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A. Based on document review and interview, it was determined for 1 of 1 Pediatric Unit, the Hospital failed to ensure code pink drills were conducted to help maintain patient safety.

Findings include:

1. The Hospital's Safety Policy and Procedure Manual, included "Infant/Child abduction (Code Pink)" (revised 1/13), which required, "Upon becoming aware that an infant/child is missing , the nursery...and the Pediatric departments will activate departmental policies regarding infant abduction... 4. Mitigating/Preparedness activities for the event...code pink drills are conducted quarterly."

2. During a tour of the pediatric unit on 5/8/13 at approximately 10:30 AM, the Nurse Manager of the pediatric unit was interviewed and stated the unit conducts code pink annually.

3. The code Pink drill reports for January 2012-April 2013 were reviewed on 5/9/13. The reports included quarterly drills conducted on the Mother-Baby and Nursery Units. However, the report lacked any drills or drill assessments conducted on the Pediatric Unit.

4. The Safety Committee Chair (E #9) and Director of Safety and Security (E#10) were interviewed on 5/9/13 at approximately 9:40 AM. E #9 and E #10 both stated that quarterly code pink drills are conducted and assessment of the code response in the mother/baby and nursery is reported for each drill. However E #9 and #10 stated that code pink drills have not been conducted in the pediatric unit (located on a different floor from the mother/baby and nursery), and therefore response by pediatric staff to code pink drills have not been observed or assessed.

5. The above findings were discussed with E #9 and #10 during the interview on 5/9/13 at approximately 9:40 AM, who stated that code pink drills should also be conducted, observed and assessed in the Pediatric Unit.


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B. Based on document review and interview, it was determined that for 1 of 4 employees (E#3) observed during a code pink drill on the mother/baby unit, the Hospital failed to ensure staff account for babies to assure they are all present in accordance with policy. This potentially affected the safety of all 10 infants on census.

Findings include:

1. Hospital policy titled,"Infant/Child Abduction-Code Pink" (revised 12/12) included, "Simultaneously or as soon as the overhead page is heard, all nurses responsible for infants/children will make an accounting of babies and children to assure they are all present."

2. On 05/07/13 at approximately 9:00 AM, a Code Pink (infant/child abduction ) was called. E#3 was with the Nursing Administrator (E#5) and surveyor, all stationed at the 3 North hallway of the mother baby unit. When the code was called, E #3 did not respond by checking room as required by policy. The surveyor asked E#3 what the overhead announcement meant. E #3 stated,"That was a code pink" E #3 then began inspecting the rooms on the 3 North hallway but omitted room 316. E#4 came down the hall and asked E#3 if all the rooms were checked and E#3 said "yes." E#4 instructed E#3 to check the rooms again. E#3 then checked room 316 which was occupied with a mother and infant.

3. The Nursing Administrator (E#5) verified the above finding during an interview on 5/7/13 at approximately 9:00 AM.

Based on document review and interview, it was determined that for one of one medical records department, the Hospital failed to ensure that medical records were completed within 30 days of discharge.

Findings include:

1. The Hospital's "Rules and Regulations & Policies of the Medical Staff" (January, 2013) page 5 required, "Hospital Stay A. Complete Record...The medical chart, including the summary shall be completed within thirty days of dismissal..."

2. On 5/9/13 at approximately 9:00 AM, the Hospital's Director of Health Information Services (E #11) presented the surveyor with a letter of attestation dated 5/9/13 which included, "...As of May 8, 2013 there are a total number of 525 delinquent charts".

3. The above findings were confirmed with the Chief Nursing Officer (CNO) on 5/9/13 at approximately 9:05 AM.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Sample Validation survey conducted on May 6, 2013, to May 9, 2013, the surveyors find that 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 portion of a Sample Validation survey conducted on May 6, 2013, to May 9, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated May 9, 2013

A. Based on document review and interview, it was determined for 3 of 10 [cardiac care unit (CCU), telemetry and surgical intensive care unit (SICU)] nursing units toured, the Hospital failed to ensure crash carts were checked before each shift to ensure safety. This potentially affected all patients on the three units.

Findings include:

1. Hospital policy titled, "Code Blue Guidelines, (revised Jan, 2012) required, "The code blue cart and defibrillator is to be checked at the beginning of every shift to ensure that the cart is locked and the defibrillator is operational. ... For shifts during which areas are closed, 'closed' will be written in the appropriate space."

2. The CCU emergency cart checklist was reviewed on 5/6/13 at 10:30 AM. The checklists lacked documentation of crash cart checks for various dates and shifts from 3/1-5/3/13. Examples included: 3/1, 3/3, 3/22 and 4/29/13 - AM shift and 3/15, 4/2 and 5/3/13 - PM shift.

3. The telemetry unit emergency cart checklist was reviewed on 5/6/13 at 1:15 PM. The check list lacked documentation of crash cart checks for various dates and shifts from 3/10-5/5/13. Examples are: 3/10, 3/13 4/5, 5/4 and 5/5/13 - AM shift and 3/21, 3/27, 4/10, 4/19, 5/2 and 5/3/13 - PM shift.

4. The SICU emergency cart checklist was reviewed on 5/6/13 at 2:00 PM. The crash cart lacked documentation of crash cart checks for various dates and shifts from 3/2-5/6/13. Examples are: 3/8, 3/14, 4/11- 4/13, and 5/6/13- AM shift and 3/2, 3/31, 4/2, 4/11, 4/23 and 5/5/13 - PM shift.

5. During an interview on 5/6/13 at 2:00 PM, the Director - Center of Nursing Excellence agreed with the above findings.


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B. Based on document review, observation and interview, it was determined that for 1 of 1 Pediatric crash cart, the Hospital failed to ensure expired supplies were not available for patient use.

Findings include:

1. The Hospital policy F-2 titled, "Code Blue (Cardiopulmonary Resuscitation) Guideline" (revised 1/12), required, "Pharmacy reviews each cart once a month...Each cart will be marked with the date of the first expiring drug/supply in the cart... Appropriate actions will be taken during monthly inspection of expired items are noted."

2. The pediatric crash cart was inspected during an observational tour conducted on 5/8/13 between 9:15 and 10:45 AM. Three crash cart drawers labeled with an expiration date of 4/13 contained the following expired supplies:
-5-6 blood specimen tubes expired on 4/31/13.
-4 intravenous catheters with an expiration of 4/2013
-2 intravenous catheters with an expiration of 12/2011

3. The above findings were confirmed with the Pediatric Unit Manager during an interview on 5/8/13 at approximately 10:00 AM.

A. Based on document review and interview, it was determined the Hospital failed to ensure staff adherence to hand hygiene for 2 of 4 (E#6 and E#7) staff members observed in the special care nursery.

Findings include:

1. Hospital policy titled, "Standard and Transmission based Precautions" (approved 11/12) included, "Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms (germs) to other patients or environments."

2. On 05/07/13 at approximately 10:20 AM, an observational tour conducted in the special care nursery. E#6 retrieved paper from the floor on 05/07/13 at approximately 10:30 AM, and then disposed of the paper in a trash receptacle. E#6 failed to perform hand hygiene after disposal of the paper.

3. On 05/07/14 at approximately 10:40 AM, E#7 was observed conducting a physical assessment and a diaper check on an infant without wearing protective gloves. After the exam, E#7 failed to perform hand hygiene but instead obtained office supplies from a drawer and then began charting. E#7 then performed hand hygiene.

4. The above findings were discussed with the Nursing Administrator (E# 5) on 05/07/13 at approximately 10:50 AM.

B. Based on observation and interview, it was determined that the Hospital failed to ensure, patient supplies and infant formula were not stored next to 5 of 12 used sharps containers. This potentially affected all infants on census in the special care nursery.

Findings include:

1. On 05/07/13 at approximately 10:40 AM, an observational tour was conducted for the special care nursery. Boxes of opened disposable gloves were stored directly next to the sharps containers at stations #2, 3, 4 and 5. Four bottles of infant formula (Enfamil) were stored directly next to a sharps container at station #12.

2. The above finding was verified with the Nursing Director (E#5) on 05/07/13 at approximately 11:00 AM.


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C. Based on document review, observation and interview, it was determined that for 1 of 1 physicians (E #1) observed, the Hospital failed to ensure medication vials' rubber stoppers were thoroughly wiped prior to accessing.

Findings include:

1. The Hospital policy titled, "Multiple and Single Dose Vials" (revised 2/10), required, "C. The rubber stopper on all vials will be thoroughly wiped with alcohol prior to accessing the vials."

2. An observation of OR 4 was conducted between 7:20 AM and 8:40 AM, E #1 accessed 5 vials, inserting a needle and drawing medication from each vial without first wiping the rubber stopper with alcohol. E #1 after drawing from two vials inserted the needle into a bag of intravenous (IV) fluid, and pushed the medication without first wiping the IV port.

3. The above findings were discussed with the Director of Surgical Services (E #2), during interview on 5/7/13 at approximately 8:45 AM.

Based on interview and document review, it was determined that the Hospital failed to ensure that a current list of suspended physicians was available in the surgical department and the surgical scheduling area.

Findings include:

1. On 5/7/13 at approximately 8:30 AM a physician suspension list was requested from the Director of Surgery (E #2). E #2 stated that the Surgical Department does not keep a list of suspended physicians and the Hospital does not suspend physicians. E #2 stated that the Medical Records Department produces a list of physicians with delinquent medical records every other week, but this list is not sent to the surgery department. E #2 obtained this list from the Medical Records Department on 5/7/13 at approximately 8:40 AM which included 114 physicians with delinquent medical records.

2. The Hospital policy entitled, "Administrative Suspension Policy for Failure to Complete Records" (reviewed 2/13) required, "The purpose of this policy is to communicate the administrative suspension process for physicians who fail to complete medical records...medical record left not completed within thirty (30) days of discharge will be considered delinquent...1. A warning notice is posted on a Friday. 2. The following Friday, those physicians who were on the Warning List who have not completed their delinquent medical records will have their privileges administratively suspended...Once a physician is listed on the Administrative Suspension list, no Departments of the Medical Center or Satellites will schedule or admit that physician's patients."

3. On 5/7/13 at approximately 10:15 AM, the CNO (Chief Nursing Officer) stated there is not a suspension list at this time because there are no physicians currently on suspension (5/7/13).

4. During an interview with the Director of Health Information Management (E #11) on 5/8/13 at approximately 1:15 AM, E #11 stated that a list of physicians with delinquent medical records is generated every two weeks and dispersed to all department chairs (including Surgical Services), the CEO, and the COO (Chief Operating Officer).

Based on document review, and interview, it was determined that for 1 of 4 (E #1) physicians observed in the Surgical Department, the Hospital failed to ensure staff wore the appropriate attire in the Operating Room (OR) as required by Hospital policy.

Findings included:

1. The policy titled, "Operating Room Policy" (reviewed 11/12), required, "The surgical hat or hood should be clean and free of lint and should confine hair."

2. An observation of OR 4 was conducted between 7:20 AM and 8:40 AM, E #1 entered OR 4 with approximately 2 inches of hair exposed at the back of his head below the surgical cap and not confined as required by policy.

3. The above finding was discussed with the Director of Surgical Services (E #2), during interview on 5/7/13 at approximately 8:45 AM.