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On the days of the Hospital Validation Survey based on interview and facility record review, the Governing Body failed to ensure that its contracted services deliver services under sanitary conditions. (Food Service Agreement)


The findings include:


On 03-29-11 at 1200, an environmental tour of the hospital was conducted with the Director of Engineering. Observations of the kitchen area showed a double door refrigerator had a large amount of brown food substances on the floor of the refrigerator on the right side. Observation of the ice machine located in the kitchen revealed a drain leading from the ice machine to the floor that was not covered. The top of the drain had old looking sediment around it. The bottom of the drain had a collection of debris including a plastic cup cover. The walk in freezer had scattered white particle debris and a discarded wrapper on the floor. A plastic bag with salmon was observed resting on the floor of the walk in freezer. Observation of several ice cream containers revealed the ice cream was very soft and pliable. Observation of a large soup container revealed crumbs, liquid splashes, and what looked like a slice of potato on the piece of equipment attached to the container. An interview with the Director of the contracted food service revealed kitchen staff was adjusting to new management changes. Review of facility contract, reads, " 2. Obligations: -----shall also (a) perform the Services in accordance with the standards of care and diligence normally practiced by recognized firms providing services of a similar nature,(b) provide the best skill and judgement of its employees and subcontractors in providing the Services,....".

On the days of the Hospital Validation Survey based on interview, clinical record review, and hospital policy review, the hospital failed to ensure consent for treatment and/or receipt of patient rights and responsibilities information was signed by all patients admitted into the hospital for 1 of 21 open records reviewed (Patient #6), and 1 of 10 closed records reviewed. (Patient #3)


The findings include:


Record review conducted on 3/29/11 at 1330 revealed Patient #6 was admitted to the hospital on 3/21/11 and had hospital forms labeled, "CONDITIONS OF TREATMENT AND ADMISSION" and "YOUR RIGHTS AND RESPONSIBILITIES AS A HOSPITAL PATIENT" that were dated 3/21/11, and showed staff documented "patient unable to sign due to condition". An interview with the Director of ICU (Intensive Care Unit) on 3/29/11 at 1530 revealed the patient was brought into the hospital by a nursing facility. The ICU Director was uncertain as to which department (nursing or business) was responsible for obtaining signatures from the responsible family member. During an interview with the patient and family member on 3/29/11 at 1150, they revealed the family member had been in the hospital with the patient all day every day since the patient's admission. The family member reported that he/she had not been asked to sign any forms by hospital representatives. No signature by the patient or the responsible party had been obtained as of 3/31/11 at 1100.

Record review was conducted on 3/30/11 at 1000 that revealed Patient #3 was admitted to the hospital on 1/15/11, and had hospital forms labeled, "CONDITIONS OF TREATMENT AND ADMISSION" and "YOUR RIGHTS AND RESPONSIBILITIES AS A HOSPITAL PATIENT". Review of the patient's medical record showed there was no patient or responsible party signature on either of the hospital forms.

Facility Policy, titled, "CONSENTS", revised 6/07, states, "...VII. AUTHORIZED CONSENT: The patient must sign his/her own consent unless the patient is legally incompetent, mentally incapacitated, an un-emancipated minor, or experiencing an emergency. In these exceptions, consent should be obtained from the person legally authorized to consent on his behalf. The following guidelines should be used to determine proper consent...B. Incompetent Adults: The consent for treatment for a patient who has been legally declared incompetent must be obtained by the person's legal guardian or committee. If there is doubt as to the patient's ability to understand the consent, the consent should be obtained from the patient's nearest relative, if available....Any time there is a question about who can legally give consent, the Director or Nursing Supervisor should be contacted and Risk Management notified...C. Next of Kin: Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner...".

On the days of the Hospital Validation Survey based on clinical record review and facility policy review, the hospital failed to ensure that all orders for restraint included signature, date, and/or time as per hospital policy for 1 of 10 closed records (Patient #4 ).


The findings include:


A record review conducted on 3/30/11 at 1030 revealed Patient #4 was admitted to the hospital on 7/8/10 with the diagnosis of Shortness Of Breath, Cough, Congestion, and Sputum Production. A verbal NON-VIOLENT RESTRAINT ORDER was initiated on 7/9/10 at 2035 but there was no date or time on the physician order indicating when the physician actually signed the verbal restraint order. There was a Non-Violent Restraint Flow sheet dated 7/9/10, 7/10/10, 7/11/10, 7/12/10, and 7/13/10 but there were no physician order for continuing restraints. The findings were verified by the Director of ICU (Intensive Care Unit) on 3/31/11 at 1100.

On the days of the Hospital Validation Survey based on random observations, staff interviews, review of hospital policy and procedures, and chart reviews, the facility failed to ensure the staff nurses assigned to pediatric patients were knowledgeable in the clinical processes for evaluation of and accurate measurement of urine output in the pediatric population for three of four pediatric patients admitted to 2 North (Patient #1, #12, and #16), and staff failed to change a 20 gauge peripheral catheter intermittent needle (INT) per hospital policy (Patient #6).


The findings are:


On 3/29/2011 at 1530, observation of Patient #12 showed an infant who was admitted on 3/29/11 for Bronchiolitis for 24 hour observation. The patient's record showed the infant weighed 11 pounds. At 1350, Licensed Practical Nurse #7 was observed going into the patient's room and returned with one diaper. During the interview on 3/29/11 at 1350, LPN # 7 reported that she did not know if the infant had wet (urinated) in other diapers throughout the day. Observation of LPN #7 weighing the patient's diaper for accurate urine output revealed the nurse placed the wet diaper on the scale wrapped in a very large clear plastic trash can liner. After weighing the wet diaper and the plastic trash liner, observation revealed the nurse did not subtract the weight of the plastic liner in order to determine the patient's accurate urine output. When asked to remove the diaper from the plastic bag and reweigh the diaper, it was revealed that there was a 10 cc (cubic centimeter) difference in weight. LPN #7 was not able to state the rationale for determining a pediatric patient's accurate urine output or the number of wet diaper changes (6 to 8 per eight hour shift for normal urine elimination) as an indicator for normal urine elimination in infants. Review of Patient #12's intake and output sheet dated 3/29/11 showed staff had no documentation of urine output from 0700 through 1600. At 1545, Licensed Practical Nurse (LPN) #7 who was assigned to the patient reported that she "waited until the end of the shift to weigh diapers". On 3/29/11 at 1045, review of the output sheets for pediatric patient #16 and #22 revealed that no output had been documented on either patient between 0700 and 1600. On 3/29/2011 at 1555, the Clinical Director of 2 North, verified that pediatric patient's Intake and Output Sheets had no urine output documented from 0700 through 1600 and the urine output should have been charted more frequently than once per 12 hour shift.
Hospital policy,titled, Pediatric Assessments: Initial and Reassessments, reads, "B. Reassessment: .... reassessments/physicial examination and observations will be documented on the form titled "Pediatric 24 Hour Nursing Flow Sheet for ages 0-17". The following areas are included: .... Intake/Output".


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A clinical record review conducted on 3/29/11 at 1330 revealed Patient # 6 was admitted to the hospital on 3/21/11 with the diagnosis of Complicated Urinary Tract Infection (UTI). An intermittent needle therapy (INT), a 20 gauge catheter was initiated on admission in the right antecubital. The IV (Intravenous) site was changed on 3/25/11, which is greater than the 72 hour timeframe stated in the hospital policy. These findings were verified by the Director of ICU (Intensive Care Unit) on 3/29/11 at 1545.

Facility Policy titled, "IV Therapy Standards" revised 10/10 states, "...D. Maintenance:...4. Adult peripheral sites shall be changed every 72 hours. If the patient's condition warrants extending this time, a physician's order is required. Pediatric peripheral sites shall remain until IV therapy is completed, unless complications occur...".

On the days of the Hospital Validation Survey based on chart review, staff interview, and review of hospital policy and procedures, the facility failed to ensure the Registered Nurse and the Respiratory Therapist had a signed physician order prior to starting oxygen therapy. (Patient #11 and Patient 16).


The findings are:


Hospital Protocol: Upstate Carolina Medical Center Oxygen Protocol Origination Date 8/99 with Revision Level 0. Prepared by the Director of Cardiopulmonary and Approved by the Medical Director reads: "II Scope/Indications Oxygen therapy may be ordered for any patient, under the Protocol, who exhibits signs of tissue hypoxia. Patient care is primary and oxygen flow is decreased as necessary. This protocol describes conditions under which oxygen flow my be decreased or discontinued. ...6. Physicians are requested to write oxygen with parameters. (e.g. Maintain O2 sat (oxygen saturation) of at least (specified) percent.".

On 3/29/2011 at 1300, a review of Patient #11's medical record showed a Physician Order Form with Admission Orders with a box checked next to "Oxygen per protocol" under item #10 Respiratory Treatment. There were no additional orders for oxygen flow rate or oxygen saturation levels. Patient #11's Patient Care Flow Sheet dated 3/28/2011 had oxygen saturation levels documented at 1000 at 95% with no oxygen given, at 1400 at 97% on Room Air, at 1800 at 96% on Room Air. At 2200, the patient care flow sheet showed the patient was now receiving 3 Liters of oxygen and had an oxygen saturation of 96%. At 0200, the patient's oxygen saturation was 97% with no oxygen documented and at 0600 at 100% with no oxygen documented. The patient's 24 hour Nursing Flowsheet-Adult dated 3/28/2011 showed a check off sheet that indicated the patient was receiving oxygen at 2 liters/minute via nasal cannula at 0730 and at 1945. There was no documentation of a change in the patient's oxygen status in the Nursing Progress notes.

On 3/30/2011 at 1000, a review of Patient #16's medial record showed a physician order signed and dated on 3/29/2011 at 0845 for "O2 (oxygen) per protocol". The physician order did not include an initial flow rate.

On 3/29/2011 at 1430, Certified Respiratory Therapist #12 reported that her understanding of the Oxygen Protocol was that the Oxygen Protocol allowed the Therapist to initiate oxygen when a patient had an oxygen saturation level under 90%..

On 3/31/2011 at 1120, the Respiratory Director reported that there were no specified parameters set for an initial oxygen flow rate in the Oxygen Protocol. The Director verified that a physician's order was needed for the Oxygen Protocol. The Respiratory Director stated she had discussed clarification of the Protocol with the Pulmonologist.

On the days of the Hospital Validation Survey based on interview, clinical record review, and hospital policy review, the hospital failed to ensure all patient clinical records were completed, dated, and timed within the 30 day timeframe for 6 of 10 closed patient records reviewed (Patient #2, 3, 4, 5, 8, and 9), as well as a method to establish the identity of the author of each entry authenticated.


The findings include:


Clinical record review conducted on 3/30/11 at 0945 revealed Patient #2 was admitted to the hospital on 1/2/11, and discharged on 1/5/11 with the diagnosis of Nausea, Vomiting, and Diarrhea. The patient's Discharge Summary (D/C) dated 1/5/11, as well as, the patient's History and Physical (H & P) dated 1/3/11 were not dated and/or timed by the physician within the 30 day timeframe.

Clinical record review conducted on 3/30/11 at 1005 revealed Patient #3 was admitted to the hospital on 1/15/11 and discharged on 1/20/11 with the diagnosis of Lethargy. The patient's D/C Summary dated 1/20/11 was not dated and/or timed by the physician within the 30 day timeframe.

Clinical record review conducted on 3/30/11 at 1030 revealed Patient #4 was admitted to the hospital on 7/8/10 and discharged on 7/16/10 with the diagnoses of Shortness of Breath (SOB), Cough, Congestion, and Sputum Production. The patient's H & P dated 7/8/10, as well as, the patient's D/C Summary dated 7/16/10 were not dated and/or timed by the physician within the 30 day timeframe.

Clinical record review conducted on 3/30/11 at 1045 revealed Patient #5 was admitted to the hospital on 1/29/11 and discharged on 2/1/11 with the diagnoses of SOB and Unresponsiveness. The patient's H & P dated 2/6/11, as well as, the patient's D/C Summary dated 3/7/11, were not dated and/or timed by the physician within the 30 day timeframe.

Clinical record review conducted on 3/30/11 at 1155 revealed Patient #8 was admitted to the hospital on 2/20/11 and discharged on 2/23/11 with the diagnosis of Dehydration. The patient's H & P dated 2/20/11, as well as, the patient's D/C Summary dated 2/23/11 were not dated and/or timed by the physician within the 30 day timeframe.

Clinical record review conducted on 3/30/11 at 1205 revealed Patient #9 was admitted to the hospital on 1/24/11 and discharged on 1/28/11 with the diagnosis of Fractured Pelvis. The patient's H & P dated 1/25/11 and the patient's D/C Summary dated 1/28/11, as well as, two consultations dated 1/25/11 and 1/27/11 were not dated and/or timed by the physician within the 30 day timeframe. The findings were verified by the Director of ICU (Intensive Care Unit) on 3/31/11 at 1100.

An interview with the HIM (Health Information Management) Technician #22 on 3/30/11 at 0915 revealed Technician #22, an employee greater than 10 years, was not aware of a method of author verification and reported that she could obtain from corporate a list of physician signatures, but there was nothing in the department presently to verify physician signatures.

On the days of the Validation Survey based on record review and policy review the hospital failed to ensure that TO/VO (telephone/verbal) physician were signed, dated, and timed within the 48 hour time frame for 7 of 10 closed patient records reviewed. (Patient #1, 2, 3, 4, 5, 8, and 9).


The findings include:


Clinical record review conducted on 3/30/11 at 0930 revealed Patient #1 was admitted to the hospital on 2/26/11 and discharged on 3/3/11 with the diagnosis of Cough/Chest Congestion. On 3/1/11, a physician order was taken by the nurse over the telephone, but the physician order did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 0945 revealed Patient #2 was admitted to the hospital on 1/2/11 and discharged on 1/5/11 with the diagnosis of Nausea, Vomiting, and Diarrhea. On 1/4/11, a physician order was taken by the nurse over the telephone, but the physician order did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 1005 revealed Patient #3 was admitted to the hospital on 1/15/11 and discharged on 1/20/11 with the diagnosis of Lethargy. On 1/18/11, a physician order was taken by the nurse over the telephone, but the physician order did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 1030 revealed Patient #4 was admitted to the hospital on 7/8/10 and discharged on 7/16/10 with the diagnoses of Shortness of Breath (SOB), Cough, Congestion, and Sputum Production. On 7/8/10, three physician orders were taken by the nurse over the telephone, but the physician orders did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 1045 revealed Patient #5 was admitted to the hospital on 1/29/11 and discharged on 2/1/11 with the diagnoses of SOB and Unresponsiveness. On 1/29/11, a physician order was taken by the nurse over the telephone, but the physician order did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 1155 revealed Patient #8 was admitted to the hospital on 2/20/11 and discharged on 2/23/11 with the diagnosis of Dehydration. On 2/20/11, 2/21/11, and 2/22/11, a physician order was taken by the nurse over the telephone, but the physician orders did not have the date and time that the physician signed the order.

Clinical record review conducted on 3/30/11 at 1205 revealed Patient #9 was admitted to the hospital on 1/24/11 and discharged on 1/28/11 with the diagnosis of Fractured Pelvis. On 2/24/11, 2/25/11, and 2/26/11, a physician order was taken by the nurse over the telephone, but the physician orders did not indicate the date and time that the physician signed the order. The findings were verified by the Director of ICU (Intensive Care Unit) on 3/31/11 at 1100.

Facility Policy, titled, "Verbal/Telephone Orders", revised 3/10, states "...VI. POLICY STATEMENTS:...C. Authentication (Verification) of Verbal or Telephone Orders: 1. Verbal orders will be subsequently dated, timed, and authenticated (verified) by the prescribing practitioner or other responsible practitioner as soon as possible not exceeding 48 hours of receipt, with the exception of orders for restraints...".

On the days of the Hospital Validation Survey based on observation and interview, the facility failed to discard outdated biologicals from Malignant Hyperthermia Cart in Post-Operative Acute Care Unit.


The findings are:


On 3/29/11 at 1600, a random observation in Post-Operative Acute Care Unit (PACU) of the Malignant Hyperthermia Cart revealed three arterial blood gas kits expired as of 02/07. The finding was verified by Director #26 on 3/29/11 at 1600.

On the days of the Hospital validation Survey based on observations, interviews, and review of hospital policies and procedures, the hospital failed to ensure that proper safety practices for storage of frozen food, cleaning of utensils for food preparation and serving and out dated food was removed from kitchen area.

The findings are:


On 03/28/2011 at 1510, observations of the kitchen's dishwasher room, revealed the rinse water for the dishes had no disinfection during the check for the ph of the pot sink. Observation showed upon putting the paper into the rinse water, there was no change in the ph of the rinse water. According to hospital policy #F018, "....Sanitizer test strips should be readily available wherever sanitizer is placed. Complete Pot sink Sanitizer Concentration Log once a day at each meal period...'.

On 03/28/2011 at 1500, observations of the kitchen freezer log showed the freezer temperature for the past month had ranged from 3 degrees to 60 degrees. The log book hanging outside the freezer door, reads, ".... If the temperature is below -10 degrees F or above 0 degrees F, notify Plant Operations and the Food Service Director". There was no documentation available that Plant Operations or Food Services was notified.

On 03/28/2011 at 1600, observations the facility refrigerator showed a container of Buttermilk on the top shelf with other food had expired on 03/20/2011. This was verified by the Dietary Director on 3/28/11 at 1600.

On the days of the Hospital Validation Survey based on observation, interview, and review of facility records, the Infection Control Officer failed to ensure to ensure that Contact and Standard Precautions were maintained according to hospital policy and procedure. (Patient #8), and failed to properly use Personal Protective Equipment (PPE) to perform a subcutaneous injection to a patient. (Licensed Practical Nurse)


The findings include:


On 3/29/11 at 1136, Certified Nurse Assistant#6 (CNA) entered Patient #8's room to obtain the 12:00 noon blood sugar sample. Observation showed CNA #6 sanitized her hands and donned gloves. CNA #6 placed the Glucometer case on Patient #8's bed. After leaving the patient's room, CNA #6 placed the glucometer case on the counter at the Nurse Station, and then, was observed to wipe the glucometer case down with Sani wipes. Observation of the patient's room showed there was no Protective Personal Equipment (PPE) was on Patient's room door during observation.

On 3/29/11 at 1355, chart review showed Patient # 8 was admitted on 3/28/11 and had a history of MRSA (Methicillin Resistant Staph Aureus) documented on the admission history. The patient's chart showed a nasal swab was obtained on the day of the patient's admission. Review of the patient's chart showed no labwork was on the chart pertaining to the nasal swab status. During an interview with Director #5, the Director verified the patient's chart had no results pertaining to the nasal swab or any identifier for staff of the patient's contact status.

Facility policy, NH-IC-IEP-3000, revised April 2010, reads, "Isolation Precautions, Scope/Purpose: Isolation Precautions are used to prevent and/or reduce the risk of transmission of infections. Nursing Service is responsible for isolation precautions in their respective areas, including notification of the physician of pertinent laboratory, clinical, or historical data requiring precautions, obtaining the order for precautions, and initiating the precautions. Is responsible for implementing isolation precautions per infection prevention and obtaining the physician's order at a later time. Is responsible for placing the correct precaution sign on the patient's door...".

On 3/30/11 at 1110, a random observation of Licensed Practical Nurse ( LPN) #18 showed the nurse administering Heparin 5000 units subcutaneous as a one time dose to Patient #19. LPN #18 cleaned Patient #19's skin with an alcohol prep, and then gave the injection to the patient without putting on gloves. On 3/20/11 at 1110, LPN #18 verified that she had not used gloves for the injection.

Policy, read, "Title Isolation Precautions. Number NH-IC-IAEP-3000. Apr 10 ++. Section V. Procedure: A. Standard Precautions. Standard precautions is a combination of Universal Precautions and Body Substance Isolation. This precaution applies to: Blood. All body fluids, secretions and excretions, except sweat, regardless of whether or not they contain visible blood. Non-intact skin. Mucous membranes. Standard precautions are to be observed on all patients, regardless of diagnosis or illness."

On the days of the Hospital Validation Survey based on interview and facility record review, the hospital failed to ensure that the preparation of radiopharmaceuticals were prepared under the direct supervision of a qualified physician or pharmacist.( Imaging Department-Nuclear Medicine)


The findings are:


On 03-29-11 at 0920, an interview with the RT-Nuclear Medicine Technician #13 revealed that occasionally the Technologist prepares radiopharmaceuticals on site. Technician #13 reported that the radiopharmacy sends Technetium to be mixed with a kit because of an add on test or an emergency, the radiopharmaceutical was not sent in advance and requires preparation on site. Technician #16 verified that the preparation of the radiopharmaceutical is done onsite without direct supervision of a physician.

On 03-30-11, facility record review of radiopharmaceuticals revealed that on 03-16-11 at 1200, the RT-Nuclear Medicine Technician prepared Tc-99 NaTc04 with a MAA Kit without supervision. The finding was confirmed with the Director of Imaging Services on 03-31-11 at 0930. The Imagining Department did not have a policy regarding the supervision of Nuclear Medicine technicians during the preparation of radiopharmaceuticals.