HospitalInspections.org

Based on document review, the facility did not complete the Certificate of Need (CON) application process for the certification of service areas and equipment.

Findings include:

-Review on 8/13/10 at 10:00 AM of the facility's CON applications revealed that four projects were not complete for equipment and service area modifications that have been in use since prior to the survey completed in 2008. Correspondence from the New York State Department of Health's Bureau of Architecture Engineering and Health Facilities Planning dated 11/7/08, 11/8/08, 12/5/08 and 12/12/08 revealed that Architect's Certifications are required to proceed with the projects. The projects are: Renovation of Operating room #3; Upgrade of three elevators in buildings A and S; Replacement of the HVAC system in S building; and the relocation of the gastroenterology suite.

These findings were verified with Staff #31 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on document review, the facility does not provide pre-employment and annual infection control education for 7 of 7 medical staff. (Staff #7-9, 12, 14, 38 and 39)

Findings include:

-Credential file review from 8/11/10 through 8/13/10 revealed the files for Staff #7-9 and 12 contained no evidence of annual infection control education/inservicing.
-Credential file review from 8/11/10 through 8/13/10 revealed the files for Staff #14, 38 and 39 contained no evidence of pre-employment infection control education/inservicing.

These findings were verified by Staff #35 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.


Based on document review, the facility does not provide advance directive education to 7 of 11 medical staff. (Staff #7-9, 12, 14, 38 and 39)

Findings include:

-Credential file review from 8/11/10 through 8/13/10 revealed the files for Staff #7-9, 12, 14, 38 and 39 contained no evidence of advance directive education/inservicing.

This finding was verified by Staff #36 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.


Based on document review, the facility did not provide orientation to the hospital and personnel policies to 3 of 3 physicians. (Staff #12, 38 and 39)

Findings include:

-Credential file review on 8/11/10 revealed the files for Staff #12, 38 and 39 contained no evidence of physician corporate orientation.

This finding was verified with Staff #36 on 8/13/10.


Based on policy and procedure review and document review, the facility does not obtain a pre-employment certificate of immunization against rubella for 2 of 3 medical staff. (Staff #38 and 39)

Findings include:

-Review on 8/12/10 of policy "Reappointment/Reappraisal Process" (revised 12/1/09) revealed the content of the application for reappointment shall contain "...documentation of mandated immunizations and/or a copy of serologic evidence of immunity".
-Credential file review on 8/11/10 revealed the files for Staff #38 and 39 contained no evidence of immunization against rubella. This finding was verified by Staff #36 on 8/12/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.


Based on policy and procedure review and document review, the facility does not obtain a pre-employment certificate of immunization against measles for 2 of 3 medical staff. (Staff #38 and 39)

Findings include:

-Review on 8/12/10 of policy "Reappointment/Reappraisal Process" (revised 12/1/09) revealed the content of the application for reappointment shall contain "...documentation of mandated immunizations and/or a copy of serologic evidence of immunity".
-Credential file review on 8/11/10 revealed the files for Staff #38 and 39 contained no evidence of immunization against measles. This finding was verified by Staff #36 on 8/12/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.


Based on policy and procedure review and document review, the facility does not ensure that annual Mantoux skin testing is performed for 3 of 11 staff. (Staff #7, 14 and 38)

Findings include:

-Review on 8/12/10 of policy "Reappointment/Reappraisal Process" (revised 12/1/09) revealed the content of the application for reappointment shall contain "...documentation of mandated immunizations and/or a copy of serologic evidence of immunity".
-Credential file review on 8/11/10 revealed the files for Staff #7, 14 and 38 contained no evidence of current Mantoux skin testing. This finding was verified with Staff #35-37 on 8/11/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.


Based on document review, the facility does not reassess the health status annually for 1 of 5 nursing staff. (Staff #14)

Findings include:

-Personnel file review on 8/11/10 revealed the file for Staff #14 contained no evidence of a current health assessment.
-This finding was verified by Staff #37 on 8/11/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.


Based on document review, the facility does not ensure facility specific education is provided to 5 of 5 physicians. (Staff #7, 8, 12, 38 and 39).

Findings include:

-Credential file review on 8/11/10 revealed the files for Staff #7, 8, 12, 38 and 39 contained no evidence of education in the areas of patient safety, patients' rights, injury prevention, staff responsibility to report professional misconduct, legal aspects of patient care, improved communication with patients and causes of malpractice claims for staff personnel engaged in patient care activities.

This finding was verified with Staff #35-37 on 8/11/10.

Based on policy and procedure review and document review, the facility does not ensure that 2 of 2 midlevel practitioners are under the supervision of a member of the medical staff. (Staff #9 and 10)

Findings include:

Review on 8/12/10 of policy "Allied Health Professional Affiliates" (revised 1/5/10) revealed allied health professional affiliates shall provde specific patient care services under the direction of the chief of the supervising department and/or their collaborating physician.

Credential file review on 8/11/10 for nurse practitioner Staff #9 revealed that the file contained a Nurse Practitioner agreement documenting an agreement of collaboration between Staff #9 and a physician in the area of pediatrics. The collaborating physician shall review the medical records of patients treated by Staff #9 no less than every three months. The agreement will be reviewed annually and any alteration of the agreement must be in writing. The document was dated 5/12/05, and there was no evidence of a current agreement found in the credential file. No evidence was found to indicate that the collaborating physician is reviewing Staff #9's caseload. This finding was verified with Staff #36 on 8/13/10.

Credential file review on 8/11/10 for physician's assistant Staff #10 revealed a credentialing and privileging document dated 7/18/08. No evidence of a collaboration/service agreement with a supervising physician was found in the file. This finding was verified on 8/11/10 with Staff #36, who stated that Staff #10 has no longer been employed by the facility since 5/31/09.

Based on policy and procedure review, observation and interview, the Grand Island extension clinic does not implement its written policies and procedures for emergency situations, as evidenced by lack of an available emergency drug box.

Findings include:

-Review on 8/10/10 of the Medication Handling Policy (effective 7/10) revealed the clinic would possess an emergency drug box that is supplied by the NFMMC pharmacy department. This box is described as a 3 drawer box with approximately 30 emergency drugs available for such use.

-Observation during tour of the clinic on 8/10/10 at 10:30 AM revealed no presence of an emergency drug box.
-This finding was verified with Staff #30 at that time.

-Interview with Staff #29 on 8/10/10 at 10:45 AM revealed the clinic does not possess any type of emergency drug box.

This finding was verified with Staff #30 on 8/10/10.

Based on medical record review, interview and observation, the hospital does not provide a copy of patients' rights to each emergency department patient, as required by New York State (NYS) regulation, for 10 of 10 patients. (Patients #17-24, 28 and 29)

Findings include:

-Medical record review on 8/10/10 revealed the records for Patients #17-24, 28 and 29 contained no evidence the patients had been provided with a copy of the written statement of patients' rights that is required per NYS regulation 405.7(a)(2). This finding was confirmed by Staff #1 at that time.
-During interview on 8/10/10 at 10:00 AM, Staff #18 stated that the written statement of patients' rights is posted on the wall in the emergency department (which was observed at that time), although patients who are discharged from the emergency department as outpatients do not receive a copy. She stated that a copy of the rights is provided in the admission packet given to those patients who are admitted to the hospital as inpatients.

Based on observation, interview and policy and procedure review, the facility does not provide policies and procedures for patient safety pertaining to exiting the psychiatric units.

Findings include:

-Observation during tour of psychiatric units A2 and A3 on 8/9/10 at 11:20 AM revealed that two of three exits on both units are labeled as emergency exits only. These exits require the use of a key to bypass the alarm system and unlock the door. On A2, it was observed that a staff member used a key and opened the door to exit the unit.
-Interview on 8/9/10 with Staff #2 revealed that an email message was sent to psychiatric staff on 7/9/10 regarding proper use of these exits. The email specified that these exits were only to be used in an emergency.
-Review from 8/9/10 through 8/13/10 of the facility's policies and procedures manuals revealed no policy addressing use of these doors.


Based on observation, document review and interview, the facility does not utilize the staff emergency call system on the psychiatric units.

Findings include:

-Review on 8/13/10 of the psychiatric staff education document "Psych Unit Alarms" (dated 1/12/09 to 2/1/09) provided by Staff #1 revealed that five panic alarm areas are set on each unit. One personal alarm for each area can be carried by an employee in that area. Personal alarms are to be taken whenever staff go to areas of high risk behavior, for conducting patient interviews with high risk patients and when removing belongings from a patient. There are alarm boxes at the nurse's station, midstation and substation.

-Observation during tour of psychiatric units A2 and A3 on 8/9/10 at 11:15 AM revealed the Staff Emergency Call System for the Psychiatric Units is not in use as approved through the NYS CON process completed earlier this year. The Staff Emergency Assistance System (using personal emergency call buttons) was approved to replace a Nurse Call System.

-Interview with Staff #3 on 8/9/10 at 11:00 AM revealed that designated staff members are to carry an emergency call button (fob) on their person while away from the nurse's station. There are five fobs per unit. When several staff members on A2 were questioned as to the location of the fobs, Staff #28 stated they were located in the drawer. It was noted that 4 of 5 fobs were located in the storage drawer at the nurse's station on A2, and the fifth fob could not be located. All five fobs were observed in the storage drawer on A3. As part of the approval of these psychiatric units, all staff were to carry fobs at all times to satisfy code requirements.

Based on document review and policy and procedure review, the facility does not review or evaluate the clinical work of the medical staff.

Findings include:

Review on 8/12/10 of the Bylaws (last revised 3/23/09) revealed the medical staff shall be responsible for the quality of medical care in the Hospital, subject to the ultimate authority of the Board. Among the duties of the Medical Staff are: to conduct an ongoing review and evaluation of the quality of each practitioner's professional performance in the hospital, including medical staff members and allied health professionals and to recommend the delineation of clinical privileges of each practitioner based upon such appraisal.

Review on 8/12/10 of policy "Reappointment/Reappraisal Process" (revised 12/1/09) revealed the content of the application for reappointment shall contain "...reappointment information regarding peer review proceedings".

Review on 8/12/10 of the policy "Rules and Regulations of the Medical Staff" (revised 4/27/10) revealed peer review is defined as a physician reviewer who has closely comparable credentials, has practiced in a similar setting and has no possible conflict of interest concerning the outcome of the review. General criteria is listed to identify cases requiring peer review for all services. Peer review activities will focus on appropriateness, competence, outcome and provision of service consistent with the patient's needs. Conclusions of the peer review process will be considered in the credentialing, privileging and reappointment process.

Review from 8/10/10 through 8/13/10 of committee minutes/peer review documentation for hospital services revealed the following:
---Cardiology performed 8 peer/case reviews from 3/10 to 5/10 which did not identify the practitioner responsible for the care and follow up actions for areas identified. No evidence of previous reviews was found.
---Anesthesia peer/case reviews are performed by support staff, not by practitioners and do not evaluate the care provided.
---Obstetrics performed 30 peer/case reviews in 5/10. No evidence was found of additional reviews.
---Emergency Department performed 4 peer/case reviews in 7/10 and 5 peer/case reviews in 8/10. No evidence of previous reviews was found.
---Psychiatric reviews were not found from 1/10 to 7/10. Reviews performed prior to that by Staff #7 did not include comments, recommendations or followup actions as applicable.
---No evidence of peer/case review was found for the services of Gastroenterology, Surgical, Hospitalist and midlevel practitioners.

These findings were verified with Staff #1 on 8/12/10 and Staff #36 on 8/13/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on policy and procedure review and document review, the facility does not ensure the delineation of privileges for 1 of 6 medical staff. (Staff #9)

Findings include:

Review on 8/12/10 of policy "Reappointment/Reappraisal Process" (revised 12/1/09) revealed members of the medical staff are reappointed every two years. Content of the application for reappointment shall contain "...clinical privileges".

Review on 8/12/10 of policy "Allied Health Professional Affiliates" (revised 1/5/10) revealed that allied health professional affiliates shall provide specific patient care services under the direction of the chief of the supervising department and/or their collaborating physician.

Credential file review on 8/11/10 for Staff #9 revealed a Nurse Practitioner Privileges document listing core privileges in pediatrics dated 5/31/05. No evidence of current delineation of privileges was found. This finding was verified by Staff #36 on 8/11/10.

Based on policy and procedure review and observation, the facility does not ensure that all necessary equipment is included on a pediatric crash cart.

Findings include:

-Review on 8/12/10 of policy "Crash Carts/Emergency Carts/Portable Monitors/Emergency Drug Boxes" (revised 4/10) revealed the pediatric emergency carts located on units S4 and ER1 are equipped with pediatric emergency supplies.
-During tour of the 4th floor on 8/9/10, it was observed that a pediatric crash cart did not include EKG leads.

This finding was verified with Staff #6 on 8/9/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on medical record review and interview, the facility does not complete admission assessments to develop a nursing care plan for 1 of 8 psychiatric patients. (Patient #4)

Findings include:

Medical record review on 8/9/10 at 10:30 AM for Patient #4 revealed the patient was admitted 7/29/10. She refused to provide the staff with information to complete the multidisciplinary assessment form. The form has direction that it is to be completed within 8 hours of admission. However, the assessment form remained uncompleted on 8/9/10. No documentation was noted in the medical record to indicate that the patient had been reapproached since her admission on 7/29/10 in an attempt to complete the assessment form.

Interview with Staff #28 on 8/9/10 at 10:30 AM revealed the assessment form is completed upon admission to the unit. She stated that if a patient refuses to provide the staff with the needed information upon admission, they are reapproached daily. In doing so, the completion or refusal is documented in the medical record. Staff #28 verified that the assessment form was incomplete and no documentation of ongoing attempts for completion was evident.

Based on medical record review, the plan of care is not always documented in the medical record, as evidenced for 2 of 5 obstetrical patients. (Patients #26 and 42)

Findings include:

-Medical record review on 8/11/10 and 8/12/10 revealed that Patient #42 delivered an infant girl via Caesarian section on 8/6/10. Although the pregnancy was almost full-term at 36 6/7 weeks gestation, the infant had intrauterine growth retardation and was small at 3 pounds 12 ounces. The mother was discharged to home on 8/9/10. The infant, Patient #26, remained at the hospital.
-The medical records for Patients #26 and 42 did not have documentation regarding the separate discharges for the mother and baby. There was no indication in either record that the baby was boarding in the nursery after its mother's discharge. The only documentation in the mother's chart regarding this issue was on 8/7/10 at 12:00 AM by nursing: "Seems weepy at times about baby needing to stay here." The mother's "Nursing Discharge/Patient Instructions" timed at 1:45 PM on 8/9/10 did not address the topics of the baby remaining in the hospital or methods of contacting staff, or visiting and caring for the baby. Review of the baby's record did not reveal any documentation regarding the plan for the baby's discharge, including discharge criteria.

These findings were verified by Staff #1 on 8/12/10.


Based on medical record review and interview, the facility does not ensure accurate documentation of patient allergies for 4 of 49 patients. (Patients #4, 5, 7 and 41)

Findings include:

-Medical record review for psychiatric Patient #4 on 8/9/10 AM revealed the patient reported an allergy to codeine, but the physician order sheet documented NKA. No further clarification was noted in the medical record.
-Medical record review for psychiatric Patient #5 on 8/9/10 at 10:30 AM revealed the patient had an allergy to milk.
-Interview with Staff #28 on 8/9/10 revealed that patient allergies are documented with a red allergy sticker applied to the outside of the medical record.
-Further review of the medical records did not reveal evidence of an allergy sticker on either chart, which was verified by Staff #28 on 8/9/10 at 11:00 AM.

-Medical record review for observation Patient #7 on 8/10/10 at 10:30 AM revealed the patient had an allergy to Vancomycin per documentation at the last office visit.
-Interview with Staff #30 on 8/10/10 revealed that patient allergies are documented with a red allergy sticker applied to the outside of the medical record.
-Further review of the medical record did not reveal evidence of an allergy sticker on the chart, which was verified by Staff #30 on 8/10/10.

-Medical record review for Grand Island extension clinic Patient #41 on 8/10/10 at 2:00 PM revealed the patient had an allergy to aspirin.
-Interview with Staff #25 on 8/10/10 revealed that patient allergies are documented with a red allergy sticker applied to the outside of the medical record.
-Further review of the medical record did not reveal evidence of an allergy sticker on the chart.
-Review on 8/10/10 of policy "Identification and Alert Wristbands" (effective 8/01, revised 4/10) revealed that patients with reported allergies should have green allergy bands applied.
-During interview with Patient #41 on 8/10/10, it was noted that staff had not applied the green allergy alert bracelet to the patient despite his self-reported allergy to aspirin.
-These findings were verified with Staff #25 on 8/10/10.

-Interview with Staff #1 on 8/11/10 revealed the facility does not have a written policy and procedure in effect to ensure documentation of allergies with/without red sticker notation on medical records as onsite staff at three different locations reported is facility practice. No process is in place to ensure consistent review, documentation and application of alert wristbands related to reported patient allergies.

Based on medical record review, the hospital does not ensure that the time of delivery of an infant is recorded accurately for 1 of 5 post-partum mothers. (Patient #43)

Findings include:

Medical record review on 8/12/10 for Patient #43 revealed that the date and time of delivery of an infant girl was documented as "8/6 1246" on the "Labor and Delivery Summary" in the "Delivery of Infant" section. Staff #21 stated that the "Labor and Delivery Summary" is the primary medical record documentation for labor and delivery information. It is documented on that form for Patient #43 that the newborn was given positive pressure ventilation via a bag and mask at "12:47". However, all other documentation in the record of occurances preceding and following delivery indicate that the infant was delivered at 11:46 AM; e.g. the fetal heart rate "Prior to Delivery" is timed at 11:35 AM on the "Labor and Delivery Summary", and elsewhere in the record it is documented that the infant was born at 11:46 AM.


Based on policy and procedure review, document review and interview, the hospital does not have a current approved abbreviation list in use for documentation in medical records.

Findings include:

-Review on 8/12/10 of the NFMMC "Approved Abbreviation List" (approved by the Medical Record Committee on 9/24/96) in the "Department of Nursing Structure Standards Volume II" manual revealed that it contains abbreviations no longer approved for use by hospital staff. For example, the list approves "SQ" for subcutaneous, and "DC" for either discharge or discontinue. However, it was observed that a list of abbreviations that are not to be used by hospital staff was posted on each hospital unit, and these two abbreviations are on that list as not to be used.
-During interview on 8/12/10 at 3:00 PM, the Director of Pharmacy, Staff #42, referred to a pharmacy document published by the Pharmacy and Therapeutics Committee that addressed unacceptable abbreviations. Review of this document "Trends in Therapy" (Volume VII #4, April 2004) when provided by Staff #1 on 8/13/10 at 8:30 AM revealed that the above two abbreviations are among those no longer in use by the hospital.
-Further review on 8/13/10 of the "Approved Abbreviation List" revealed that other abbreviations in the list are no longer commonly accepted according to current practice standards. For example, the list shows that "R" is approved for right, "L" for left, and "bilat." for bilateral. However, this is unacceptable per the "New York State Surgical and Invasive Procedure Protocol" (9/06), which states that laterality must be documented as "right", "left" or "bilateral".
-Review on 8/13/10 of the NFMMC Department of Finance Policy C-103 "Abbreviations" (effective 10/10/05, reviewed 10/08), Department of Health Information Management, provided by Staff #1 on 8/13/10 at 8:30 AM revealed that only standard abbreviations will be permitted in hospital documentation, and "Any new forms used in the medical record should be compliant with the list of standardized abbreviations." However, the policy includes only a list of the ten prohibited abbreviations that is posted on the hospital units as described above.


22484



Based on medical record review, entries in the medical record are not legible, complete, dated, timed and authenticated by the person responsible for providing the service, as evidenced for Patients #47-49.

Findings include:

-Medical record review on 8/12/10 for Patient #47 revealed that on the admission assessment dated 7/18/10, the social work screen/discharge planning consideration section was signed by "chg nurse". The nutritional screen was signed off by "Jackie". The occupational screen lacked a signature, date and time. The advance directives section listing type of directives was blank.

-Medical record review on 8/12/10 for Patient #48 revealed that on the plan of care dated 6/25/10, it was documented that UNTYS was contacted at 2347 and awaiting return call. The area for outcome of organ/tissue donation and rationale if not suitable was blank.

-Medical record review on 8/12/10 for Patient #49 revealed that the Consent for CVP Line dated 12/12/09 had no evidence of a physician signature.


22935



Based on medical record review, physician orders are not legible in 3 of 8 psychiatric medical records. (Patients #44-46)

Findings include:

Medical record review on 8/12/10 at 2:30 PM for Patient #44 revealed the following illegible contents:
- 8/11/10 - Progress notes written by Staff #7 and 33.
- 8/12/10 - Progress note written by Staff #7.
- Physician order written questionably 8/10/10 (unable to determine as the date could not be read) by Staff #7.

Medical record review on 8/12/10 at 2:30 PM for Patient #45 revealed the following illegible contents:
- 8/11/10 - Progress note written by Staff #34.
- 8/11/10 - Progress note written by Staff #7.
- 8/12/10 - Progress notes written by Staff #7 and 33.
- Physician order written questionably 8/11/10 (unable to determine as the date could not be read) by Staff #7.

Medical record review on 8/12/10 at 2:30 PM for Patient #46 revealed the following illegible contents:
- 8/11/10 - Progress note written by Staff #7.
- 8/11/10 - Physician order written by Staff #7.

The documentation in these findings was deciphered and verified with Staff #41 on 8/12/10 at 2:30 PM.

Based on policy and procedure review and observation, the sample drug closet at the Grand Island extension clinic is not administered with acceptable professional principles.

Findings include:

-Review on 8/10/10 of policy "Pharmaceutical Sample Inventory" (effective 7/10) revealed that all drug samples will be outlined in a log in system and will contain information such as acceptance, expiration date, distribution date, dosage, etc. In addition, the policy states the log forms will be in triplicate.
-Tour of the clinic on 8/10/10 at 10:30 AM did not reveal evidence of triplicate log forms of this type. A clipboard in the room held a sample log, but was not triplicate, nor did it contain acceptance dates, etc., of the medications in the sample closet. This finding was verified with Staff #30 on 8/10/10 at 10:45 AM.

Based on observation, the hospital does not ensure that pharmaceutical medications and physician prescription pad are kept secured in a locked area.

Findings include:

-During tour on 8/9/10 at 1:40 PM of the Cysto Room, it was observed that a tray of drugs and biologicals was unattended.
-During interview on 8/9/10, Staff #27 indicated that Anesthesia Services should have removed the tray of medications from the room when the room was vacated.

-During tour on 8/9/10 of the Surgical Sterile hallway, a medication prescription pad assigned to Staff #40 was found unattended on top of the crash cart.

These findings were verified by Staff #27 on 8/9/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on policy and procedure review and observation, the facility does not ensure that outdated drugs and biologicals are not available for patient use.

Findings include:

Review on 8/12/10 of policy "Checking Drugs and Biologicals" (effective 11/08) revealed all outdated, mislabeled, discontinued, expired or otherwise unusuable drugs and biologicals shall not be available for patient use. A check will be performed on the first day of each month by the appropriate assigned individual in each patient care area. Upon initial use of a multidose vial, date and initials will be documented on the label. Multiple dose vials will be discarded 30 days after initial use.

Observation on 8/9/10 at 10:00 AM of the Intensive Care Unit Medication Room revealed the following expired items were present:
---2 sterile scalpels expired in 2006.
---1 bottle of sterile water opened, but not initialed or dated.
---1 bottle of compound Benzoin Tincture opened, but not initialed or dated.
---1 bottle of 0.9% Sodium Chloride expired 7/1/10.

These findings were verified with Staff #6 on 8/9/10.

Observation on 8/9/10 at 10:45 AM of the Pediatric Crash Cart revealed the following expired items were present:
---2 bottles of 4.2% Sodium Bicarbonate expired 7/1/10.
---2 bottles of 0.9% Sodium Chloride expired 7/1/10.

These findings were verified by Staff #6 on 8/9/10.

Observation on 8/9/10 at 10:55 AM of the S4 Medication Room revealed the following expired items were present:
-In the blood draw bin:
---1 bottle of sterile water opened, but not initialed or dated.
---1 green top blood tube expired 2/10.
-In the upper cabinet:
---1 bottle of 2% Lidocaine opened, but not initialed or dated, and expired 9/09.

These findings were verified with Staff #6 on 8/9/10.

Observation on 8/9/10 at 11:00 AM of the medication room on the womens psychiatric floor revealed the following expired items were present:
---1 full box of pink top BD Vacutainers expired 6/10.
---1 full box of blue top BD Vacutainers expired 6/10.

This finding was verified with Staff #3 on 8/9/10.

Observation on 8/9/10 at 11:15 AM of the S3 Medication Room revealed the following expired items were present:

-In the upper cabinet:
---1 blood collection bag opened on the shelf.
---1 specimen swab expired 9/30/08.
---1 specimen swab expired 11/30/07.
---1 specimen swab expired 10/31/08.
---3 rayon swabs expired 1/07.
---3 rayon swabs expired 6/09.
---2 rayon swabs expired 3/06.
---1 rayon swab expired 2/07.
---1 thin prep pap test expired 2/21/10.
---1 red blood tube expired 7/09.
---3 yellow top blood tubes expired 3/09.
---1 yellow top blood tube expired 2/09.
---2 yellow top blood tubes expired 12/08.
---1 yellow top blood tube expired 8/08.
---1 green top blood tube expired 10/09.
---1 blue top blood tube expired 10/08.
---1 blue top blood tube expired 11/08.
---2 blue top blood tubes expired 3/09.
---2 purple top blood tubes expired 8/09.
---1 grey top tube expired 7/1/10.
-In the blood draw bin:
---1 25 gauge needle opened.
---1 5cc syringe opened.
-In the refrigerator:
---1 gray top tube expired 5/10.

These findings were verified with Staff #6 on 8/9/10.

-Observation on 8/9/10 at 1:30 PM of the Surgical Recovery Room revealed 1 Cetacaine Topical Anesthesia Spray expired 11/08.

This findings was verified by Staff #27 on 8/9/10.

Observation on 8/9/10 at 1:50 PM of the medication cupboard and supply cart in the surgical sterile hallway revealed the following expired items were present:
---2 gold top tubes expired 7/10.
---7 bottles of 2% Xylocaine expired 8/1/10.
---4 tubes of Gentak Opthalmic Ointment expired 7/10.
---2 1000ml bags of 5% Dextrose and 0.45% Sodium Chloride expired 11/1/09.

These findings were verified by Staff #27 on 8/9/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 10/14/08.

Based on observation, the facility does not maintain infection control standards.

Findings include:

-Observation during facility tour on 8/10/10 at 2:00 PM revealed dust accumulation on horizontal surfaces in the sterile core. Areas such as, but not limited to, under the scrub sink on the control peddle, on top of a supply cabinet adjacent to the store room, and above the door to the doctors' locker room.

These findings were verified with Staff #32 on 8/10/10.

-Observation during facility tour on 8/12/10 at 2:00 PM revealed outdated Steris Chemical indicator test strips, which are used for testing the Steris Colonoscope Processor. The package expiration date was 6/2009; furthermore, the package was not dated when opened as required by manufacturer's recommendations.

These findings were verified with Staff #32 on 8/12/10.

-Observation during facility tour on 8/13/10 at 11:25 AM revealed clean phlebotomy supplies stored in the glass room along with regulated medical waste. Ventilation status was not determined at this time; however, clean supplies are required to be stored in a positive pressure room, while soiled items and waste are to be stored in a negative pressure room.

These findings were verified with Staff #1 on 8/13/10.

-Observation during facility tour on 8/13/10 at 11:35 AM revealed carpet floor covering in the clean storeroom servicing the laboratory. The carpet was littered with dust and debris. Clean storage room floors must be comprised of easily cleanable material.

These findings were verified with Staff #1 on 8/13/10.

Based on medical record review, the anesthesiology staff do not perform a complete postoperative anesthesia evaluation between 3 and 48 hours postoperatively, as evidenced for Patients #16 and 43.

Findings include:

-Medical record review on 8/11/10 for Patient #16 revealed that the Post Anesthesia Evaluation form dated 8/6/10 did not show evidence that a post-anesthesia evaluation was performed on the patient between 3 and 48 hours postoperatively.

-Medical record review on 8/12/10 for Patient #43 revealed no documentation on the surgical forms or the progress notes that the patient received a post-anesthesia evaluation between 3 and 48 hours postoperatively after surgery performed on 8/6/10.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEYS COMPLETED 7/1/05 AND 10/14/08.