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Based on observation, review of documentation and interviews with staff, the facility failed to ensure that patients receive care in a safe setting, as crash carts in the Newborn Nursery were not checked daily, and syringes with needles were found behind an unlocked door and available to patients and visitors.

Findings were:

A review of facility policy entitled, "Emergency Crash Cart Security and Accountability," reference #6001 stated, "The nursing personnel shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact." Additionally, a form entitled, Daily Crash Cart Log Sheet was reviewed. The log includes all elements required for checking the crash cart daily, such as the functions of emergency equipment on the cart as well as the intact lock.

A tour of the Newborn Nursery was conducted the morning of 3/20/2012 in the company of the Quality Director, staff 25, and the Clinical Coordinator, staff 24. According to the Daily Crash Cart Log Sheet for the month of March, the crash cart was checked 5 days of the 20 days; for the month of February 2012, the crash cart was also checked only 5 days; and for the month of January 2012, the crash cart was only checked 15 days. This finding was confirmed by staff 24 and staff 25 during the tour.

During the tour conducted the morning of 3/20/2012, syringes and needles were found in the Labor & Delivery clean utility room in a ready-to-go kit that nurses use to take into patient rooms for procedures. This room was unlocked, giving access to patients and visitors. This finding was also confirmed by staff 24 and staff 25 during the tour.

Based on review of documents and interviews with staff, the facility medical staff failed to ensure that its bylaws were enforced, as all patient records were not completed within 30 days of discharge, and telephonic orders were not authenticated within 24 hours as required by medical staff rules and regulations.

Findings were:

Hospital Rules and Regulations of the Medical Staff, last approved 2/28/2011, section 3.2, entitled Patient's Medical Record, states that "All physicians shall complete their discharge record within thirty days..." The Rules and Regulations also state in section 2.1, entitled Routine Care, that "All orders dictated over the telephone shall be signed by the appropriately authorized person to who [sic] dictated with the name of the practitioner per his own name. The responsible physician shall authenticate such orders within 24 hours."

Review of document entitled NTMC Delinquency Rate, created by the facility Health Information Management Department, revealed that the delinquency rates for the year 2011 ranged between 13.71% and 44.67%. For example, in May of 2011, there was an average of 197 discharged patients; the number of records that had not been completed within 30 days was 61, and the delinquency rate was 30.96%

Review of the medical records for patients 1-10 and patients 33-38 revealed that telephonic orders were not authenticated with the date and time of the responsible practitioner; therefore it could not be determined if the orders were signed within 24 hours as required by facility rules and regulations. Additionally, the records of patient 2 and patient 36 contained telephonic orders not signed by the responsible practitioner within 24 hours. For example, patient 33's record contained 2 telephonic orders, one written 2/11/12 and another 2/13/12. The physician signed the orders, but did not include the date and time of the signature. Patient 36's record contained a telephonic order written 2/12/12 that had not been signed, dated, or timed by the responsible practitioner.

These findings were confirmed in an in-person interview conducted the morning of 3/21/2012 with staff 25, the Director of Quality.

Based on review of records and interview with staff, the facility failed to ensure that nursing staff keeps a nursing care plan current for each patient.

Findings were:

Review of records for patients 33-38 revealed that the nursing care plans (problem lists), developed at the time of admission by a registered nurse, were not kept current throughout the stay. For example, patient 33's electronic problem list was created at admission; however, the interventions and resolution of the plan were not included in the record.

An in-person interview was conducted with the Clinical Analyst, staff 28, the morning of 3/21/2012 in a facility conference room. According to staff 28, the nursing personnel have not been fully trained and many are not familiar with how to document interventions and evaluations in order for them to be included on the problem list (care plan).

Based on observation, review of documentation and interview with staff, the facility failed to maintain equipment in such a manner that the safety and well-being of patients are assured. Various tears and dents were noted on mattresses and equipment used by patients.

Findings were:

Facility policy entitled Equipment Condition, reference #5008, stated that "All appropriate personnel will be responsible for assessing the condition of equipment utilized." Further review of the policy revealed, "The overall appearance must be up to departmental standards ... The Interior and exterior of the equipment must be free of rust, corrosion, lint, dents, and deposits."

A tour of the facility Cardiopulmonary Rehabilitation area and the Radiology Department was conducted the afternoon of 3/19/2012 in the company of the Rehabilitation Department Director, staff 20. In the rehab gym was a Schwinn stationary exercise bicycle with approximately 1/8 inch x 1/8 inch circular tear on the black seat, and the left foam hand rail was also torn approximately 5 inches. In the rehab gym there was also a Healthrider stationary exercise bicycle with a black seat cover torn approximately ? inch. In the radiology department, a white vinyl mattress was found with a tear in the center of the mattress in the shape of an "L," approximately 2 inches x 1 inch; both corners were also torn approximately 2 ? inches x 3 inches exposing the yellowing matting underneath. The x-ray table had 7 dents (holes) on the center of the table. There were 3 lead aprons torn (1- ? in x ? in) and the vinyl was pulling apart from the seams. These items and equipment were available for patient use. The above findings were confirmed in an interview with staff 20 during the tour.

A tour of the Physical Therapy area and the Labor and Delivery Department was conducted the morning of 3/20/2012 in the company of the Director of Quality, staff 25. In the physical therapy gym, there was a Nordic Track exercise machine that had a right hand rail torn approximately 2 inches. In the Labor and Delivery Operating Room, the operating room table's right arm pad was torn in multiple areas approximately ? inch each exposing the netting underneath. This equipment was available for patient use. The above findings were confirmed in an interview with staff member #25 during the tour.

Based on observation, review of documentation and interviews with staff, the infection control officer failed to identify potential sources of infection in 2 patient care areas of the facility.

Findings were:

A review of facility policy entitled "Infection Control Program/Plan," reference #1001, stated in the section entitled Infection Risk Analysis that "The infection Control Preventionalist shall be responsible for identifying, investigating, reporting, preventing and controlling infections and communicable diseases through the following activities: Maintenance of a sanitary hospital environment..."

A tour of the facility Cardiopulmonary Rehab area was conducted the afternoon of 3/19/12 in the company of the rehab director, staff # 20. Seven clean oxygen tanks were found in the dirty utility room and available for patient use, potentially causing cross-contamination (the passsage of pathogens indirectly from one patient to another). These findings were acknowledged by staff #20 during the tour.
A tour of the facility Labor and Delivery Department was conducted the morning of 3/20/12 in the company of the Clinical Coordinator, staff #24. In the Labor and Delivery Operating Room, there was a reddish-brown substance on the lap belt of the operating room table which appeared to be blood. Underneath the mattress of the operating room table were spots of dried liquid, indicating the area had not been adequately cleaned. There was a reddish brown substance on the floor underneath the operating room table. This OR was available for patient use. These findings were confirmed during the tour by staff #24.

Based on review of documentation and interview with staff, it was determined the facility failed to properly reassess outpatient surgery patients at discharge per facility policy.

Findings included:

In facility policy entitled, Patient Assessment and Re-assessment, under the section Surgical Services, "the patient's postoperative status is assessed ....upon discharge from the post anesthesia recovery room."

A review of patient records revealed that the nursing staff failed to reassess post-surgical patients upon discharge, as evidenced by lack of documentation of vital signs upon discharge. Patients 11-17 did not have temperature, blood presure, or respirations documented at the time of discharge home.

The above was confirmed in an interview with staff member #25 the afternoon of 3/20/12.