HospitalInspections.org

Referenced code: Title 42 CFR 485.623(a)
Based on observation and interview, it was determined the facility failed to maintain the building physical structure in a state of good repair for in two of two (Patient Room W334 and E327) patient rooms observed in that laminate had peeled of the edge of a window sill, large chip in the edge of a window sill and peeling wallpaper. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for injury and infection control issues. Findings follow:

A. While on tour of the facility on 10/30/2017 at 3:10 PM, observation showed a large strip of laminate had peeled off of the edge of the window sill in Patient Room W334. Another area of the same window sill edge had a large chip in it.
B. While on tour of the facility on 10/30/2017 at 3:50 PM, observation showed two areas of wallpaper peeling off of the wall near the bottom corners of the window in Patient Room E327.
C. During the tour, the Director of Nursing (DON) verified the failed practices.

Based on observation and interview, it was determined three of three (Operating Rooms (ORs) #1 and #2 and the Endoscopy Room in the hospital surgical unit) ORs and two (Procedure Rooms #1 and #2 in the Pain Clinic) of two Procedure Rooms were not protected by either isolated power or Ground-Fault Circuit Interrupter (GFCI) receptacles; there was no evidence presented a risk assessment had been performed to indicate that the ORs, Endoscopy Room, or Procedure Rooms were not to be considered as "wet locations" in which the receptacles needed to be protected. The failed practice had the potential to affect all patients and staff utilizing these areas because it could not be assured any electrical biomedical equipment connected to the receptacles would not present an electric shock hazard. There was a census of 21 patients on 10/30/17. Findings follow:

A. While touring the facility on 10/30/2017 at 2:15 PM, observation showed a Line Isolation Monitor (LIM) and an isolation panel were installed in OR #1; interview with the Assistant Director of Nursing revealed the monitors and isolation panels were no longer in use. Observation of GFCI receptacles were not in place in OR #1.
B. While touring the facility on 10/30/2017 at 2:30 PM, observation showed an LIM and an isolation panel were installed in OR #2; interview with the Assistant Director of Nursing revealed the monitors and isolation panels were no longer in use. Observation of GFCI receptacles were not in place in OR #2.
C. While touring the facility on 10/30/2017 at 2:45 PM, observation showed an LIM and an isolation panel were installed in the Endoscopy Room; interview with the Assistant Director of Nursing revealed the monitors and isolation panels were no longer in use. Observation of GFCI receptacles were not in place in the Endoscopy Room.
D. While touring the facility on 10/30/2017 at 3:50 PM, observation showed an LIM and an isolation panel were installed in Procedure Room #1 in the Pain Clinic; interview with the Assistant Director of Nursing revealed the monitors and isolation panels were no longer in use. Observation of GFCI receptacles were not in place in Procedure Room #1.
E. While touring the facility on 10/30/2017 at 3:55 PM, observation showed an LIM and an isolation panel were installed in Procedure Room #2 in the Pain Clinic; interview with the Assistant Director of Nursing revealed the monitors and isolation panels were no longer in use. Observation of GFCI receptacles were not in place in Procedure Room #2.
F. No evidence was presented to indicate a risk assessment had been performed to eliminate the two ORs, the Endoscopy Room, or the two Procedure Rooms from being considered as "wet locations."
G. See K914.

Referenced code: NFPA 99; 2012 edition, Sections: 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2

Based on observation and interview on 10/30/17 at 2:30 PM, it was determined three of three portable nerve stimulation devices had not had an inspection or preventative maintenance performed on them since September of 2016. At a minimum the units should have the current leakage tested per NFPA 99, Section: 10.3.5 and the manufacturer's instructions at least once per year. The failed practice had the potential to affect the safety of all patients on which the devices were used because it could not be assured that the devices would function as designed. There was a census of 21 patients on 10/30/17. Findings follow:

A. While on tour of the facility on 10/30/17 at 2:15 PM, observation showed that a portable nerve stimulation device in Operating Room (OR) #1 had an inspection sticker on it marked "September 2016."
B. While on tour of the facility on 10/30/17 at 2:30 PM, observation showed that a portable nerve stimulation device in OR #2 had an inspection sticker on it marked "September 2016."
C. While on tour of the facility on 10/30/17 at 2:45 PM, observation showed that a portable nerve stimulation device in the Endoscopy Room had an inspection sticker on it marked "September 2015."
D. During an interview on 10/31/17 at 3:00 PM with Chief Facilities Engineer, he stated that the devices were not part of the hospital's current inventory and had not been inspected for the current year (2017).
E. See K921.

Referenced code: NFPA 99; 2012 edition, Sections: 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Based on review of the Bylaws of the Professional Staff, review of Professional Staff Credential Files and interview, it was determined the Governing Body failed to assure the monitoring and implementation for the Bylaws of the Professional Staff in that five (#1, #2, #3, #4, #8) of eight (#1-#8) Professional Staff were not recredentialed every two years or by January 1st of the following year. The failed practice did not assure Professional Staff Member #1-#4 and #8 had been evaluated to determine their ongoing scope of clinical expertise and compliance with medical staff's membership criteria. The likelihood existed for five (#1, #2, #3, #4, #8) Professional Staff to provide services in the facility without being recredentialed. Findings follow:

A. The Bylaws of the Professional Staff were reviewed on 11/01/17 at 1:15 PM showed that:
1) Reappointments to the Active and Associate Staff shall be for a term of two (2) years ending on the last day of the calendar year."
2) Applications for reappointment to the Active and Associate Staff must be presented to the Medical Staff Services Secretary at least ninety (90) days prior to the end of final year of the applicant's current term on the Professional Staff.
3) The Board of Directors shall take action upon the applications for reappointment with the decision effective on January 1st of the following year.
B. Professional Staff Credential Files were reviewed on 11/01/17 at 2:15 PM. Professional Staff Member #1 had not been recredentialed since 02/03/14. Professional Staff Members #2, #3, #4, and #8 recredentialing was effective 02/28/17 instead of 01/01/17.
C. During an interview on 11/02/17 at 9:30 AM the Chief Executive Officer verified the recredentialing had been done in February of 2017 instead of effective January 1, 2017 for Professional Staff Members #2, #3, #4, and #8. In addition in the same interview, it was verified Professional Staff Member #1 had not gone through the recredentialing process since 02/03/14.

Based on observation, clinical record review, policy and procedure review and interview, it was determined the facility failed to follow its policies and procedures in that 1 (#12) of 2 (#12 and #21) patients were placed in a monitored camera room without a physician's order and failed to get patient consent from 2 of 2 (#12 and #21) patients to be viewed by staff via the camera. Failure to ensure a physician ordered Patient #12 to be constantly viewed by camera did not allow the physician to direct the total care of Patient #12 and failure to obtain permission from Patient #12 and Patient #21 (or their responsible party) did not allow the patients to be knowledgeable, comfortable and agreeable to being constantly viewed on camera by staff at the nursing desk. Failure to adhere to policies and procedures affected Patients #12 and #21. Findings follow:

A. Observation at 3:45 PM on 10/30/17 showed a computer monitor at the nursing station with two patients (#12 and #21) visible on the monitor. The Assistant Director of Nursing (ADON) was asked why Patients #12 and #21 were being monitored. The ADON stated Patient #21 had behavioral issues, was a high fall risk and was trying to pull out the feeding tube. The ADON stated Patient #12 had no reason to be monitored and the monitor was left on from a previous patient. The ADON stated a physician's order was required for a patient to be monitored via the camera.
B. Review of Patient #12's clinical record showed no physician's order to be monitored with a camera. The above findings were verified during interview with the ADON at 3:45 PM on 10/30/17 and at 3:45 PM on 11/01/17.
C. Review of Patient #12's clinical record showed no consent for monitoring with a camera. The findings were verified by the ADON at 3:45 PM on 11/01/17.
D. Review of Patient #21's clinical record showed no consent for monitoring with a camera. The findings were verified by the Informatics Technician #1 at 1:00 PM on 11/01/17.
E. Review of the policy and procedure titled, "Consent to Photography/Video Taping/ Other Imaging/Audio Recording," received from the Executive Assistant at 1510 on 10/31/17 showed that a consent was to be obtained from the patient with an explanation of the purpose, proposed use, and security mechanisms to protect patient privacy. The duration of retention of the images were to be given to the patient as well.

Based on observation and interview, the facility failed to store and handle opened single dose injectable medications were not available for use on more than one patient in one (Operating Room (OR) #2 Anesthesia Cart) of two (OR#1 Anesthesia Cart, OR#2 Anesthesia Cart) anesthesia carts. The opened single dose injectable medications did not contain bacteriostatic agents rendering them unusable. The likelihood existed for the spread of infection if administered to surgical patients. Findings follow:

A. A tour of Surgery on 10/30/17 at 2:45 PM showed the anesthesia cart located in Operating Room #2 contained the following opened single dose injectable medications available for further patient use:
1) One Ondansetron 4 milligrams (mg)/2 milliliters (ml);
2) One Cleocin Phosphate 900 mg/6 ml; and
3) One Sodium Chloride 20 ml.
B. During an interview on 10/30/17 at 2:55 PM, the Operating Room Manager verified the single dose injectable medications had been opened for patient use and not disposed of and were still available for further patient use.


Based on observation, review of manufacturer's guidelines, and interview, the facility failed to have a process to ensure multiple dose vials (MDV) of Succinylcholine 200 milligrams (mg)/10 milliliters (ml) and Rocuronium Bromide 50 mg/5 ml , once removed from refrigeration, that were stored at room temperature did not exceed the length of time allowed by manufacturer's requirements on two of two anesthesia carts. The failed practice affected six of six MDV of Succinylcholine 200 mg/10 ml and six of six MDV of Rocuronium Bromide 50 mg/5 ml that were stored at room temperature rendering the medications unusable. The likelihood existed for the stability/potency of the medications to be compromised and for the compromised medications to be administered to surgery patients when ordered. Findings follow:

A. A tour of Surgery on 10/30/17 at 2:45 PM showed four unopened MDV of Succinylcholine 200 mg/10 ml and three unopened MDV of Rocuronium Bromide 50 mg/5 ml were observed on the anesthesia cart stored at room temperature in Operating Room #1. Two unopened MDV of Succinylcholine 200 mg/10 ml and three unopened MDV of Rocuronium Bromide 50 mg/5 ml were observed on the anesthesia cart stored at room temperature in Operating Room #2. There was no process to reflect evidence as to how long the medications had been stored at room temperature.
B. Review of the manufacturer's storage guidelines for Succinylcholine and Rocuronium Bromide was conducted on 10/30/17 at 2:45 PM showed that once Succinylcholine was removed from refrigeration the medication could only be stored for 14 days at room temperature. Manufacturer's guidelines for Rocuronium Bromide showed that once removed from refrigeration the unopened MDV of medication could be stored for 60 days at room temperature or if opened for 30 days.
C. During an interview on 10/30/17 at 2:55 PM, the Operating Room Manager verified there was no evidence as to how long the Succinylcholine and Rocuronium Bromide had been stored at room temperature.


Based on review of Pharmacy Policy, review of Pharmacy Medication Area Reports, and interview, the facility failed to ensure the pharmacists or pharmacy technicians conducted monthly inspections for two (Computed Tomography (CT) Area, Magnetic Resonance Imaging (MRI) Area) of six (CT Area, MRI Area, Emergency Department, Three West Nursing Unit, Three East Nursing Unit, Surgery Department) medication areas according to policy. The likelihood existed for unusable medications to be available for patient use in the medication areas not inspected. Findings follow:

A. Review of Pharmacy Policy 400.100.240 on 10/31/17 at 10:10 AM showed that reflected all medication areas would be monitored monthly as part of reviews.
B. Review of Pharmacy Medication Area Reports on 10/31/17 at 10:20 AM showed that there was no evidence the pharmacists or pharmacy technicians had monitored monthly the medications located in the CT Area or the MRI Area.
C. During an interview on 10/31/17 at 1:30 PM, the Director of Pharmacy verified neither pharmacists or pharmacy technicians had conducted monthly monitoring of the medications in the CT Area or the MRI Area.

Based on observation and interview, it was determined the facility failed to have a system in place to control infections in that multiple dose vials (MDV) of injectable medications were opened in an immediate patient care treatment area without being dedicated to one patient only or discarded after use for two (Surgery, Emergency Department) of five (Surgery, Emergency Department, Post Anesthesia Care Unit, Three West Nursing Unit, Three East Nursing Unit) patient care treatment areas toured. The likelihood existed for the MDV of medications to be exposed to contamination and administered to other patients. Findings follow:

A. A tour of Surgery on 10/30/17 at 2:45 PM showed MDVs of injectable medications were opened in the immediate patient care treatment area and available for further patient use as follows:
1)Anesthesia Cart in Operating Room #1
a) One Xylocaine 2 % 20 milliliters (ml); and
b) One Neostigmine 10 milligrams (mg)/10ml.
2) Anesthesia Cart in Operating Room #2
a) One Xylocaine 2% 20ml;
b) One Glycopyrolate 1mg/5ml;
c) One Neostigmine 10mg/10ml; and
d) One Labetolol 100mg/20ml.
B. During an interview on 10/30/17 at 2:55 PM , the Operating Room Manager the MDVs of injectable medications were opened in the immediate patient care treatment areas of surgery were still available for patient use.
C. A tour of the Emergency Department on 10/30/17 at 2:00 PM showed MDV of injectable medication was observed opened in the immediate patient care treatment area and available for further patient use: One Marcaine 0.25%.
D. During an interview on 10/30/17 at 2:10 PM , LPN#2 verified the MDV of medication were opened in the immediate patient care area of the Emergency Department was still available for further patient use.


29485

Based on observation, policy and procedure review and interview, it was determined the facility failed to ensure expired supplies were not available for patient use in three (Operating Suite, Pain Clinic and Respiratory Therapy) of six (Operating Suite, Pain Clinic, Respiratory Therapy, Emergency Room, Medical Surgical Floor and Central Sterile) areas. Failure to ensure only currently dated supplies were available for use had the potential to affect the efficacy of patient care, staff safety and the cleaning of equipment. The failed practice had the likelihood to affect patients receiving care in the Operating Suite, Pain Clinic and Respiratory Therapy. Findings follow:

A. Observation in the dark room of the Operating Suite showed four of four three inch by nine inch Vaseline Gauze Strips expired 09/17. During an interview on 10/30/17 at 2:20 PM, Surgical Technician #1 verified the expired Vaseline Gauze Strips.
B. Observation in OR (Operating Room) #1 showed one 32 ounce bottle containing 4 ounces of Vindicator dated and timed 07/01/17 at 4:00. During an interview on 10/30/17 at 2:20 PM, Surgical Technician #1 verified the findings for Vindicator.
C. Observation in the Scope Room showed one opened box of powder free exam gloves expired 10/16 and one 28 ounce bottle of Hil-Phene dated and timed 08/01/17 at 4:20 PM. During an interview on 10/30/17 at 3:05 PM, Surgical Technician #1 verified Surgical Technician #1 verified the findings for the exam gloves and Hil-Phene.
D. Observation in the Scope Cleaning Room showed one of two boxes of powder free exam gloves expired 09/15. During an interview on 10/30/17 at 3:15 PM, Surgical Technician #1 verified the expired exam gloves.
E. Observation in the Pain Clinic Procedure Room #2 showed one 32 ounce bottle of Vindicator containing 16 ounces dated 06/01/17. During an interview on 10/30/17 at 4:10 PM, the Chief Quality Officer verified the findings for Vindicator.
F. Observation in the Respiratory Therapy Department at 2:00 PM on 10/31/17 showed eight of eight Kendall 5500 Diagnostic Tab electrode packs expired 06/15 and six of six Pediatric Tracheotomy Care Trays expired 01/17. During an interview on 10/31/17 at 2:15 PM, the Manager of Respiratory Therapy verified the electrode packs had expired.
G. Review of the policy and procedure received from the Executive Assistant on 10/31/17 titled, "Reduction in Risk of Transmission," showed expired supplies were not to be used in the facility.
H. During an interview with the Chief Quality Officer at 1610 on 10/30/17, he stated the bottles containing the cleaners Vindicator and Hil-Phene were dated when filled and were good for 30 days.


Based on observation and interview, it was determined the facility failed to prevent the spread of infection in three (Operating Suite, Pain Clinic) of six (Emergency Room, Medical Surgical Floor, Operating Suite, Pain Clinic, Respiratory Therapy and Central Sterile) areas as follows:
1) Failed to identify equipment in poor repair in that tape and tape residue, wooden arm boards with nicked areas, arm board cushions with rips exposing the cushion beneath, cushioned positioning device with a tears exposing the cushion beneath, mattress with multiple rips exposing the cushion beneath and rip in the seat of a chair exposing the cushion beneath.
2) Failed to identify whether supplies (syringes housed in clear buckets and opened oxygen extension tubing out of the packaging and hanging on the oxygen delivery) removed from their packaging was clean or dirty.
3) Failed Separated clean patient supplies ((non re-breather masks and Oxymasks) from kitchen and employee personal items (cereal, coffee filters, purses, jackets, etc.)

The failed practice had the potential to allow cross contamination between patients and the use of unclean supplies. The failed practice had the potential to affect any patient undergoing surgery in the operating suite, undergoing pulmonary function testing, care and treatment requiring the use of respiratory therapy supplies and care and treatment in Procedure Room #2 in the Pain Clinic. Findings follow:

A. Observation in Operating Room (OR) #2 at 2:25 PM on 10/30/17 showed one arm board with bits of tape on both sides, one wooden arm board with nicked areas on all edges as well as a one inch long splinter hanging from one side, and one arm aboard cushion with a one by ¾ inch L shaped tear on the right side which were unable to be cleaned due to the breech of surface integrity. During an interview at 2:27 PM on 10/30/17, Surgical Technician #1 verified use of tape, the nicked wooden arm board and the tear in a cushioned arm board.
B. Observation of the medication carts in OR #1, OR #2 and the Scope Room on 10/30/17 at 2:55 PM showed clear buckets attached to the medication carts. Each of the buckets contained paper clips, needle caps, opened syringes ranging in size from 20 milliliters (ml) to 60 ml, a nerve stimulator in each, and the one in the Scope Room also contained an IV (intravenous) bag hanger. The OR Manager was asked at 2:55 PM on 10/30/17 what the buckets were for and the OR Manager stated she did not know, it could be for trash. Licensed Practical Nurse (LPN) #1 was asked during an interview at 3:00 PM on 10/30/17 what the syringes in the bucket were for since they were opened. LPN #1 stated the Anesthesiologist opened them and if the syringes were not used, he put them in the bucket for later use. LPN #1 was asked if the syringes were used on patients and she stated she didn't think so and was not sure what the Anesthesiologist was doing with the opened syringes.
C. Observation in OR #1 at 2:40 PM on 10/30/17 showed two of two arm board cushions with tape residue and four frayed corners, two of two wooden arm boards with nicks and chips of wood missing on the edges, one of one black polymer cushion used to position patients had a three inch rip on the bottom and one three by three inch V-shaped rip on the end which were unable to be cleaned due to the breech of surface integrity. During an interview at 2:40 PM on 10/30/17, Surgical Technician #1 verified the findings in OR #1.
D. Observation in PACU (post anesthesia care unit) on 10/30/17 at 3:40 PM showed bed one with a three inch rip on the left and right sides of the foot of the bed mattress as well as a one inch rip on the right side of the head of the bed, bed three with multiple rips at both corners of the bed mattress which were unable to be cleaned due to the breech of surface integrity. During an interview at 3:20 PM on 10/30/17, the Assistant Director of Nursing verified the rips in the mattress.
E. Observation in the Cardio-Pulmonary Function Testing Room showed an oxygen extension tubing out of the packaging and hanging on the oxygen delivery device and staff unable to determine if it was clean or dirty. During an interview at 3:40 PM on 10/30/17, the Chief Quality Officer verified the oxygen extension tubing was out of packaging and on the oxygen delivery device.
F. Observation in Procedure Room #2 in the Pain Clinic on 10/30/17 at 4:10 PM showed one of two chairs with a three inch rip in the seat which were unable to be cleaned due to the breech of surface integrity. During an interview at 4:10 PM on 10/30/17, the Chief Quality Officer verified the rip in the seat of one chair.
G. Observation in the Respiratory Department showed food items (cereal, a gallon of water, coffee filters, one cup containing something red, and a white paper sack) lying on the counter immediately adjacent to the rack containing clean respiratory supplies and two purses, two jackets on clothes hangers and an umbrella were observed to be hanging on the bins containing patient care equipment (non re-breather masks and Oxymasks). The food and clothing items had the potential to contaminate the patient care items. During an interview at 2:10 PM on 10/31/17, the Manager of Respiratory Therapy stated the counter was the kitchen/break area for the Respiratory Therapy Department and the white paper sack contained her lunch.





38994

Based on observation, interview, policy and procedure review, review of the facilities Environmental/Infection Control Surveillance Report and review of manufacturer's directions for use, it was determined the facility failed to monitor and inspect their Maloney Dilators in that five of five were expired. Failure to assure the Maloney Dilators were not expired did not ensure they were safe for patient use and had the potential to affect any patient whose care required esophageal dilatation. Findings follow:

A. Observation during tour of the Scope Room on 10/30/17 at 3:50 PM showed 4 of 5 (Maloney dilator 36 French, Maloney dilator 44 French, Maloney dilator 40 French and Maloney dilator 50 French) Maloney dilators had expired on 06/30/03. One of 5 (Maloney dilators 48 French) Maloney dilators had expired on 09/30/03.
B. During an interview on 10/30/17 at 3:50 PM, the Assistant Director of Nursing verified the above finding in "A" and verified the Maloney dilators were not monitored or inspected on a routine basis.
C. Review of policy and procedure titled, "Reduction in Risk of Transmission" showed that " expired supples in any area of the faciity were not to be used; monthly checks were to be performed to check for expired items which were to be disposed of when discovered.
D. Review of the facilities Environmental/Infection Control Surveillance reports dated 07/28/17, 09/29/17 and 10/27/17 showed that no expired Maloney dilators were found in the Scope Room.
E. Review of the manufacturer's directions for use for Maloney dilators showed that:
1) Inspect older dilators for wear.
2) Worn dilators should not be used.
3) Signs of wear can include: surface cracks, cuts, and extremely faded print.
4) Make sure the three year expiration date has not be exceeded.
F. The above findings in B,C,D, and E were verified with the Infection Control Nurse on 11/1/17 at 12:55 PM.


Based on observation, interview and policy and procedure review, it was determined the facility failed to follow its own policy and procedure for Storage of Endoscopes to control infections in that an endoscope was found hanging in the scope storage cabinet with 8 inches of the tip of the scope bent and laying on the floor of the cabinet. The failed practice did not ensure that the endoscope was free from surface/airborne contamination and had the potential to affect any patient whose care required a lower endoscopic procedure. Findings follow:

A. Observation of the Scope Room on 10/30/17 at 3:15 PM showed 1 of 1 CF-HQ 190L endoscope was found with 8 inches of the tip of the scope bent and laying on the floor of the scope storage cabinet.
B. During an interview on 10/30/17 at 3:15 PM, Scrub Technician (ST) #1 verified the CF-HQ 190L endoscope tip was bent and laying on the floor of the scope storage cabinet.
C. Review of the policy and procedure titled, "Endoscopes," showed that endoscopes would be stored in a manner that limited exposure to surface/airborne contamination and damage to the endoscope; the scopes were not to be coiled, but hung to allow for vertical storage according to manufacturer's guidelines.
D. The findings in A, B, C, and D were verified with the ST #1 on 10/30/17 at 3:15 PM.

Based on observation, interview, review of manufacturer's directions for use, and review of policy and procedure, it was determined the facility failed to follow its own policy and the manufacturer's directions for use for the use of Cidex ortho-phthalaldhyde (OPA) for high level disinfection (HLD to assure the facility had a system for identifying and controlling infections. The failed practice did not assure instruments cleaned by HLD were thoroughly clean and disinfected prior to patient use. The failed practice had the potential to affect all patients who came in contact with instruments cleaned by HLD. Findings follow:

A. During tour of the dirty instrument area in the Operating Suite on 10/30/17 at 3:30 PM, the Cidex OPA Log showed that the Cidex OPA was not changed every 14 days. The Cidex OPA was due to be discarded and replaced on 10/25/17, the Cidex Log showed this was not done on due date 10/25/17. The Cidex OPA log from 8/25/17 to 10/30/17 showed that the temperature of the Cidex OPA was not being monitored or recorded. The above finding in "A" was verified by ST #1 and the Assistant Director of Nursing on 10/30/17 at 3:30 PM.
B. During interview with the Radiology Manager on 10/31/17 at 12:45 PM, it was determined that the Cidex OPA temperature in the Ultrasound Suite was not being monitored or recorded.
C. During interview with the Cardiopulmonary Manager on 10/31/17 at 2:10 PM, she stated "all instruments were cleaned by cold chemical soak in the Operating Suite."
D. Review of manufacturer's directions for use of Cidex OPA showed that Cidex was effective for a period of 14 days at a temperature of 68 degrees Fahrenheit or higher and required use of a submersible thermometer.
E. Review of the policy and procedure and review of the Cidex OPA test strip manufacturer's directions for use showed that the facility was not performing the Quality Control Procedure for use of Cidex OPA as follows:
1) Facility policy showed that:
a) Use full strength Cidex OPA solution as the positive control
b) To prepare a negative control, dilute 1 part Cidex OPA solution with 1 part of water.
c) Submerge 3 test strips in each freshly prepared solution for 1 second each.
d) Remove test strips from solution.
e) The 3 strips dipped in the full strength, positive control, should now show a complete purple color on the indicating pad at 90 seconds.
f) The 3 strips dipped in the diluted, negative control solution should either remain completely blue or show an incomplete color change to purple at 90 seconds.
g) Refer to the color chart of the test strip bottle for interpretation of results.
2) Manufacturer's directions for use showed that:
a) Prepare positive and negative control solution for testing, first verify that the labeled expiration date for the solution is appropriate. This solution may be used as a positive control. b) To prepare a negative control, dilute one part of full strength solution with 1-part water. Label each control separately.
c) Submerge three test strips in each of the above freshly prepared solutions for one second each and remove.
d) The three strips dipped in the full strength positive control solution should exhibit a complete purple color on the indicating pad at 90 seconds.
e) The three strips dipped in the diluted negative control should either remain completely blue or exhibit an incomplete color change to purple when read at 90 seconds. Refer to the color chart on the test strip bottle for interpretation of results.
F. The findings in A, B, C, and D were verified with the Assistant Director of Nursing on 10/31/17 at 3:30 PM.

Based on observation, interview and review of the Milk Cooler temperature log, it was determined the Dietary Department did not record corrective action for the "Milk Cooler" for temperatures outside of 37 degrees Fahrenheit as identified on the log. The failed practice did not assure the milk or milk products were stored safely for patient consumption. The failed practice had the potential to affect any patient receiving milk or milk products during their hospital stay. Finding follow:

A. During tour of the Kitchen on 10/31/17 at 9:50 AM, the the Milk Cooler Temperature log for October 2017 was reviewed and showed that in 22 of 31 days the temperatures were above 37 degrees Fahrenheit with no corrective action taken.
B. The finding in "A" were verified with the Infection Control Nurse on 10/31/17 at 10:20 AM.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to perform a nutritional screening within 24 hours of admission on five of five (#9-#13) in-patients. Failure to perform a nutritional screening within 24 hours of admission did not ensure patients at nutritional risk were identified and nutritional measures initiated. The failed practice affected Patients #9-13. Findings follow:

A. Review of the policy and procedure titled, "Nutritional Screening," received from the ADON at 1415 on 11/1/17 showed that all admitted patients were to be evaluated within 24 hours of admission for nutritional risk. The ADON stated during an interview at 1430 on 11/01/17 there was no mechanism in the electronic medical record to perform a nutritional screening.
B. Review of the clinical records of Patients #9-13 showed no nutritional screens were performed. During clinical record review from 1400 to 1555 on 11/01/17 and 1015 to 1115 on 11/02/17, the ADON verified no nutritional screens were performed.

Based on policy and procedure review, clinical record review and interview, it was determined the nursing staff failed to follow policy and procedure in that reassessments of pain levels were not performed within 30 minutes for four (#9-12) of five (#9-13) patients. Failure to reassess the level of pain control/relief within 30 minutes had the potential to allow inadequate pain relief and did not ensure staff followed policy. The failed practice affected Patient #9, #10, #11 and #12 on 11/01/17. Findings follow:

A. Review of the policy and procedure titled, "Pain Control Policy," received from the Executive Assistant on 10/31/17 showed that any implementation of a pain control mechanism required reassessment within 30 minutes to determine the amount of pain control/relief achieved.
B. Review of the clinical records of Patients #9-12 showed that reassessments were not performed within 30 minutes of the implementation of the pain control/relief mechanism. For example:
1) Patient #9 received Oxycodone IR 10 mg (milligrams) at 9:36 AM, at 2:08 PM and 5:55 PM on 10/30/17 and reassessments were not performed 30 minutes after administration.
2) Patient #10 received Oxycodone IR 15 mg at 4:32 AM and 2:01 PM on 10/23/17; Hydrocodone/APAP (acetaminophen) 10/325 mg at 8:38 AM on 10/23/17, Oxycodone IR 15 mg at 8:56 AM and at 3:14 PM on 10/25/17 and reassessments were not performed 30 minutes after administration.
3) Patient #11 received Hydrocodone/APAP 5/325 mg at 12:02 AM on 11/02/17 and reassessments were not performed 30 minutes after administration.
4) Patient #12 received Tramadol 50 mg at 5:25 on 10/27/17, 4:55 AM and 11:56 PM on 10/28/17, 5:55 AM, 2:29 PM and 11:46 PM on 10/29/17 and reassessments were not performed 30 minutes after administration.
C. During an interview at 10:25 AM on 11/02/17, the ADON verified the findings in A and B. The ADON stated that the policy and procedure was old. The ADON stated that the facility intended to change it during the annual review process to reflect the actual practice of reassessment of pain level one hour after administration of any pain relieving act.

Based on interview, clinical record review, and policy and procedure review, it was determined nursing care plans were not reviewed every shift for two (#10 and #12) of five (#9-13) in-patients or updated for three (#9, #10 and #12) of five (#9-13) in-patients. Failure to review the nursing care plan every shift or update it to reflect current problems did not allow staff to plan and provide care to attain the patient's highest level of physical and mental well-being. The failed practice affected Patients #9-12. Findings follow:

A. Review of the policy and procedure titled, "Documentation-Plan of Care Standards," received from the Executive Assistant on 10/31/17 showed that upon entering the hospital the plan of care was initiated, reviewed every shift and updated as necessary depending on changes of patient's condition.
B. During an interview at 2:00 PM on 11/01/17, the Assistant Director of Nursing (ADON) stated that for Braden Scores of 15 and the nursing staff should initiate pressure relieving mechanisms and update the nursing care plan to reflect the Braden Score and the mechanisms instituted. The ADON stated the pressure relieving mechanisms staff should place on the nursing care plan and implement were zero pressure to heels, turning the patient every two hours, and Eucerin Cream to the affected/reddened area every shift or as ordered.
C. Review of Patient #9's nursing care plan showed that it was not updated to reflect an initial Braden score of 18 and interventions needed to decrease the risk of pressure ulcers. Review of the clinical record showed no evidence of zero pressure to heels and no evidence of turning every two hours. During an interview at 2:00 PM on 11/01/17, the ADON verified the nursing care plan did not include interventions needed to decrease the risk of pressure ulcers for a Braden score of 18.
D. Review of Patient #10's nursing care plan showed that it was not reviewed on three (10/24/17 and 10/25/17 7 AM to 7 PM and 10/29/17 7 PM to 7 AM) of 21 (10/21/17 through 10/21/17 7) shifts. Review of the clinical record showed that the nursing care plan was not updated to reflect a Braden score of 18 on 10/22/17, 10/25/17 and 10/28/17. During an interview at 3:10 PM on 11/01/17, the ADON stated that the nursing care plan should have been updated to reflect Patient #10's history of decubitus as well as risk.
E. Review of Patient #12's nursing care plan showed that it was not reviewed one (10/29/17 7 PM to 7 AM) of seven (10/27/17 through 10/30/17) shifts. During an interview at 9:50 AM on 11/02/17, the ADON verified Patient #12's nursing care plan was not reviewed every shift.

Based on clinical record review, review of policy and procedure and interview, it was determined 2 (#16 and #20) of 7 patients did not have a History and Physical (H&P) signed by the performing surgeon. One (#17) of 7 patients did not have a H&P present in the clinical record. One (#19) of 7 patients had a H&P that was greater than 7 days old. The failed practice did not ensure facility staff were knowledgeable and prepared to care for the surgical patient. The failed practice affected patient #16, #17, #19 and # 20. Findings follow:

A. Review of clinical record of Patient #16 showed the H&P dated 09/28/17 was not signed by the performing surgeon.
B. Review of clinical record of Patient # 20 showed the H&P dated 08/31/17 was not signed by the performing surgeon.
C. Review of clinical record of Patient #17 showed no H&P for surgical encounter dated 09/12/17.
D. Review of clinical record of Patient #19 showed the H&P dated 08/16/17 was greater than 7 days old and not updated by the performing surgeon.
E. Review of policy and procedure titled, "History and Physical on Patient Record," showed that:
1) There must be a complete history and physical examination in the medical record of every patient prior to surgery, except in emergencies.
2) The H&P must be performed by a physician within 7 days prior to the hospital admission/outpatient surgery, or 48 hours after hospital admission, but prior to surgery/outpatient procedure.
F. The findings in A,B,C, D, and E were verified with Informatics Technician #1 on 11/01/17 at 2:19 PM.

Based on interview, it was determined there was not a tracheotomy kit in the operating suite. Failure to ensure a tracheotomy kit was available in the operating suite did not allow the facility to be prepared to meet the patient's medical needs in the event of an emergency. The failed practice affected all patients who have undergone procedures in the operating rooms of the facility. Findings follow:

During the facility tour at 2:55 PM on 10/30/17, the Operating Room Nurse Manager stated a tracheotomy kit was not located in the operating suite and the nearest one available was located in the Emergency Room.

Based on surgery privileges review, review of medical staff bylaws, Operating Room Log review, policy and procedure review, and interview, it was determined the facility failed to ensure the Operating Suite staff had access to current surgical privileges for 1 (#4) of 10 (#1-#10) surgeons. Failure to ensure the operating staff had access to current surgical privileges did not ensure the staff was knowledgable of what surgeries each surgeon was allowed to perform. The failed practice had the potential to affect all patients whose surgical procedure was performed by Surgeon #4 from 05/04/17 through 10/31/17. Findings follow:

A. Review of the policy and procedure titled, "Surgical Privileges for Outpatient Surgery Professional Staff," received from the Executive Assistant on 10/31/17 showed that a current roster listing each practitioner's specific surgical privileges must be available in the surgical suite.
B. Review of the Bylaws of the Professional Staff received on 11/01/17 showed that the medical staff were to serve an initial provisional appointment of at least one full Professional Staff year (January to December) then all reappointments were to be for a term of two years ending on the last day of the calendar year.
C. Review of the hard copy and the computer based Operating Room surgeon's privileges received from the Operating Room Nurse Manager at 2:55 PM on 10/30/17 showed that Surgeon #4's surgical privileges were issued 05/04/15. There was no evidence of Surgeon #4's reappointment with approved surgical privileges beginning 05/04/17.
D. Review of the Operating Room Log received from the Chief Quality Officer at 9:30 AM on 11/2/17 showed that from 10/17/17 through 10/31/17 Surgeon #4 performed four surgical procedures.

Based on interview and review of a personnel file, it was determined the facility failed to assure patient activities were provided by a qualified individual or by consultation with an occupational therapist, therapeutic recreation specialist, or other professions with recreation therapy education or experience. Without qualified individual or by consultation it could not be assured the activity needs of the patients would be met. The failed practice had the potential to affect any patient admitted to Swing-Bed. Findings follow:

A. The Director of Nursing on 11/02/17 at 10:55 AM stated the person assigned to provide activity was not a certified activity professional.
B. Review of the personnel file showed that the person assigned as Activities Director did not have qualifications, certification or licensure as an activities professional.
C. The avove finding in B were verified with the Director of Nursing on 11/02/17 at 10:55 AM.