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Based on Fire Department inspection document review and interview, it was determined the facility failed to meet the Standard 485.623(d) Life Safety from Fire because the facility failed to obtain the services of a central offsite monitoring service to automatically notify the fire department in the event of a fire alarm system activation, as required by NFPA 101, Chapter 9.6.4 from 01/01/13 to 04/09/14. The failed practice had the potential to affect all patients, staff, and visitors because the fire department was not automatically notified of the fire alarm or sprinkler system activation which had the potential to delay fire department response time to the facility. The facility had a census of 19 inpatients on 04/07/14. See K-51 and K-56.

The Administrator was informed on 04/08/14 at 1435 there was Immediate Jeopardy to patient health and safety related to the unmonitored fire alarm and sprinkler systems. The Immediate Jeopardy was removed with the following plan: A fire watch was implemented every 15 minutes throughout the building while a new dialing system was installed. The service company installed the dialer and tested the system at 1445 on 04/09/14. A copy of the monitoring service agreement was provided and the facility was taken off of fire watch.

Based on Fire Department inspection document review, emergency lighting system testing documentation review, observation, and interview it was determined the facility did not meet Life Safety Code requirements related to off-site fire alarm and sprinkler system monitoring, annual testing of battery powered emergency light fixtures, and monthly testing of line isolation panels. The failed practice had the potential to affect all patients, staff, visitors, and surgical patients. The facility had a census of 19 patients on 04/07/14 and had 3 patients scheduled for surgery on 04/09/14. See K-51, K56, K46, and K-130.

Based on observation, review of Governing Board Minutes for April 2013 through March 2014 and interview, it was determined the Governing Board failed to ensure physicians completed the clinical records within 15 days as required by Medical Staff Rules and Regulations as there were 755 delinquent clinical records. The failed practice did not ensure clinical records were complete and available for further and future medical needs, and had the potential to affect any patient with an incomplete record. Findings follow.

A. Review of the Medical Staff Rules and Regulations stated, " Medical records are delinquent if not completed within fifteen (15) calendar days of record availability. The practitioner involved shall be informed by administration in writing of delinquent medical records. Admitting privileges may be withdrawn until medical records are completed, upon order of the MEC (Medical Executive Committee) and administration. "
B. During a tour of the Health Information Department on 04/09/14 at 1030, a list of current delinquent clinical records was provided to Surveyors #1 and #2. The number of delinquent records past the 15 calendar days was 755.
C. Findings were confirmed by the Director of Health Information on 04/09/14 at 1100.

Based on review of Director of Pharmacy Services job description and interview, the facility failed to have policies and procedures in place to ensure annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood (per United States Pharmacopeia Chapter 797, 2008). By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. Review of Director of Pharmacy Services job description revealed the Director would verify random checks were made to check staff aseptic technique.
B. During an interview with the Director of Pharmacy on 04/08/14 at 1445, the Director stated they did observe the personnel once a year, but did not perform annual re-certification of IV Admixture technique for all personnel who compound (ie: media fill tests or take samples of finished products and have them tested for sterility).

Based on observation during the Surgical Services tour at 1325 on 04/08/14 it was determined the facility failed to separate clean from dirty in that one of three endoscopes hanging in Scope Closet #1 was touching the bottom of the cabinet and one scope was touching another scope in Closet #1. Failure to ensure the scopes were not touching a dirty surface or each other had the potential for cross contamination of the sterilized items. The failed practice affected any patient whose care required the use of the scopes. Findings follow:

A. During the Surgical Services tour at 1325 on 04/08/14 three endoscopes were observed hanging in Scope Closet #1. One scope was observed to be touching the bottom of the bare cabinet. Another scope was observed to be touching another scope.
B. The above was verified by the Surgical Services Manager at 1350 on 04/08/14.


30634

Based on observation and interview, it was determined the facility failed to ensure kitchen utensils and supplies were free of crumbs and debris, were stored in a way as to prevent contamination, and food items were dated. The failed practice created the potential for food items to become contaminated due to unclean supplies used during the cooking/preparation process and could affect any patient receiving food from the kitchen. Findings follow.

A. During a tour of the kitchen from 1320 - 1345 the following was observed:
1) Crumbs in a container of clean silverware.
2) Employee eyeglasses, an uncovered beverage, and uncovered employee food items located adjacent to clean silverware.
3) Bucket in which the clean ice scoop was stored contained a brownish liquid in the bottom.
4) Numerous measuring cups of various sizes were stored under the grill on top of foil lined trays. The trays had evidence of crumbs, debris, and had a sticky film on them.
B. Findings were confirmed by the Certified Dietary Manager at the time of the tour.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery for 6 of 6 (#2, #6, #11-#13 and #15) surgical patients. The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, and created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Review of operative reports for Patients #2, #6, #11-#13 and #15 revealed the time of surgery was not documented.
B. Findings of Patient #6 were confirmed by the Obstetrics/Nursery Manager on 04/10/14 at 1115.
C. Findings of Patient #2, #11-#13 and #15 were confirmed by the Electronic Health Record Coordinator on 04/10/14 at 1100.


31039

Based on review of Medical Staff Rules and Regulations, observation, list of delinquent clinical records and interview, the facility failed to ensure clinical records were completed within 15 calendar days per Medical Staff Rules and Regulations in that there were 755 incomplete clinical records. By not completing clinical records in 15 calendar days, the facility could not assure continuity of medical care. The failed practice had the likelihood to affect all patients. Findings follow:

A. Review of Medical Staff Rules and Regulations revealed clinical records were delinquent if not completed within 15 calendar days of record availability.
B. During a tour of Health Information Department on 04/09/2014 at 0930, observation revealed multiple shelves with hundreds of delinquent clinical records.
C. Review of a list of Delinquent Medical Records, provided by the Director of Health Information, revealed 755 delinquent clinical records.
D. Findings were verified, through interview, with the Director of Health Information on 04/09/2014 at 1100.

Based on clinical record review and interview, it was determined the facility failed to ensure a History and Physical was documented for 3 (#4, #7, and #8) of 10 (#1-#10) in-patients. Pertinent, History and Physical information regarding the patient's past and current health information including current physical and mental status did not allow practitioners to be knowledgeable and proactive in identifying possible complications during the patient's admission. The failed practice affected Patients #4, #7, and #8 and had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of clinical records revealed a History and Physical was not documented for Patients #4, #7, and #8.
B. Findings for Patient #4 were verified by the Electronic Health Record Coordinator on 04/10/14 at 1100.
C. Findings for Patient #7 were verified by the Quality Director on 04/10/14 at 1155.
D. Findings for Patient #8 were verified by the Infection Control Nurse on 04/10/14 at 1030.

Based on interview, it was determined the facility failed to develop and implement a discharge/transfer notice for Swing-Bed patients. Failure to develop and implement a discharge/transfer notice form to issue to patients did not allow the patient and/or his family to be knowledgeable regarding the reason for discharge or transfer, and the names, addresses and phone numbers of organizations able to assist the patient and/or family in appealing the discharge/transfer. The failed practice affected 3 (#1-3) of 3 (#1-3) swing bed patients on 04/08/14. Findings follow:

A. The Utilization Review/Swing Bed Nurse was asked for a copy of the discharge/transfer notice during an interview at 1015 on 04/08/14. The Utilization Review/Swing Bed Nurse stated there was not a discharge/transfer notice for Swing Bed patients.
B. The above information was verified by the Utilization Review/Swing Bed Nurse at 1030 on 04/08/14.

Based on interview and clinical record review, it was determined two of two (#1-#2)Swing-Bed patients clinical records reviewed revealed they were not informed of scheduled activities as there was no activity calendar in the record; there was no activities calendar developed to post on the Unit or in patient rooms. Failure to develop an activities calendar did not allow the Swing-Bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice affected Patient #1-#3 on 04/08/14 and any patient admitted to Swing-Bed status. Findings follow:

A. Review of the clinical records for Patients #1 and #2 revealed there was no evidence of an activities calendar.
B. The Utilization Review/Swing Bed Nurse was asked for an activities calendar during an interview at 1015 on 04/08/14. The Utilization Review/Swing Bed Nurse stated an activities calendar was not developed for the Swing Bed patients.
C. The above information was verified by the Utilization Review/Swing Bed Nurse at 1030 on 04/08/14.

Based on interview, it was determined the facility did not have a dentist on staff or an agreement with a dentist to provide 24 hour emergency dental care. Failure to ensure the availability of dental care to the Swing-Bed patients did not ensure the needs of the patient would be met. The failed practice affected three of three swing bed patients on 04/08/14. Findings follow:

During an interview with the Utilization Review/Swing Bed Nurse at 1015 on 04/08/14, she stated the facility did not have an agreement to provide dental services to Swing-Bed patients.