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Based on observation, staff interviews, and review of maintenance records between June 16 and June 17, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623 Condition of Participation: Physical Environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K 29: hazardous areas improperly enclosed;
K 30: gift shop did not resist the passage of smoke;
K 38: dead bolt in egress door, slippery and non-maintainable egress path;
K 50: fire drills were not conducted at all required intervals;
K 51: unauthorized access to fire alarm system power source;
K 52: fire alarm system not fully tested per NFPA 72,
K 54: smoke detectors lacking sensitivity testing per NFPA 72;
K 62: sprinkler system was not properly maintained per NFPA 25;
K 69: commercial range hood was not cleaned per NFPA 96;
K 106: Level 1 electrical power system was not compliant with NFPA 99;
K 130: miscellaneous findings within a clinic setting;
K 131: procedure for controlling spills not available in the lab;
K 144: Level I emergency generator without a remote stop switch and without annunciator panel to operating staff; and
K 147: deficiencies in the electrical systems.

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, interview and record review the hospital failed to ensure availability of spill kits for hazardous waste. in 1 of 1 area (Family clinic). This has the potential to affect all 5 patients served at the facility during this survey.


Findings include:

Facility policy #WR 09-018 entitled; "Waste Management - Chemical Waste" dated 10/2013 states: "Chemical waste must be disposed of in a manner that minimized risk to the handlers and the environment."


The MSDS (material safety data sheet) for 10% Neutral Buffered formalin states;

"EMERGENCY OVERVIEW
Warning! May cause respiratory tract irritation. Harmful if inhaled. Harmful if absorbed through the skin. May cause lung damage. May cause pulmonary edema. May cause eye irritation and transient injury. May cause severe skin irritation. May cause reproductive and fetal effects. Contains formaldehyde which can cause cancer. May cause allergic respiratory and skin reaction."

1. Per observation, while touring the procedure room in the Family Clinic with DON G on 06/17/14 at 11:25 AM, approximately 30 specimen containers containing 30 ml of 10% Neutral Buffered formalin were found kept in an unlocked cabinet. G was interviewed at the time of the tour, G stated there was no spill kit available for a formalin spill and was not aware of any special procedure for that eventuality.

Based on observation, staff interviews, and review of maintenance records between June 16 and June 17, 2014, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 485.623(b) Standard: Safety from Fire was NOT MET.

Findings include:

The facility was found to contain the following deficiencies
K 29: hazardous areas improperly enclosed;
K 30: gift shop did not resist the passage of smoke;
K 38: dead bolt in egress door, slippery and non-maintainable egress path;
K 50: fire drills were not conducted at all required intervals;
K 51: unauthorized access to fire alarm system power source;
K 52: fire alarm system not fully tested per NFPA 72,
K 54: smoke detectors lacking sensitivity testing per NFPA 72;
K 62: sprinkler system was not properly maintained per NFPA 25;
K 69: commercial range hood was not cleaned per NFPA 96;
K 106: Level 1 electrical power system was not compliant with NFPA 99;
K 130: miscellaneous findings within a clinic setting;
K 131: procedure for controlling spills not available in the lab;
K 144: Level I emergency generator without a remote stop switch and without annunciator panel to operating staff; and
K 147: deficiencies in the electrical systems.

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview this facility failed to maintain a complete credential file by failing to determine hospital privileges for 1 of 1 mid-level practitioners (Nurse Practitioner [NP] S) for the Emergency Department (ED). Failure to maintain complete credential files has the potential to affect all patients who would be seen by this NP in the ED.

Findings include:

A review of the credential file for NP S was completed on 6/17/2014 at 7:30 AM. It was noted that the core privilege document used by this facility to determine privileges for NPs was blank and unsigned by the NP, a supervising physician, or the medical director.

In an interview with Quality Director M on 6/17/2014 at 11:40 AM, Director M stated that NP S started with the organization in 2012 in one of the clinics providing care for patients at the clinic and has a separate credential file for the clinic. NP S recently started shadowing with physicians in the ED for experience/competence in the care of emergency patients.

Director M acknowledged that the privilege list was blank and unsigned and is therefore incomplete.

Based on observation and interview the facility failed to ensure that drugs and biologicals were secured in 2 of 5 areas (ED {emergency department}, Family clinic). This has the potential to affect all 5 patients served at the facility during this survey.


On 6/16/2014 at 4:15 PM a tour of the ED was conducted accompanied by DON (director of nursing) G. The department has two emergency carts, one for adults and one for children. Both of these carts contain medications, needles, and syringes. Both of these carts are equipped with break away locks.

In an interview and observation with DON G during the tour, G stated that patients are in the vicinity of the carts, with the privacy curtains pulled, without staff being present to observe the integrity of the cart contents at all times. During this interview there was a patient in the ED bay with the emergency cart and the privacy curtain was pulled and no other staff were present with the patient.

DON G agreed that it could be possible that unauthorized access to the contents of the carts could occur using the facility's current security of only a break away lock.

On 6/17/2014 at 11:25 AM a tour of the Family Clinic was conducted accompanied by DON (director of nursing) G. The nursing station wall cupboard contained 30 expired hemoccult test cards dated 05/2014. Exam room #4 whose door was unlocked and open, an unlocked wall cabinet contained medications including; ketorolac, methoprednisone and cefriaxone. The procedure room was unlocked and the door was open, the wall cupboard contained unsecured biologicals and medications including; xylocaine, lidocaine and specimen containers of formalin.

Based on observation, record review, and interview this facility failed to ensure there is a comprehensive infection control program to monitor, prevent and control potential infections in 5 out of 8 department observations (Medical/Surgical (Med/Surg) unit, Emergency Department (ED), Medication Preparation room, Radiology Department and Decontamination/Sterilization area) and two of two staff performing patient care (Staff H and L) for 2 of 2 patients (Pt #1 and 6). This deficiency potentially affects all patients treated at this facility including the 5 in-patients present and 1 of 1 out-patients observed during the course of the survey.

Findings include:

There were no surgical procedures to be observed during the course of the survey.

In an interview with Infection Control Coordinator (ICC) I and Director of Nursing G on 6/16/2014 at 11:10 AM, ICC I stated the facility follows the recommendations of the Centers for Disease Control (CDC) and the Association of periOperative Registered Nurses (AORN) for infection control practices. DON G stated that the expectation of all staff is that hands are cleansed upon entry and exit of patient rooms as well as other times in the patient room depending on cares.

The facility's policy titled, "Hand Hygiene," dated 11/13, was reviewed on 6/17/2014 at 11:45 AM. The policy follows guidelines from the CDC and states in part that, "Waterless hand cleaner should be used to decontaminate hands: 1. After contact with patients. 2. Between patient to patient contact. 3. When moving from a contaminated body site to a clean body site during patient care. 4. After contact with inanimate objects in the immediate vicinity of the patient. 5. After removing gloves." The policy does not reflect the facility's expectation of cleansing hands upon entry and exit of patient rooms/care areas.


ED tour:
On 6/16/2014 at 4:15 PM a tour of the ED was conducted accompanied by DON G. In unoccupied ED rooms/bays the following were observed:
-laundry hanging out of the top of a closed laundry hamper,
-trash to the top of uncovered trash bins and used gloves on the floor next to the trash bin,
-three used urine hats in an uncovered trash bin in a bathroom shared between two rooms.
-damaged/missing laminate along the corridor side of the nursing station exposing a porous non-cleanable surface.

Per interview with DON G during the tour, the laundry is to be removed when it it half full and should not be hanging out of the bin and the trash gets removed at the change of shift or when the ED aide thinks it should be emptied. DON G also stated that the urine hats should not have been left in the bathroom sitting exposed in the trash bin.

In the Medication Preparation (prep) room (observations made 6/16/2014 at 4:30 PM with DON G) :
-pharmacy labeling equipment and office supplies stored under the sink which could be damaged/contaminated if water would leak.
-no cleaning agents (virex spray or disinfecting towelettes) in the medication preparation area.
Per interview with DON G during this observation, G stated that staff would go to one of the ED rooms/bays to get the virex spray if needed for the prep counter.

Decontamination/Sterilization (D/S) observations:

A tour of the D/S area was conducted on 6/16/2014 at 2:40 PM accompanied by Surgery Lead RN E and DON G, RN E stated that the facility did not have a policy for re-cleaning the endoscopes after they were cleaned and put in the cabinet to dry. RN E stated the scopes stay in the cabinet until they are used.

A review of the endoscope cleaning logs was completed on 6/17/2014 at 7:30 AM. It was noted that the date the scopes were cleaned was frequently 1-2 weeks, to up to a month, between uses according to the log sheets for the four endoscopes. In an interview with Director of Ambulatory Services, RN J on 6/17/2014 at 8:13 AM, RN J confirmed that the "date" column on the log sheets was the date the scope was cleaned.

At 9:04 AM on 6/17/2014 RN E and RN J brought the 2010 edition of the AORN manual in which identified that the endoscopes should be re-cleaned after 5 days of non-use. RN E and RN J confirmed the facility is not doing this. The facility's policy for the cleaning and caring for endoscopes does not reflect this practice and is outdated as the reference is from the 1990 AORN manual.

Observations of care:
On 6/16/2014 at 4:35 PM Registered Nurse (RN) H was observed performing medication administration to Pt. #1 on the Med/Surg unit. RN H was not observed to have cleansed hands prior to entering the automated medication dispensing unit in the medication room, or upon entry to Pt. #1's room and using the computer while in Pt. #1's room, or before opening the peel packed medications into a medication cup and handing them to Pt. #1 after touching the computer keyboard. RN H did not follow facility policy for hand hygiene.

On 6/17/2014 at 11:14 AM RN L was observed performing a clean technique wound care on Pt. #6's right heel wound. The wound care was performed in one of the ED rooms as Pt. #6 was an out-patient. Upon entry to the room RN L failed to cleanse hands and applied gloves and a gown for the wound care procedure. RN L then removed the outer kerlix wrap of Pt. #6's right foot, reached into the plastic bag of clean supplies with the contaminated gloves on, removed the glove from the left hand, with gloved right hand removed the smaller dressing that was covering the wound and then removed the glove from the right hand. Without washing hands RN L then applied new gloves and exited and entered the room with gloves on and not cleansing hands. Upon returning RN L then cleansed the wound with saline soaked gauze starting from the center and working outward but then went back to the center of the wound again with the same gauze that the outside of the wound had been cleansed with thereby potentially contaminating the compromised non-intact tissue. With the same gloves, after washing the wound, RN L entered the clean supply bag again to obtain supplies, handled two tubes of ointment, contaminating the outsides of the tubes with the contaminated gloves, and after applying a clean dressing with the contaminated gloves removed these gloves, did not cleanse hands, and exited and entered the room twice for supplies without cleansing hands at any of these points. RN L then used L's right hand to put L's hair behind L's ear, and applied gloves to complete Pt. #6's wound care, clean up supplies and trash from the procedure, and clean the area with disinfectant. RN L did not follow facility policy for hand hygiene, did not change gloves at appropriate intervals, and did not perform wound care in accordance with basic wound care protocols (not returning to the inside of the wound after cleansing the outside of the wound).

These findings were discussed with Director of Nursing G on 6/17/2014 at 3:40 PM.

During a tour of the nursing unit with Housekeeping director D on 06/16/14 at 3:10 PM the following observations were made in the soiled utility room across from the nursing station; Clean patient care items including; an IV pump, blood pressure monitors, thermometers, clean washcloths, skin lotion and shaving cream were stored in this dirty area. Per interview with D at the time of the tour patient care items should not be stored in this area.

A tour of the old darkroom in the radiology department was conducted on 06/17/14 at 1:30 PM. Observations of the area revealed broken, stained floor tiles and the storage of a wheelchair and clean, uncovered bath blankets. Per interview with Maintenance Director B on 06/17/14 at 10:30 AM, this room is not used anymore.









26711

Based on record review and interview the hospital failed to ensure staff re-evaluated pain in 3 of 6 patients (#2, 10 and 22) who were complaining of pain out of a total sample of 22 patients. This has the potential to affect all 5 patients receiving services at this facility at the time of the survey.

Findings include:

Hospital policy WR 30-013 entitled: "Pain Management" dated 04/2014 states under "Procedure" section "2"; "Pain is assessed and effectiveness of interventions is documented: ...d. With each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect based on classification and route. General time frames are: PO (oral) 30-60 minutes, IM (intramuscular) 30-60 minutes."

According to the medical record (MR) pt. #2 was given oxycodone orally for pain at the following times;
-7:50 AM on 01/28/14 and was not re-evaluated for pain until 1:41 PM.
-1:35 PM on 01/28/14 and was not re-evaluated for pain until 4:10 PM.


According to the MR pt. #10 was given hydrocodone orally for pain at the following times;
-8:20 AM on 03/22/14 and was not re-evaluated for pain until 10:10 AM, there was no documentation of pain rating on reassessment.
-1:30 PM on 03/22/14 and was not re-evaluated for pain until 2:46 PM.
-8:45 PM on 03/22/14 and no re-evaluation was documented.
-9:24 PM on 03/23/14 and no re-evaluation was documented.


According to the MR pt. #22 was given Tylenol orally for pain at the following times;
-8:39 PM on 06/04/14 and was not re-evaluated until 7:30 AM on 06/05/14.
-5:02 PM on 06/07/14 and no re-evaluation was documented.


Findings were confirmed per interview with Medical Records Director K on 06/17/14 at 1:30 PM. K stated pain re-evaluations should be done within 60 minutes.

Based on record review and interview this facility failed to maintain medical records (MR) that are complete and/or accurate with a chronological time line for events in 1 of 2 sexual assault MR's (Pt. #4) and 3 of 3 emergency department records (Pt. #14, 15, and 16) out of a total of 22 MRs reviewed. Failure to maintain complete and accurate medical records has the potential to affect all patients receiving care in this facility, including the 5 (averaged) patients present during the course of the survey.

Findings include:

In an interview with Director of Nursing (DON) G 6/16/2014 at 4:15 PM (during the tour of the emergency department [ED]) regarding documentation of arrival times for patients presenting for emergency services, DON G stated that the time documented as the arrival time is the time the ED aide puts the patient in the room. If the ED is busy the registration desk may enter the arrival time. DON G stated that the facility is not capturing the time that patient's who might walk in through the front door, which should be the arrival time for services.

While reviewing the MR's for Pt.s #14, 15, and 16 with DON G on 6/17/2014 between 2:45 PM and 3:00 PM it was determined that the arrival time listed on the ED log does not coincide with the arrival times documented in the MR's of all of these patients. DON G confirmed these findings.
Pt. #14 is in the log as arriving at 2:57 PM, the MR indicates arrival time as 2:55 PM.
Pt. #15 is in the log as arriving at 7:01 AM, the MR indicates arrival time as 7:04 AM.
Pt. #16 is in the log as arriving 4:46 PM, the MR indicates arrival time as 4:40 PM in one area, and 5:06 PM in another area.

Pt. #14's closed ED record also showed that Pt. #14 was transferred to a higher level of care due to not being stabilized at this facility (according to the transfer form). The form indicates in section 2, that if patient is not stabilized prior to transfer then section 2, which asks for the reason for transfer, needs to be complete. This section is not complete on Pt. #14's form. This was confirmed by DON G at the time of the record review.

A MR review was conducted on 6/17/2014 at 10:15 AM on Pt. #4's closed sexual assault record. On the document titled, "Disposition of Evidence for Sexual Assault," there is no time documented for when the nurse released the evidence to the police.

In an interview with DON G after the record review (6/17/2014 at 1:00 PM), DON G agreed that the record was not complete and a time should be documented.

Based on record review and interview the facility failed to ensure the medical record(MR) contained dated signatures of providers in 7 of 22 MR's reviewed (#7, ,9 ,11, 14, 15, 19, 20). This deficiency has the potential to negatively effect all 5 patients being served by the hospital at the time of the survey.

Findings include:


A MR review was conducted on 6/17/2014 at 3:00 PM of pt. #7's closed record accompanied by K who confirmed these findings. A verbal order written on 09/29/13 at 9:28 AM was not countersigned by the physician.


A MR review was conducted on 6/17/2014 at 2:45 PM of pt. #9's closed record accompanied by K who confirmed these findings. A verbal order written on 03/01/14 at 7:30 AM was not countersigned by the physician. A verbal order written on 03/04/14 at 2:15 PM is signed by the physician but lacks a date and time.

A MR review was conducted on 6/17/2014 at 3:15 PM of pt. #11's closed record accompanied by K who confirmed these findings. A verbal order written on 0314/14 at 4:15 PM was countersigned by the physician but lacks a date and time.



26711


A MR review was conducted on 6/17/2014 at 2:45 PM on Pt. #14's closed emergency department (ED) record accompanied by DON G who confirmed these findings. The order sheet signed by the ED physician does not include a time it was signed. These orders included six medications, diagnostic imaging, and a foley catheter.

A MR review was conducted on 6/17/2014 at 2:46 PM on Pt. #15's closed ED record accompanied by DON G who confirmed these findings. The order sheet signed by the ED physician does not include a time or date it was signed. These orders included six medications.

A MR review was conducted on 6/17/2014 at 2:46 PM on Pt. #19's closed surgical record accompanied by RN E who confirmed these findings. The discharge instructions/discharge order from the MD does not include a date or time the MD signed it.

A MR review was conducted on 6/17/2014 at 3:10 PM on Pt. #20's open swing bed record accompanied by DON G who confirmed these findings. Pt. #20 has verbal orders written by nursing staff on 5/15/2014, 5/18/2014, and 5/24/2014 that have not been signed by the physician.

Per interview with Medical Records Director K on 06/17/14 at 3:20 PM verbal orders should be countersigned within 48 hours. K stated these orders should have been signed by physicians and included both date and time.

Based on record review and interview this facility failed to maintain a policy that is in accordance with their Organ Procurement Organization (OPO) agreement in 1 of 1 policy/agreement reviewed.

Findings include:

An interview with Director of Nursing (DON) G was conducted on 6/16/2014 at 4:00 PM. DON G stated that the facility usually notifies the OPO after death and does not usually contact them for imminent death because they would not maintain a patient on life support for procurement anyway.

The Letter of Agreement from the OPO, dated December 17, 2007 was reviewed on 6/17/2014 at 12:05 PM. The agreements states that the hospital shall accept the definition of "imminent death," and shall comply with the timelines set forth by the OPO for notification.

A definition of imminent death and timely notification is not part of the facility's policy.

This was discussed in interview with Quality Director M on 6/17/2014 at 12:10 PM who stated these definitions were not in the policy.