was unsupervised by staff.


18816

Example by surveyor 18816:

Per surveyor 18816 tour of the facility birthing suite on 3/6/12 at 2:00 PM the crash cart in the back hallway does not have a lock to prevent unauthorized access and is not in view at all times. This is confirmed with RN (Registered Nurse) Z on 3/6/12 at 2:00 PM.

Based on observation, staff interview and review of maintenance records between 3/05-3/07/2012, the facility failed to construct, install and maintain the building systems to ensure life safety to patients due to (i) one non-latching fire-rated doors in occupancy separation wall and fire barrier; (ii) corridor walls not being smoke-tight and one space not separated from corridor; (iii) four noncompliant corridor doors; (iv) locking arrangements - delayed locking and card access - on doors in the means of egress corridor; (v) lack of complete smoke detection coverage in one large space open to corridor; (vi) sprinkler heads of intermediate temperature rating in two nonhazardous areas; (vii) lack of identification on critical branch electrical receptacles in critical care areas, and of normal power electrical receptacles in two operation rooms; and (viii) lack of positive air pressure in two spaces, and of ventilation in one space.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for all patients.

Refer to the following K tags for details: K 11, K-17, K-18, K-38, K-52, K-56, K-147, A-709, and A-726.

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to all patients.

Findings include:

1. Failed to protect the life safety of patients from fire due to two sets of fire-rated doors in fire separation walls that did not fully close and latch;
2. Failed to protect the life safety of patients from fire due to (i) corridor walls of 3rd floor patient rooms not smoke-tight, and (ii) one space used for wheel chair storage not separated from corridor with corridor wall;
3. Failed to protect the life safety of patients from fire due to (i) a wide gap at the meeting edge of two sets of corridor doors on the 1st Floor, and (ii) lack of positive latching hardware on two corridor doors;
4. Failed to protect the life safety of patients from fire due to (i) delayed egress locking arrangements on more than one door in an egress path, and (ii) three locked doors in means of egress corridors that did not provide an easy access to exits.
5. Failed to protect the life safety of patients from fire due to lack of complete smoke detection coverage in the Cafeteria space open to corridor;

6. Failed to protect the life safety of patients from fire due to sprinkler heads not of ordinary-temperature rating in two nonhazardous areas in accordance with NFPA 13 5-3.1.4.1; and

7. Failed to protect the life safety of patients from fire due to (i) essential power system supplied critical branch receptacles not identified as to the panelboard and circuit number, and (ii) lack of normal power supplied electrical receptacles in two operation rooms.

Refer to the following K tags for details: K 11, K-17, K-18, K-38, K-52, K-56, and K-147

Based on observation and staff interview, the facility did not provide proper ventilation due to (i) lack of positive pressure in two spaces, and (ii) lack of ventilation in one space. This deficient practice had a potential of cross-contamination of air with undesirable contaminants, and causing possible infection.

Findings include

During a tour of the facility with Staff D (chief operations officer), Staff MM (facility services director), and Staff PP (maintenance supervisor) between 3/5 - 3/7/12, Surveyor 12316 observed that (i) on 3/5/12 at 1:38 pm, the Clean Supply room with med supplies adjacent to the north smoke barrier of Smoke Compartment 2 on the 3rd Floor was not under positive pressure relative to adjacent spaces to cause airflow from the clean space to adjacent spaces. It was instead under negative pressure causing airflow in the wrong direction;
(ii) on 3/6/12 at 9:40 am, the Central Processing/Sterilizing room on the 2nd Floor was not under positive pressure relative to the corridor north of the room to cause airflow from the room to corridor. It was instead under negative pressure causing airflow from corridor to the Central Processing room, which is a wrong direction; and
(iii) on 3/6/12 at 3:58 pm, the Clean Supply Storage in the Eagle Room of the outpatient radiology area on the 2nd Floor did not have ventilation.

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observations, policy and procedures, and staff interviews, the hospital failed to provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases in 6 of 13 departments observed (Lab, Surgery, Dietary, Housekeeping, Laundry, Nursing). This has the potential to impact all 28 inpatients receiving care at this facility at the time of this survey.



29963


Findings by Surveyor 29963:

Per Policy entitled Medication No Interruption Protocol dated 3/2012 under safety/Precautions states: Upon returning to medication room, will clean red No Interruption Basket with approved cleaning agent after each use.

On 3/7/12 at 8:45 a.m. observed RN FF return to medication room after administering medication in a patients room and did not disinfect the basket.

The above findings were confirmed in an interview with RN R on 3/7/12 at 2:35 p.m.

Per interview on 3/5/12 at 1:50 p.m. with Manager L, it was revealed that privacy curtains throughout the facility are not on a routine cleaning schedule to protect patients and staff from cross contamination of microorganisms and communicable diseases.

The above findings are confirmed with staff D and I at time of interview.

Per interview on 3/5/12 at 1:50 p.m. with Manager L, it was revealed that there are no quality control checks being done for the automated housekeeping dispensing systems of cleaning solutions. Interview also confirmed there is no policy in place for quality control checks on the cleaning solution dispensing systems to ensure that the appropriate mixture is obtained for disinfection purposes.

The above findings are confirmed with Staff D and I at time of interview.


26711

The facility's policy titled, "Hand Hygiene," dated 5/2010, was reviewed on 3/6/2012 at 12:00 p.m. The policy states, in part, in section .04, B. "Decontaminate hands using appropriate method: 1. Before having direct contact with patients....3. After contact with patient's intact skin....4. After contact with body fluids....6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient....7. After removing gloves."

The facility's policy titled, "OR [operating room] Attire," dated 1-2010 was reviewed on 3/7/2012 at 3:20 p.m. On page 2, .02 A. g. states, "Protective Eyewear: 1. Protective eyewear or face shields will be worn at all times when scrubbing and when there is a risk of exposure. 2. Protective eyewear must cover the side and bottom of the eyes. Approved eyewear is found at the scrub sink."

Findings by Surveyor #26711:

Laboratory
A tour of the Laboratory (Lab) was conducted on 3/5/2012 at 2:15 p.m. accompanied by Director (Dir.) E and Manager (Mgr) F. There was a build up of dust noted on the ledge of the backsplash of the counters in Hematology, the Blood Bank, and Microbiology. This finding was confirmed at the time of discovery with Mgr. F when F swiped a finger on the ledge and came back with dust build up. The Lab should be free from dust and debris.

An observation of an outpatient blood draw was conducted on 3/5/2012 at 2:50 p.m. accompanied by Dir. E. Phlebotomist (Phleb.) G was observed as follows: with the same gloves worn to touch the skin of Pt. #2, Phleb. G was observed entering the drawers of the supply cart on two occasions, and use a pen that was laying on top of the cart to document on the labels of the tubes of blood, thereby potentially contaminating the remaining clean supplies in the drawers and the pen used for future documentation.

An observation of Phleb. W was conducted on 3/6/2012 at 4:00 p.m. accompanied by Dir. E. Phleb W. After obtaining a blood sample from Pt. #38, Phleb. W, with gloved hands used to touch the skin and obtain blood of Pt. #38, reached into W's pocket for a pen, used the pen to document on the labels for the tubes, and handled the bio-hazard bag to put the tubes of blood in before removing the gloves and washing hands thereby potentially contaminating the pen, pocket, and bio-hazard bag.

Surgery
A tour of the Surgery Suite and an observation of Pt. #3's surgical procedure was conducted on 3/6/2012 from 7:30 a.m.-11:45 a.m. accompanied by Dir. P and QS I. The following observations were made:
--At 7:48 a.m. Surgical Technician (ST) M dropped a wrapped sterile pack on the floor while setting up for surgery. ST M picked up the wrapped pack and put it back in the bin with the rest of the wrapped surgical supplies. (In an interview with Dir. P at 11:20 a.m. on 3/7/2012, Dir. P stated that if a wrapped pack fell on the floor it should not be used for the surgical case.)
--MD N and MD O did not have side shields on their regular prescription glasses to avoid splashes from entering their eyes during the procedure.
--Dir. P confirmed that the use of immediate use sterilization techniques (also known as flash sterilization) are being performed for the purpose of not enough equipment. Dir. P stated that on some days when eye surgeries are being done they can do up to 10 cases per day and only have 6 sets of equipment requiring the facility to do immediate use sterilization to complete the surgeries.

Kitchen
A tour of the kitchen was conducted on 3/7/2012 from 10:27 a.m.-11:15 a.m. accompanied by Mgr. X, Dir. Y, and QS I. It was noted that cardboard shipping containers were being brought in to the food preparation area and stored on shelving units. Emptied boxes were being broken down and placed in a bin adjacent to a food preparation area until the bin was full and then they are brought out to the dumpster. Cardboard shipping containers can harbor microorganisms that could contaminate food and should not be brought into food preparation areas.

These findings were again discussed on 3/7/2011 at 2:30 p.m. in the presence of QS I and RN R

Based on Medical Record (MR) review, policy and procedure review and staff interview, this facility failed to ensure the post-anesthesia evaluation by a person qualified to administer anesthesia included respiratory function (including respiratory rate, airway patency and oxygen saturation); cardiovascular function (including pulse rate and blood pressure); mental status; temperature; pain; nausea and vomiting; and postoperative hydration in 4 out of 5 (Pt. #3, 14, 35, and 36) Surgical patient record reviews out of a total of 34 MR reviewed.
In 1 of 5 Surgical patient record reviews (Pt. #37), no post anesthesia evaluation is documented.

Findings include:

The facility's policy titled, "Post Operative Anesthesia Evaluation," dated January 2012, was reviewed on 3/6/2012 at 11:30 a.m. The policy indicates the following are to be documented in the Pt. record: "1. cardiopulmonary status, 2. level of consciousness, 3. any follow up care or instructions to the patient, 4. any complications that occurred during post-anesthesia recovery."
The policy does not reflect all of the data required to be performed by the qualified anesthesia provider.

This policy also states to document this evaluation in the progress notes. In an interview with Director (Dir.) P on 3/7/2012 at 8:50 a.m., the post-anesthesia evaluation is not documented on a progress note, rather is to be documented on the Pre Anesthesia Evaluation form, in the bottom right corner.

A MR review was completed on Pt. #37's closed surgical record on 3/7/2012 accompanied by Registered Nurse (RN) V. There is no post-anesthesia evaluation documented for Pt. #37. This finding was confirmed at the time of discovery by RN V.

MR reviews were completed for Pt. #3 and 14 on 3/6/2012 between 1:20 p.m. and 2:45 p.m. accompanied by RN Q, and for Pt. #35 and 36 on 3/7/2012 between 1:27 p.m. and 2:05 p.m. accompanied by RN V.

Pt.s # 3, 14, 35, and 36 do not have complete post operative evaluations documented according to the Centers for Medicare and Medicaid guidelines. These findings were confirmed at the time of discovery and after review of the policy.

Based on Medical Record (MR) review, and staff interview, this facility failed to establish individualized goals for 14 out of a total of 25 Pt's who had an inpatient admission and required a care plan (Pt. #4, 14, 15, 16, 17, 18, 23, 24 25, 26, 27, 28, 29, 37). Failure to complete a nursing care plan specific to the needs of the patient has the potential to affect all 28 patients present during the survey.

Findings by Surveyor #26711 include:

An interview with Registered Nurse (RN) I was conducted on 3/7/2012 at 7:30 a.m. during MR reviews. RN I stated that the goals that nurses pick for patients and enter into the care plans are not able to be individualized to each patient. RN I stated that this would have to be brought to the provider of the software to enable staff to do this.
At 9:23 a.m. RN V clarified that the ability to add "evidenced by" statements to computer generated goals is possible, thereby enabling staff to individualize these goals to the patient's needs.

Pt. #14's closed surgical MR was reviewed on 3/6/2012 at 2:15 p.m. accompanied by RN Q.
Pt. #15, 16, 17, and 18's open inpatient MRs were reviewed on 3/7/2012 between 7:15 a.m. and 9:45 a.m. accompanied by RN T.
Pt. #37's closed surgical MR was reviewed on 3/7/2012 at 2:05 p.m. accompanied by RN V.

Pt.'s 14, 15, 16, 17, 18, and 37 had computer generated goals entered by nursing that were not altered to reflect the individualized needs of the patients.

These findings were confirmed by RN's Q, T, and V at the time of the MR reviews.



18816

Examples by surveyor 18816:

Per Pt (Patient) 4's MR (medical record) review by surveyor 18816 on 3/6/12 at 8:05 AM the nursing care plan does not have goals that are unique to the Pts needs. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.




29972

Findings by surveyor #29972

Per Pt #23 and Pt #24's medical record review on 3/7/12 at 9:30 am, the nursing care plans do not have individualized goals unique to the patients needs. These findings were confirmed with Staff A director of Quality on 3/7/12 at 1:25 pm.





29963



Findings by surveyor 29963 include:

Pt. # 25, 26, 27, 28, and 29 open medical record review on 3/7/2012 between 7:30 a.m. and 10:40 a.m. with RN V. All MR's had computer generated goals entered by nursing that were not altered to reflect the individual needs of the patients.

These findings were confirmed with RN V and RN R at the time of the MR review.

On 3/7/2012 at 7:30 a.m. open medical record review on pt. # 25 with RN V and RN R revealed a score of 2 on the falls risk which would place pt to be at risk for falls. No careplan addressing falls noted. Pt # 25 scored a 17/23 points on her Braden score which places pt. at risk for alteration in skin integrity. No careplan addressing potential for alteration in skin integrity.

On 3/7 2012 at 10:25 a.m. open medical record review on pt. # 29 with RN V and RN R revealed a score of 15/23 points on her Braden score which places pt. at risk for alteration in skin integrity. No careplan addressing potential for alteration in skin integrity.

These findings were confirmed with RN V and RN R at the time of the MR review.

Based on MR (medical record) review, review of P&P (policy and procedures) and interview with staff, in 14 of 34 MR's the facility failed to ensure all entries are documented with a date and time, the MD (medical doctor) notification time is documented in ER (emergency room) records, discharge instructions are complete and in the record, and all dictations have a dictation and transcription time. This deficiency affects all 28 inpatients and 171 ER Pt (Patient) at the facility during survey.

Findings include:

Per Rules and Regulations for Medical Staff, reviewed 4/6/11, state, 3.5. Clinical Entries, 3.5.1 All clinical entries in the patients medical record shall be legible, complete, accurately dated, timed and authenticated.


Examples by surveyor 18816:

Pt #4's MR review by surveyor 18816 on 3/6/12 at 8:05 AM revealed the Pt arrived in the ER on 5/19/11 at 9:51 AM. There is no documented time the MD was notified of Pt #4's arrival. The H&P (History & Physical) and Death Summary do not have a time dictated nor a time transcribed. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #5's MR reviewed by surveyor 18816 on 3/7/12 at 12:50 PM revealed the Pt arrived in the ER on 3/15/11 at 5:51 PM. There is no documentation time the MD was notified of Pt #5's arrival, and no documented time the MD saw Pt #7. The Consent for Organ/Tissue Donation is not dated and timed when completed by the RN or Requestor. This is confirmed in interview with IS (Informatics Specialist) AA on 3/7/12 at 12:50 PM.

Pt #7's MR reviewed by surveyor 18816 on 3/6/12 at 10:00 AM revealed the Transfer Form does not have a time the MD completed the form. This is confirmed in interview with RN Q on 3/6/12 at 10:00 AM.

Pt #8's MR reviewed by surveyor 18816 on 3/6/12 at 10:30 AM revealed the Pt arrived in the ER on 11/2/11 at 3:41 PM. There is no time documentated when the MD was notified of Pt #8's arrival. There is no time documented on the Discharge Instructions. This is confirmed in interview with RN Q on 3/6/12 at 10:30 AM.

Pt #9's MR reviewed by surveyor 18816 on 3/6/12 at 10:55 AM revealed the Pt arrived in the ER on 1/5/11 at 2:33 PM. There is no time documentated when the MD was notified of Pt #9's arrival. There is no MD authentication of the PA (Physician Assistant) notes. The Discharge Instructions do not have a signature, date and time when completed with the Pt. This is confirmed in interview with RN Q on 3/6/12 at 10:55 AM.

Pt #10's MR reviewed by surveyor 18816 on 3/6/12 at 1:00 PM revealed the SANE (Sexual Assault Nurse Examiner) notes do not have dates and times when the examination documentation is completed. This is confirmed in interview with DQ (Director of Quality) A on 3/6/12 at 1:00 PM.

Pt #11's MR reviewed by surveyor 18816 on 3/6/12 at 1:00 PM revealed the SANE notes do not have dates and times when the examination documentation is completed. This is confirmed in interview with DQ A on 3/6/12 at 1:00 PM.

Pt #12's MR review by surveyor 18816 on 3/7/12 at 1:10 PM revealed the Medication Reconciliation forms are not signed with a date and/or time by the MD. Pt #12 had an epidural placed on 1/1/11 to relieve labor pain, there is no post anesthesia note to ensure complete recovery from the epidural anesthetic. The Delivery Summary is not timed when signed by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:10 PM.

Pt #13's MR review by surveyor 18816 on 3/7/12 at 1:40 PM revealed the Neonatal Examinations dated 1/1/12, 1/2/12 and 1/3/12 are not timed when completed by the MD. An MD progress note completed on 1/4/12 is not timed by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:40 PM.

Pt #32's MR review by surveyor 18816 on 3/7/12 at 10:40 PM revealed the Neonatal Examination completed on 3/7/12 is not timed by the MD. This is confirmed in interview with RN Z on 3/7/12 at 10:40 AM.


26711

Findings by Surveyor #26711:

An MR review was completed on Pt. #3's closed surgical MR on 3/6/2012 at 1:20 p.m. in the presence of RN Q. Pt. #3 had been discharged just prior to the MR review. The discharge instructions were not dated or timed by Pt. #3.

An MR review was completed on Pt. #14's closed surgical MR on 3/6/2012 at 2:15 p.m. in the presence of RN Q. The discharge instructions were not dated or timed by Pt. #14.

An MR review was completed on Pt. #16's open MR on 3/7/2012 at 7:55 a.m. in the presence of RN T and Quality Specialist (QS) U. There is a pre-printed order for Heparin in the MR dated 3/7/12 that does not include a time the MD signed it.

An MR review was completed on Pt. #37's closed surgical MR on 3/7/2012 at 2:05 p.m. in the presence of RN Q. The discharge instructions were not dated or timed by Pt. #37. The discharge summary, dictated by a physician assistant on 12/8/11, was not co-signed by the MD for more than 30 days (1/14/12). The operation report, dictated by a physician assistant on 12/5/11, was not co-signed by the MD for more than 30 days (1/14/12), and there are medication reconciliation forms (dated 12/8/11) and a post-operative order form (dated 12/5/11) completed by the physician assistant that were not co-signed by the MD for more than 30 days (1/14/12).

These findings were confirmed and verified at the time discovery with the staff members accompanying Surveyor #26711 at the times of the MR reviews.

Based on MR (medical record) review, review of rules and regulations and interview with staff, in 4 of 34 (Pt #4, 13, 23, 24) inpatient MR's the facility failed to ensure all verbal, standing and telephone orders are authenticated by the MD (Medical Doctor) with a signature, date and/or time within 48 hours of being written. This deficiency potentially affects all 28 inpatients at the facility during survey.

Findings include:

The facility's Medical Staff Rules and Regulations, dated 4/5/2011, were reviewed on 3/7/2012 at 1:05 p.m. On page 10, 4.1.3 states in part, "All verbal and telephone orders must be dated, timed and authenticated by the ordering Practitioner within forty-eight (48) hours."

Pt (patient) #4's MR reviewed by surveyor 18816 on 3/6/12 at 8:05 AM revealed there are verbal and telephone orders written between 5/19/11 and 5/21/11 that are not authenticated by the MD within 48 hours of when they were written. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #13's MR reviewed by surveyor 18816 on 3/7/12 at 1:40 PM revealed there are telephone orders written on 1/2/12 that are not authenticated with a time by the MD. This is confirmed in interview with IS AA on 3/7/12 at 1:40 PM.


29972

Finding by surveyor #29972:

Pt #23's MR's reviewed on 3/7/12 beginning at 9:30 AM revealed telephone orders written on 10/12/11 on the "ER Admission Order Form" that are not authenticated by physican until 10/18/12, 6 days after the orders were written. This is confirmed in interview with Information Specialist U on 3/7/12 at 9:30 am.

Pt #24's MR's reviewed on 3/7/12 beginning at 10:45 AM revealed telephone orders written on 1/10/12 that are not authenticated by physican until 1/16/12, 6 days after the orders were written. This is confirmed in interview with Information Specialist U on 3/7/12 at 11:00 am.

Based on Medical Record (MR) review, observation, and staff interview, this facility failed to obtain proper authentication on admission consents (dates, times, and/or signatures) for 6 of 25 patients (Pt. #1, 4, 5, 18, 35, 37); failed to obtain an admission consent on 1 out of 25 (Pt. #17); and failed to identify all surgical personnel who would be involved in manipulating tissue on the surgical consents in 3 out of 5 surgical MR reviewed (Pt. #3, 14, and 37). Failure to obtain a properly authenticated consent has the potential to affect all 28 present during the survey.

Findings by Surveyor #26711 include:

An MR review was completed on Pt. #1's open MR on 3/7/2012 at 7:15 a.m. in the presence of Registered Nurse (RN) T and Quality Specialist (QS) U. Pt. #1's admission consent for care is not signed, dated, or timed by Pt. #1.

An MR review was completed on Pt. #17's open MR on 3/7/2012 at 9:14 a.m. in the presence of RN T and QS U. Pt. #17 does not have an admission consent for care.

An MR review was completed on Pt. #18's open MR on 3/7/2012 at 9:24 a.m. in the presence of RN T and QS U. Pt. #18's admission consent for care is not dated or timed by Pt. #18.

An MR review was completed on Pt. #35's closed MR on 3/7/2012 at 1:27 p.m. in the presence of RN V. Pt. #35's surgical consent was signed on 10/11/11 in the MD office and was not re-signed and witnessed prior to surgery on 11/17/11. The consent was more than 30 days old.

An MR review was completed on Pt. #37's closed MR on 3/7/2012 at 2:05 p.m. in the presence of RN V. Pt. #37's admission consent for care is not dated or timed by Pt. #37.

In an interview with Director (Dir.) P on 3/6/2012 at 11:30 a.m., Dir. P stated that there are some physicians who have Physician Assistants (PA) and these PAs are privileged to assist with the surgery. The PAs can mark the skin for the surgical site and can close incisions for the physician. Dir. P stated that the PAs are not named on the surgical consent.

An MR review was completed on Pt. #3's closed surgical MR on 3/6/2012 at 1:20 p.m. in the presence of RN Q. Pt. #3 had a surgical procedure on 3/6/2012 (observed by Surveyor #26711) and PA FF was in the Operating Room (OR) with Medical Doctor (MD) O. PA FF is not named on the surgical consent.

An MR review was completed on Pt. #14's closed surgical MR on 3/6/2012 at 2:15 p.m. in the presence of RN Q. Pt. #14 had a surgical procedure on 11/8/11 and PA FF was in the OR with the MD. PA FF is not named on the surgical consent.

An MR review was completed on Pt. #37's closed surgical MR on 3/7/2012 at 2:05 p.m. in the presence of RN V. Pt. #37 had a surgical procedure on 12/5/11 and PA FF was in the OR with the MD O. PA FF is not named on the surgical consent.

These findings were verified and confirmed at the time of discovery with the staff members in attendance of the MR reviews.


18816

Examples by surveyor 18816:

Pt (Patient) #4's MR (medical record) review by surveyor 18816 on 3/6/12 at 8:05 AM revealed the Pt arrived in the ER (Emergency Room) on 5/19/12 at 9:51 AM. The consent on file is dated 5/18/12, no new consent is completed for the 5/19/12 admission. This is confirmed in interview with RN (Registered Nurse) Q on 3/6/12 at 8:05 AM.

Pt #5's MR review by surveyor 18816 on 3/7/12 at 12:50 PM revealed the consent signed by two witnesses are not dated and timed by the witnesses. This is confirmed in interview with IS (Information Specialist) AA on 3/7/12 at 12:50 PM.

Based on MR (medical record) review, review of rules and regulations, and interview with staff, in 2 of 30 (Pt #9 and 12) inpatient MR's and 3 of 8 (MD BB, MD CC, MD DD) medical doctors reviewed, the facility failed to ensure MR's are complete within 30 days of discharge. This deficiency potentially affects all 28 inpatients at the facility during survey.

Findings include:

The Medical Staff Bylaws/Rules and Regulations, which are reviewed annually and were last reviewed in April of 2011, state:
On page 8 of the Rules and Regulations, 3.8.2 states, " The patents medical record shall be reasonably complete at the time of discharge. All remaining documents shall be completed and authenticated within fifteen (15 ) days following discharge. If any physician has failed to complete a patient's record within this time period, the physician shall be notified that s/he may be subject to corrective action if records are not timely completed. If the record is not completed within seven (7) calendar days after such notification, a second reminder letter will be sent to the physician. If the medical record is not completed within 30 days following discharge, the delinquent physician will be subject to action consistent with the Medical Staff Bylaws."

On page 39 of the Bylaws of the medical staff, #3 states, "A Practitioner will be considered to have voluntarily relinquished the privilege to admit new patients or schedule new procedures whenever he/she fails to complete medical records within time frames established by Medical Staff and/or Hospital policy, after received written notice of such deficiency. This relinquishment of privileges shall not apply to patients admitted at the time of relinquishment, or to imminent deliveries. The relinquished privileges will be automatically restored upon completion of the medical records and compliance with medical records policies."

Pt (patients) #9's MR reviewed by surveyor 18816 on 3/6/12 at 10:55 AM revealed the Pt was seen by a PA (Physician Assistant) in the Emergency Room on 1/5/12. There is no MD authentication of the PA notes. This is confirmed with RN Q on 3/6/12 at 10:55 AM.

Pt #12's MR review by surveyor 18816 on 3/7/12 at 1:10 PM revealed the Pt was discharged on 1/3/12. The Discharge Summary is not dated and timed by the MD. This is confirmed in interview with IS (Informatics Specialist) AA on 3/7/12 at 1:10 PM.


29963


Findings include:

During an interview of the Medical Records (MR) Dir. K on 3/5/2012 at 1:15 p.m. accompanied by CFO EE, it was discovered that several physicians had delinquent records past 30 days.

According to Dir. K, the expectation is that the record will be complete within 30 days. The physicians are called and reminded. No tracking of delinquent physicians has been done. Letter will be sent out starting in March and then staff will start reinforcing the policy.

Dir. K stated this information has been shared with physicians at Medical staff meetings on 11/17/11 and 12/15/11.

A sampling of MR's were reviewed. MD BB had 3 delinquent MRs dating back to 12/11 that needed completion. MD CC had 4 delinquent MRs dating back to 5/11. MD DD had 13 delinquent MRs dating back to 10/09. .

These findings were confirmed by Dir. K on 3/3/2012 at the time of the findings.

Based on observation and staff interviews the hospital failed to ensure 4 of 6 medication carts were properly secured from unauthorized access. This could potentially impact all 28 patients receiving care at this facility.

Findings Include:

Per observation, by surveyor #29963 while touring the Emergency Department (ED) on 3/5/12 at 2:55 p.m. with Dir. of ED J and Quality Specialist (QS) I, a crash cart which contained drugs and biologicals was sitting next to patient gurney's in trauma room B and D. The crash carts contained a break away locking device to alert staff if someone had accessed the cart for use. The carts do not have a permanent locking device to ensure unauthorized access by patients, families and visitors.

Per Dir ED J, patients, families and visitors are at times left unattended in the trauma bay with curtain drawn and out of continuous staff view. As a result, the cart which contains drugs, biological's and intravenous solutions could be accessed without staff knowledge resulting in tampering, destruction, or removal of the crash cart contents.


26711

Findings by Surveyor #26711:

During a tour of the Post Anesthesia Care Unit, accompanied by Dir. P and Quality Specialist (QS) I on 3/6/2012 at 9:45 a.m. an emergency cart (crash cart) which contained medications was noted to be in the hallway and was equipped with a break away lock.

Dir. P stated that this cart is placed in the Surgical suite after hours, however housekeeping would still have access to the medications in this cart when it was unsupervised by staff.


18816

Example by surveyor 18816:

Per surveyor 18816 tour of the facility birthing suite on 3/6/12 at 2:00 PM the crash cart in the back hallway does not have a lock to prevent unauthorized access and is not in view at all times. This is confirmed with RN (Registered Nurse) Z on 3/6/12 at 2:00 PM.

Based on observations, policy and procedures, and staff interviews, the hospital failed to provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases in 6 of 13 departments observed (Lab, Surgery, Dietary, Housekeeping, Laundry, Nursing). This has the potential to impact all 28 inpatients receiving care at this facility at the time of this survey.



29963


Findings by Surveyor 29963:

Per Policy entitled Medication No Interruption Protocol dated 3/2012 under safety/Precautions states: Upon returning to medication room, will clean red No Interruption Basket with approved cleaning agent after each use.

On 3/7/12 at 8:45 a.m. observed RN FF return to medication room after administering medication in a patients room and did not disinfect the basket.

The above findings were confirmed in an interview with RN R on 3/7/12 at 2:35 p.m.

Per interview on 3/5/12 at 1:50 p.m. with Manager L, it was revealed that privacy curtains throughout the facility are not on a routine cleaning schedule to protect patients and staff from cross contamination of microorganisms and communicable diseases.

The above findings are confirmed with staff D and I at time of interview.

Per interview on 3/5/12 at 1:50 p.m. with Manager L, it was revealed that there are no quality control checks being done for the automated housekeeping dispensing systems of cleaning solutions. Interview also confirmed there is no policy in place for quality control checks on the cleaning solution dispensing systems to ensure that the appropriate mixture is obtained for disinfection purposes.

The above findings are confirmed with Staff D and I at time of interview.


26711

The facility's policy titled, "Hand Hygiene," dated 5/2010, was reviewed on 3/6/2012 at 12:00 p.m. The policy states, in part, in section .04, B. "Decontaminate hands using appropriate method: 1. Before having direct contact with patients....3. After contact with patient's intact skin....4. After contact with body fluids....6. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient....7. After removing gloves."

The facility's policy titled, "OR [operating room] Attire," dated 1-2010 was reviewed on 3/7/2012 at 3:20 p.m. On page 2, .02 A. g. states, "Protective Eyewear: 1. Protective eyewear or face shields will be worn at all times when scrubbing and when there is a risk of exposure. 2. Protective eyewear must cover the side and bottom of the eyes. Approved eyewear is found at the scrub sink."

Findings by Surveyor #26711:

Laboratory
A tour of the Laboratory (Lab) was conducted on 3/5/2012 at 2:15 p.m. accompanied by Director (Dir.) E and Manager (Mgr) F. There was a build up of dust noted on the ledge of the backsplash of the counters in Hematology, the Blood Bank, and Microbiology. This finding was confirmed at the time of discovery with Mgr. F when F swiped a finger on the ledge and came back with dust build up. The Lab should be free from dust and debris.

An observation of an outpatient blood draw was conducted on 3/5/2012 at 2:50 p.m. accompanied by Dir. E. Phlebotomist (Phleb.) G was observed as follows: with the same gloves worn to touch the skin of Pt. #2, Phleb. G was observed entering the drawers of the supply cart on two occasions, and use a pen that was laying on top of the cart to document on the labels of the tubes of blood, thereby potentially contaminating the remaining clean supplies in the drawers and the pen used for future documentation.

An observation of Phleb. W was conducted on 3/6/2012 at 4:00 p.m. accompanied by Dir. E. Phleb W. After obtaining a blood sample from Pt. #38, Phleb. W, with gloved hands used to touch the skin and obtain blood of Pt. #38, reached into W's pocket for a pen, used the pen to document on the labels for the tubes, and handled the bio-hazard bag to put the tubes of blood in before removing the gloves and washing hands thereby potentially contaminating the pen, pocket, and bio-hazard bag.

Surgery
A tour of the Surgery Suite and an observation of Pt. #3's surgical procedure was conducted on 3/6/2012 from 7:30 a.m.-11:45 a.m. accompanied by Dir. P and QS I. The following observations were made:
--At 7:48 a.m. Surgical Technician (ST) M dropped a wrapped sterile pack on the floor while setting up for surgery. ST M picked up the wrapped pack and put it back in the bin with the rest of the wrapped surgical supplies. (In an interview with Dir. P at 11:20 a.m. on 3/7/2012, Dir. P stated that if a wrapped pack fell on the floor it should not be used for the surgical case.)
--MD N and MD O did not have side shields on their regular prescription glasses to avoid splashes from entering their eyes during the procedure.
--Dir. P confirmed that the use of immediate use sterilization techniques (also known as flash sterilization) are being performed for the purpose of not enough equipment. Dir. P stated that on some days when eye surgeries are being done they can do up to 10 cases per day and only have 6 sets of equipment requiring the facility to do immediate use sterilization to complete the surgeries.

Kitchen
A tour of the kitchen was conducted on 3/7/2012 from 10:27 a.m.-11:15 a.m. accompanied by Mgr. X, Dir. Y, and QS I. It was noted that cardboard shipping containers were being brought in to the food preparation area and stored on shelving units. Emptied boxes were being broken down and placed in a bin adjacent to a food preparation area until the bin was full and then they are brought out to the dumpster. Cardboard shipping containers can harbor microorganisms that could contaminate food and should not be brought into food preparation areas.

These findings were again discussed on 3/7/2011 at 2:30 p.m. in the presence of QS I and RN R