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Based on document review and interview, it was determined that for 3 of 3 patient records (Pt #8, Pt #9 and Pt. #5) reviewed for care plans, the Hospital failed to ensure that individualized care plans were developed for the patients.

Findings include:

1. On 8/27/18 at approximately 11:00 AM, the Hospital's policy entitled, "Patient Care Planning" (11/2017) was reviewed and required, "...After an appropriate assessment has occurred, each patient has an individualized, goal-directed plan of care in place with appropriate interdisciplinary, patient, and family input. The plan of care is based upon the patient's goals and assessed needs... The plan of care and associated goals are updated based on re-assessment of the patient's needs, response to treatment and preferences..."

2. On 8/27/18 at approximately 11:15 AM, Pt #8's clinical record was reviewed. Pt #8 was a 54 year old male, admitted to the Hospital on 8/22/18 with the diagnosis of chest wall mass. Pt #8's physician's order, dated 8/23/18, indicated, "...Insert and/or maintain indwelling urethral catheter ..." Pt #8's care plan did not include nursing interventions or treatment goals for the urinary catheter care.

3. On 8/27/18 at approximately 11:20 AM, Pt #9's clinical record was reviewed. Pt #9 was a 77 year old female, admitted to the Hospital on 8/23/18, with the of diagnosis bilateral lower leg cellulitis (skin disorder caused by bacteria). Pt #9's physician's order, dated 8/23/18, indicated, "...contact isolation..." Pt #9's care plan did not include nursing interventions or treatment goals for contact isolation.

4. On 8/27/18 at approximately 11:30 AM, an interview was conducted with the Manager of Oncology (E#1). E#1 stated that patients should have interventions and treatment goals listed in their care plans.


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5. On 8/27/18 at 10:50 AM, Pt. #5's clinical record was reviewed. Pt. #5 was a 69 year old female, admitted on 8/17/18, with a diagnosis of osteomyelitis (inflammation of the bone) of the left foot. Nursing notes, dated 8/25/18, included Pt. #5's most recent bowel movement was on 8/16/18, nine days earlier. A subsequent nursing note dated 8/27/18, included Pt. #5 had a bowel movement on 8/26/18. However, Pt. #5's current Plan of Care, dated 8/18/18, lacked goals related to impaction. The Plan of Care included nutrition as an intervention for the goal of skin integrity, but not for impaction.

6. On 8/27/18 at 11:00 AM, an interview was conducted with the 2 North Manager (E #3). E #3 stated that a goal related to Pt. #5's impaction was missing in the Plan of Care.

Based on document review and interview, it was determined that the Hospital failed to ensure the completion of medical records within 30 days of patient discharge.

Findings include:

1. On 08/29/18, the Hospital's "Rules and Regulations of the Medical Staff" (approved October 23, 2017), were reviewed and included, "...Medical Record...2. Each patient's medical record shall be accurate and timely...3. A practitioner's scheduling privileges will be automatically suspended upon weekly issuance of the suspension list by Medical Information Services: a. in the event one or more incomplete patient medical records of the practitioner are available and have not been completed within thirty (30) consecutive days after the discharge of the patient..."

2. On 8/29/18 at approximately 2:20 PM, the Accreditation Coordinator (E #18) presented a document, dated 8/29/18, that included, "This letter certifies that [the Hospital] has 39 delinquent medical records as of August 29, 2018."

3. On 08/29/18 at approximately 1:00 PM, an interview with the Director of Medical Records (E #10) was conducted. E #10 stated that the medical records must be completed within thirty (30) days after discharge.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on August 27-29, 2018, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on August 27-29, 2018, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that for 1 of 3 (EC #1) emergency carts on the Neuro/Trauma/ Intensive Care Unit (NTICU) and 1 of 2 (EC#4) emergency carts in Radiology, the Hospital failed to ensure the emergency carts were checked daily per policy.

Findings include:

1. The Hospital's policy titled, "Emergency Cart Maintenance" (reviewed 6/7/18) was reviewed on 8/27/18 and required, "...An assigned staff person checks the patency of the seals on emergency cart upon unit arrival and daily to ensure that supplies and accessories are present and in operating condition..."

2. On 8/27/18 between approximately 9:15 AM and 11:15 AM, a tour of the NTICU was conducted. There were 3 emergency carts on the unit, 2 adult emergency carts (EC #2 and EC #3) and 1 pediatric emergency cart (EC #1). Logs which included documentation of the daily checks were present and current for EC #2 and EC #3. However, there were no logs present for EC #1 to document completion of the required daily checks.

3. During an interview with the NTICU Charge Nurse (E #2) on 8/27/18 at approximately 10:15 AM, E #2 stated that the emergency carts are supposed to be checked every night by the night shift staff. E #2 stated that she did not know the last time EC #1 was checked and there were no logs maintained for EC #1.

4. During an interview with the NTICU Nurse Manager (E #4) on 8/27/18 at approximately 10:20 AM, E #4 stated that EC #1 should be checked daily, and a log of the daily checks should be maintained.


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5. On 8/28/18 from 9:25 AM - 10:00 AM, an environmental tour of the Radiology Department was conducted. The pediatric emergency cart (EC #4), located beside an adult emergency cart (EC #5), in the radiology hallway across from x-ray room A, lacked an emergency cart/resuscitative supplies daily checklist.

6. On 8/28/18 at 9:40 AM, an interview was conducted with an X-ray Technician (E #9). E #9 stated that the adult and pediatric emergency carts should be checked daily and documented on the daily checklist.

B. Based on document review, observation and interview, it was determined that for 1 of 2 pediatric emergency carts reviewed for daily monitoring, the Hospital failed to ensure that intravenous needles were secured and not accessible for unauthorized use. This failure potentially affects the safety of approximately 175 patients who receive radiology services daily.

Findings Include:

1. The Hospital's policy titled, "Emergency Cart Maintenance" reviewed/revised 6/7/2018 was reviewed on 8/28/18. The policy required, "Process ...3 ...The emergency cart is always locked when not in use ..."

2. On 8/28/18 from 9:25 AM - 10:00 AM, an observational tour of the Radiology department was conducted. The two bottom drawers of the pediatric emergency cart, located in the radiology hallway across from x-ray room A, were not locked. The two bottom drawers contained intravenous needles that were easily accessible and available for unauthorized use. Staff and patients were walking the hallway where the unsecured intravenous needles were observed.

3. On 8/28/18 at 9:40 AM, an interview was conducted with an x-ray technician (E #9). E #9 stated that the emergency cart drawers should be locked when not in use.

A. Based on document review, observation and interview, it was determined that for 2 of 5 operating room (OR) staff members in OR #5 (E #11 & E #12), the Hospital failed to ensure compliance with surgical attire policy.

Findings include:

1. The Hospital's policy entitled, "[Hospital] Dress Code for Surgical Areas" (revised 2/17) was reviewed on 8/29/18 and required, "...Headgear...Head and facial hair is completely covered in semi-restricted and restricted areas..."

2. On 8/29/18 between 10:05 AM and 10:35 AM, during observation of the OR #5, it was noted that the Surgical Technician (E #11) & the Registered Nurse (E #12) had hair that was not confined in the surgical head covering.

3. On 8/28/18 at 10:40 AM, an interview was conducted with the Manager of Surgical Services (E #13). E #13 stated that all hair should be covered with a surgical head cover. There should not be any exposed hair.


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B. Based on document review, observation, and interview, it was determined that for 2 of 2 bottles of enzymatic detergent observed in the Gastrointestinal (GI) Lab, the Hospital failed to ensure that expired cleaning solutions were not available for use. This potentially affected an average of 3 procedures per week that required the use of this specific detergent to clean instruments.

Findings include:

1. The Hospital's policy titled, "High-Level Disinfection and Liquid Chemical Sterilization" (revised 8/27/18), was reviewed on 8/29/18 and required, "Chemical disinfectants should be kept in their original container... The label contains the name of the product, concentration, expiration date..."

2. On 8/29/18 at approximately 10:10 AM, during an observational tour of the GI Lab, 2 of 2 bottles of enzymatic detergent were available for use, yet had an expiration date of 2/28/18.

3. On 8/29/18 at approximately 10:15 AM, an interview was conducted with the Clinical Nurse Manager of Ambulatory Services (E#14). E#14 stated that she would dispose of the expired solutions.

C. Based on document review, observation, and interview, it was determined that for 3 of 6 jugs of 2% milk, 3 of 3 frozen hamburger patties, 6 of 6 frozen pureed chicken pouches, 2 of 3 trays of frozen pureed sausage, 3 of 3 boxes of potatoes, 4 of 4 frozen briskets, and 3 of 3 frozen pork shoulders, the Hospital failed to ensure that all food items were properly labeled and that expired food items were not available for use. This potentially affected the 158 patients on census on 8/28/18.

Findings Include:

1. The Hospital's Contracted Food Service guidelines titled, "Food Handling" (revised 9/27/17), was reviewed on 8/29/18 and required, "Discard foods that are not used by the manufacturer's 'Use By/Best Before' date or the ... [Labeled] 'Use by' date... Put this information on the label: Product Name; Open/Production/Freeze Date; ... 'Use By' Date; Initials of Associate... Label all food products upon receipt without a manufacturer's 'Use by/Best Before' date with the 'Receive' date... and ensure proper food rotation using the First-In-First-Out (FIFO) Method."

2. On 8/28/18 at approximately 11:00 AM, an observational tour of the cold food storage area was conducted.
- 3 of 6 one-gallon jugs of 2% milk had a use by date of 8/25/18.
- 3 of 3 frozen hamburger patties (in an opened bag) were labeled with a use by date of "4-17" (the year was not written).
- 6 of 6 frozen pouches of "pureed chicken" were labeled with a use by date of 3/4/18.
- 2 of 3 trays of opened frozen pureed sausage were not labeled with the date opened or a use by date.
- 3 of 3 boxes containing potatoes were not labeled with the date received or a use by date.
- 4 of 4 wrapped frozen briskets were not labeled with the date received or a use by date.
- 3 of 3 wrapped frozen pork shoulders were not labeled with the date received or a use by date.

3. On 8/28/18 at approximately 11:15 AM, an interview was conducted with the Food Production Supervisor (E# 6). E# 6 stated that the expired food items should have been disposed of and not available for use. E# 6 stated, "We use the First-In-First-Out method," and agreed that all food items should be labeled to ensure that staff know which items to use first.