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Based on observation and interview, the governing body failed to ensure that the Contracted Services Company for Housekeeping participated in Quality Assessment and Performance Improvement (QAPI). Findings include:

On 5/14/13 at approximately 10:30 through 12:30 during the observational tour of the facility, it was noted that the patient care units (ICU, 3 West, 3 South and 2 South) were dusty and the refrigerators were dirty. Interview with Staff A at that time revealed that both cleaning and maintenance of patient refrigerators were performed by a contracted service. Interview with the CEO, on 5/16/13 at approximately 10:00, revealed that performance improvement problems were not reported to the the facility's QAPI program.

Based on Quality Assessment Performance Improvement (QAPI) document review and interview the facility failed to ensure that the medical records, housekeeping, and organ procurement programs were incorporated in the QAPI program. Findings include:

During QAPI document review on 5/15/2013 at approximately 1400 it was discovered that there was no QAPI involvement noted in the meeting minutes by the medical records, housekeeping, or organ procurement programs.

Review of the document titled "Performance Improvement Projects" has no projects listed for medical records, housekeeping, or organ procurement.

Interview of staff A on 5/16/2013 at approximately 1130 am revealed , "no QAPI involvement for medical records", "housekeeping is a contract service and does their own QAPI", and "organ procurement has only done education to the Intensive care nurses".

Based on medical record review which included one of 39 (Patient #32) medical records reviewed, interview, and policy review the facility failed to ensure that all patient medical records were completed within 30 days of discharge of the patient. Findings include:

During medical record review on 5/15/13 at approximately 1115 it was revealed that patient #32's medical record was not completed within 30 days following discharge. Patient #32 was discharged from the facility on 1/8/13 and the discharge summary was dated 2/20/13.

During interview on 5/15/13 at approximately 1300 Staff X was asked "How many open medical records over 30 days do you have at this time?" to which she replied "463."

On 5/16/13 at approximately 1030 review of the document titled "Bylaws Rules and Regulations of the St Mary Mercy Hospital Medical Staff" section 17.11 revealed the following: "The medical record of discharged patients shall be accurate, legible and completed within a period of time that in no event exceeds twenty-eight (28) days following discharge."

Based on interview and record review on May 15, 2013 between 8:30AM and 9:30AM it was determined that calibration non-compliances revealed in the December 15, 2012 report from radiation physics consultants for equipment in radiology room #4 had not been logged into the bio-medical preventive maintenance system or resolved. As such patient safety from ionizing radiation and/or accurate images could not be assured.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/15 & 5/16/2013, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags for buildings 1 and 2 on the CMS-2567 dated 5/16/13, for Life Safety Code.

Based on observation and interview the facility failed to ensure that the supplies and equipment were maintained at an acceptable level of safety and quality which has the potential to adversely affect patient care. Findings include:

On 5/14/13 at approximately 1330 during observations on the Medical Care Unit it was found in the crash cart room one bottle of blood glucose test strips that expired 11/30/12 and two sets of pediatric pacing pads that expired 4/10 and 3/13. These findings were confirmed at the time of observation by staff Q.

On 5/15/13 at approximately 1055 during observations in the Operating Room corridor it was found in the Hyperthermia Cart two radial arterial catheter kits that expired on 8/12 and 9/12 and two 20 gauge intravenous catheters that expired 3/13. These findings were confirmed at the time of observation by staff V.

On 5/15/13 at approximately 1600 during observations in the out patient wound care clinic it was found the patient's Hoyer lift and doppler machine were being stored in the dirty utility. This finding was confirmed at the time of observation by staff CC.



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The following were observed as not providing a safe or a sanitary environment:
1. On May 14, 2013 at 10:02 AM loose corridor handrail was found north of the mental health nurse station.
2. Uncovered supply carts filled with various patient care supplies was found on May 14, 2013 at 11:43 AM in the ICU corridor and on May 14, 2013 at 3:55 PM in the wound care clinic corridor such that supplies could become contaminated.
3. Examples of low shelves (that do not allow for routine floor cleaning) were found in the lab on May 14, 2013 at 1:00 PM and in pharmacy bulk storage on May 15, 2013 at 8:57 AM.
4. A torn stool cover (that does not allow for cleanable surfaces) was found in endoscopy reprocessing room on May 14, 2013 at 2:18 PM.
5. Corrugated cardboard boxes (that cannot be cleaned) were found on a cart in interventional procedure room #2 on May 14, 2013 at 2:20 PM.
6. Coffee, creamer, and sugar were found in the radiology clean supply room that can contaminate patient care supplies and attract vermin on May 14, 2013 at 3:17 PM.
7. Twenty six holes were found in the wall of the obstetrical medication room on May 15, 2013 at 9:42 AM.
8. Only 98 - 105 footcandles of artificial illumination were measured in the delivery room #1 on May 15, 2013 at 9:54 AM versus the required 150 footcandles to ensure patient safety.
9. On May 15, 2013 at 9:56 AM an open bin of disposable handtowels was found at the handwash sink in nursery. This design allows for wet hands accessing toweling to drip on the rest of the stack, thereby providing possible harborage of air borne infectious agents.
10. On May 15, 2013 at 11:14 AM the PACU air borne infectious isolation room was found to lack the required door closer to ensure contaminated air would not infect those outside the room.
11. On May 15, 2013 at 11:15 AM the PACU air borne infectious isolation room was found to lack a scrubbable ceiling needed to ensure that the next room occupants after a contaminated case would not be infected.
12. On May 15, 2013 at 11:16 AM the 17 full oxygen tanks were found in the PACU soiled utility room that were intended for patient use and as such could be contaminated and infect patients or staff.

Based on observation, interview and document review, the facility failed to develop, implement, monitor and evaluate a program for the prevention of healthcare associated infections that encompasses the scope of services provided, resulting in the potential risk for transmission of infection among all patients, visitors and staff.

Findings include:

See Tag

A-749 failure to monitor and provide a sanitary environment

Based on observation, interview and policy review the Infection Control Officer failed to monitor and maintain a clean and sanitary environment and failed to identify and take measures to prevent the patients' Foley catheter bags from touching the floor for 5 (#4, #37, #38, #39 and #385-6) of 8 patients, resulting in the potential for transmission of infectious agents among all patients, visitors and healthcare workers.

Findings include:

On 5/14/12 at approximately 1115 during observations on the Labor and Delivery unit it was found in the pantry that the refrigerator was dirty with dried spills and accumulated crumbs. The ice machine had white film around the lip of the dispenser, yellow/orange residue build up in the catch basin and the grate had white film built up. It was further observed that the staff were storing their personal drinks, food, utensils, table and chairs in the patient's pantry. Observations of the refrigerator, freezer and cooler temperature logs revealed that they were not being checked twice daily as per policy. There were 4 out of 12 days in May, with no temperature recorded. The housekeeping closet floor was dirty with debris and dried substances, the rinse/drain basin used for mop water and rinsing was black with dirt and grime accumulation. These findings were confirmed at the time of observation by staff R and Q.

On 5/16/13 at approximately 1000 during review of the policy titled, "Refrigerator and Freezer Temperature Documentation", it was found under #8, "Documentation and Maintenance of the temperature logs on the patient care unit refrigerators that are stocked daily will be completed jointly by the stock position and the Host/Hostess staff".

On 5/14/13 at approximately 1340 it was observed on the Medical Care Unit in the pantry that the ice machine had white film build up around the lip of the dispenser, the catch basin and the grate. Dirty meal trays were also being stored in the pantry. During further observations, in the medication room, it was found that patient medications were being stored directly next to a handwashing sink, within the splash zone of possible contamination. The drawers in the medication room had dust and debris build up in them. These findings were confirmed at the time of observation by Staff Q.

On 5/14/12 at approximately 1430 it was observed on the Inpatient Rehabilitation unit that the pantry drawers had debris and dust build up. This finding was confirmed by staff K at the time of observation.

On 5/14/13 at approximately 1530 during observations on 3 south it was observed the pantry #2's refrigerator was dirty with dried spills and accumulated crumbs. The ice machine had white film around the lip of the dispenser, residue build up in the catch basin and the grate had white film built up. The pantry drawers were dirty with dust and debris. These findings were confirmed by staff U at the time of observation.

On 5/15/13 at approximately 1500 it was observed in the out patient infusion clinic that the refrigerator and freezer had debris build up and dried spills. This finding was confirmed at the time of observation by staff DD.

On 5/14/13 at approximately 1430 during an interview with staff GG and HH it was asked by this surveyor who's responsibility is it to maintain refrigerator and freezer temperature logs on the units, the response by both staff members was, "The host/hostess assigned to the unit". When asked who's responsibility it is to keep the pantry clean, including the refrigerator and drawers, the response by both staff members was, "The host/hostess assigned to the unit".

On 5/15/13 between 1400 and 1500 during an interview with staff A and staff JJ revealed that when asked what process-type infection prevention monitors are conducted staff JJ indicated that "we monitoring hand hygiene, appropriate use of personal protective equipment, environmental rounds (for cleanliness) and compliance to isolation precaution protocols". When asked how often these are done staff JJ said "monitoring has be rather sporadic lately, I have had to send out many reminders (for units to get them completed)". Staff JJ was asked about what types of surveillance (patient outcomes) are being monitored, she replied CAUTI (catheter associated urinary tract infections) and C-Diff (healthcare associated clostridium difficile infection". When asked whether these process monitors and surveillance results are reported in the Infection Control Committee meeting, staff JJ responded that "we do but we had to cancel our February (2013) and April (2013) meetings".


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On 5/14/13 at approximately 1130 the following was observed while on tour of floor 2 south:
(a) Hair and debris noted in pantry drawers
(b) Debris and a pink stain noted in the pantry refrigerator
(c) Accumulated dust and debris on top of the pantry refrigerator
(d) Refrigerator temperature log with documentation missing for 4 out of 13 days
(e) Cooler temperature log with documentation missing for 6 out of 13 days

Staff L was queried as to whose responsibility it was to clean the pantry drawers, refrigerator, and complete the refrigerator and cooler temperature logs to which she replied "I believe dietary is responsible for cleaning and checking the temperatures."


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On 5/14/13 at approximately 11:00, during the observational tour of Medical Unit 4 West, patient #4's Foley bag (urinary drainage bag) was noted touching the floor. The Unit Manager (Staff C) was queried at that time regarding the Foley bag and verified that that was an unacceptable practice. Two days later on 5/16/13 at approximately 11:30, patient #37 on 3 South and patients #38 and #39 on 2 South were also noted to have Foley bags touching the floor. Interview with Staff A at that time revealed that when the beds are in the lowest position, the bags generally touched the floor.


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On 5/14/2013 at approximately 10:00 am it was revealed return air vents in the speciality care unit 385 had excessive accumulation of dust occluding the return air vent system in three of three rooms, (385-3, 385-7, and 385-8). An interview with staff H confirmed the findings. When asked if the accumulation of dust was acceptable standards for infection control practice in the speciality unit, staff H responded "it is not acceptable. We (hospital) have a contracted service for housekeeping services".

On 5/14/2013 at approximately 10:15 am it was revealed the microwave in the speciality care unit 385 had splattered food contents. An interview with staff H confirmed the findings. When asked if this was an acceptable condition of the inside of the microwave, staff H responded "no".

On 5/14/2013 at approximately 10:20 am it was revealed the patient refrigerator in the speciality care unit 385 had hair and dust in the refrigerator. Also stored in the door of the patient refrigerator was two (2) 1000 ml bags of 0.9% normal saline. When asked if it was acceptable practice to keep medical supplies in the refrigerator intended for food only staff H responded "no. I've never seen medical supplies kept in the food refrigerator". When asked if the refrigerator was considered clean staff H responded "no. It is dietary's responsibility to keep the refrigerator clean".

On 5/14/2013 at approximately 11:00 am it was revealed in room 385-6 the patient's Foley bag (urinary drainage bag) was touching the floor. Staff H confirmed the finding. When asked if the Foley bag should be touching the floor she responded, "no".

On 5/14/2012 at approximately 11:20 during initial tour of the soiled utility room located between the speciality care units it was revealed used sharps lying on the sink area, spilled and dried fluid located on the sink area and on the top of the biohazard lid top, and high amount of dust located on the top of the shelf located within the room. Staff H confirmed the findings. When asked if used sharps should be located outside of the sharps container staff H responded "no. The sharps should have been disposed of in the sharps container".

On 5/14/2013 at approximately 2:00 PM it was revealed in the psychiatric unit a high accumulation of dust on the clock at the nurses station, picture frames located throughout all hallways in the unit, and air ventilation returns. Staff F was asked if this was acceptable standards for infection control practice and she responded "absolutely not". Staff F was asked if there existed a regular scheduled monitoring of housekeeping responsibilities and she responded "yes. Undoubtedly, we need to focus on these areas".

Based on medical record review and document review the facility failed to ensure that all patients had a completed anesthesia informed consent in 3 out of 5 (#12, #14, & #15) surgical patients. Findings include:

On 5/14/13 at approximately 1130 during medical record review it was revealed that the anesthesia consent forms for patients #12, #14, & #15 were incomplete in that the type of anesthesia to be used was not documented. The anesthesia consent form contains boxes next to the various types of anesthesia available. On the consent forms for patients #12, #14, & #15, the boxes were blank, no type of anesthesia was checked.

On 5/16/13 at approximately 1115 review of the document titled "Anesthesia Informed Consent" revealed the following: "...I understand that the type(s) of anesthesia checked below will be used for my procedure..."