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Based on document review and observation, the facility failed to ensure outdated items were removed from the crash cart for 2 of 4 crash carts and failed to ensure facility policy included checking supplies for outdates.

Findings include:

1. Facility policy titled "Code Blue" last reviewed/revised 11/9/11 has a section for "Routine Checking of Resuscitation Cart", however only requires check of medications and IV bags and not supplies.

2. During tour of of the emergency department (ED) beginning at 1:35 p.m. on 10/16/12 and accompanied by Nursing Director #1 and RN #2, the following was found in the crash cart in room #2:
(A) One (1) Cricothyrotomy cath set with an expiration date of 6/12.
(B) Four (4) 1 cc syringes with an expiration date of 11/10.
(C) Two (2) 3 ml 22 G 1 1/2 " syringes with and expiration date of 9/11, one (1) with an expiration date of 6/11, and one (1) with an expiration date of 8/10.
(D) One (1) pedi-cap Co2 detector with an expiration date of 8/12.

3. During tour of the medical/surgical unit beginning at 2:10 p.m. on 10/16/12 and accompanied by Nursing Director #1 and RN #3, the following was observed in the crash cart.
(A) One (1) Ntg pump set with an expiration date of 8/12.

Based on Life Safety Code survey, Perry County Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(d), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

The original hospital building was constructed in 1949 and is a two story structure with a split level basement. A two story structure with a split level basement was added to the south end of the original building in 1952 and a second two story structure with a basement was added to the east side of the original building in 1974. A one story addition with a basement was built in 1994. The original building and the 1952 and 1974 additions were determined to be of Type II (000) construction and partially sprinklered. The basement and the second floor of the original building and the 1952 and 1974 additions are fully sprinklered and the only portions of the first floor which are sprinklered are Medical Records, Radiology and the Gift Shop. The 1994 addition is separated from the other portions of the facility by a two hour rated fire wall and was determined to be of Type I (332) construction and fully sprinklered. The entire facility has smoke detection in all corridors. The facility has a capacity of 25 and had a census of 12 at the time of this survey.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure the building construction type of the original building and the 1952 and 1974 additions was a permitted type (see K 012), failed to ensure 8 of 16 vertical stairwell openings were enclosed with construction having at least a one hour fire resistance and 1 of 1 dumbwaiters was provided with fire doors with a fire protection rating of one hour (see K 020), failed to ensure 1 of 2 kitchen doors opening into the Cafeteria is provided with a positive latching device to latch the door into the door frame and 1 of 25 doors serving hazardous areas such as soiled linen rooms automatically close and latch into the door frame (see K 029), failed to ensure lighting for 2 of 4 exit means of egress from the split level basement was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness (see K 045), failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters and on the third shift for 4 of 4 quarters (see K 050), failed to ensure a sprinkler head was installed in 1 of 2 elevator rooms to provide coverage for all portions of the building (see K 056), failed to ensure 1 of 1 sprinkler system components was inspected quarterly for 1 of 4 calendar quarters (see K 062), failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area (see K 64), failed to ensure 3 of 117 fire dampers in the facility were inspected and provided necessary maintenance at least every six years (see K 067), failed to ensure a monthly load test for 1 of 1 emergency generators was conducted for 1 of 12 months (see K 144), failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period (see K 154) and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period (see K 155).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged, and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure the building construction type of the original building and the 1952 and 1974 additions was a permitted type, failed to ensure 8 of 16 vertical stairwell openings were enclosed with construction having at least a one hour fire resistance and 1 of 1 dumbwaiters was provided with fire doors with a fire protection rating of one hour, failed to ensure 1 of 2 kitchen doors opening into the Cafeteria is provided with a positive latching device to latch the door into the door frame and 1 of 25 doors serving hazardous areas such as soiled linen rooms automatically close and latch into the door frame, failed to ensure lighting for 2 of 4 exit means of egress from the split level basement was arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness, failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters and on the third shift for 4 of 4 quarters, failed to ensure a sprinkler head was installed in 1 of 2 elevator rooms to provide coverage for all portions of the building, failed to ensure 1 of 1 sprinkler system components was inspected quarterly for 1 of 4 calendar quarters, failed to maintain 1 of 1 portable K-class fire extinguishers in the kitchen cooking area, failed to ensure 3 of 117 fire dampers in the facility were inspected and provided necessary maintenance at least every six years, failed to ensure a monthly load test for 1 of 1 emergency generators for 1 of 12 months, failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.

Findings:
1. Review of Fire Safety Evaluation System (FSES) "Executive Summary" documentation dated 12/30/00 from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated the construction type of the original building and the 1952 and 1974 additions was stated as Type II (000) and the minimum permitted classification for this building is Type II (222) and indicated the dumbwaiter in the 1974 building addition "is equipped with standard steel doors that do not bear a label indicating the fire resistance rating."
2. Review of "Fire Drill Report Form" documentation from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated second shift fire drills conducted on 12/09/11, 03/16/12 and 09/14/12 were conducted, respectively, at 4:10 p.m., 4:40 p.m. and 4:37 p.m. Third shift fire drills conducted on 12/16/11, 03/30/12, 06/04/12, and 08/08/12 were conducted, respectively, at 6:10 a.m., 6:14 a.m., 6:38 a.m. and 6:18 a.m.
3. Review of "Fire Sprinkler Inspection Report" documentation dated 08/06/12 and "Report of Inspection" documentation dated 12/16/11 and 03/02/12 from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated documentation of a second quarter (April, May, June) 2012 sprinkler system inspection report was not available for review.
4. Review of Life Safety Services (LSS) "Fire & Smoke Damper Inspection Summary Report" documentation dated April 7-9, 2009 and LSS "Invoice" documentation dated 04/14/09 from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated documentation of testing performed for 3 of 117 fire dampers within the last six years was not available for review. The LSS documentation dated April 7-9, 2009 indicated fire dampers identified as FD-B-014, FD-1-008 and FD-009 were not tested because they were listed as "nonaccessible." The "Invoice" documentation dated 04/14/09 there was nowhere to cut an access door to test the three aforementioned fire dampers.
5. Review of "Emergency Powered Generator Log" and "Inspection Log" documentation from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated monthly load test documentation for March 2012 was not available for review.
6. Review of "Perry County Memorial Hospital Policies & Procedures: Fire Alarm Failure" documentation from 8:20 a.m. to 11:25 a.m. on 10/16/12 indicated the fire watch policy identified fire alarm system impairment but did not include sprinkler system impairment, the fire watch policy did not include a statement on sprinkler system impairment or fire alarm system impairment should the system be impaired for four hours or more in twenty four hour period and the fire watch policy did not include notification of the Indiana State Department of Health.
7. Observations from 12:10 p.m. to 2:30 p.m. on 10/16/12 indicated the first floor of the original building and the 1952 and 1974 additions were not sprinklered except for the medical records storage room, radiology and the gift shop, the Courtyard stairwell in the basement, the stairwell by the storage room in the basement, stairwell by the maintenance room near the boiler room in the basement, the Courtyard stairwell on the first floor, the stairwell by Radiology on the first floor, the stairwell by Medical Records on the first floor, the Obstetrics area stairwell door by Room 218 on the second floor and the stairwell by the entrance to Obstetrics had no fire rating label affixed to each stairwell entry door, the kitchen door which opens into the Cafeteria by the serving line and 1 of 25 doors serving hazardous areas such as soiled linen rooms were not equipped with a positive latching device to latch the door into the frame, the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard were each equipped with only one light fixture with one bulb, the Elevator Machine Room near the Diabetes Education Room was not sprinklered, only one sidewall spare sprinkler was located in the spare sprinkler cabinet in the basement boiler room, a placard was not conspicuously placed near the K-class portable fire extinguisher which states the fire protection system shall be activated prior to using the K-class portable fire extinguisher and a remote shut off device was not found for the 565 kW diesel fired emergency generator.
8. Interview at the time of document review and of the observations with DPO confirmed the original building and the 1952 and 1974 additions were not sprinklered except for the medical records storage room, radiology and the gift shop, stairwell entry doors are not rated at least one hour fire resistance, the dumbwaiter doors were not provided with a fire resistance rating for the doors, the entry door to soiled linen Room 276 was equipped with a self closing device, but the door did not close fully to latch into the frame leaving a one inch gap between the door and the frame, the kitchen door which opened into the Cafeteria by the serving line was not equipped with a positive latching device to latch the door into the frame, only one light fixture with one bulb was provided at the exit means of egress from the basement exit by the kitchen and the basement exit to the Courtyard, second and third shift fire drills were not conducted at unexpected times under varying conditions, the Elevator Machine Room near the Diabetes Education Room did not have a sprinkler head installed in the room, only one sidewall sprinkler was located on the premises in the spare sprinkler cabinet, a placard was not conspicuously placed near the K-class portable fire extinguisher stating the fire protection system shall be activated prior to using the K-class portable fire extinguisher, fire damper testing within the last six years was not available for review, the generator was installed prior to 2003 and there was no remote emergency shut off device for the emergency generator, the fire watch policy did not include a statement on sprinkler system impairment or fire alarm system impairment should the systems be impaired for four hours or more in twenty four hour period.

Based on observation, the facility failed to appropriately discard single dose vial medications for 1 of 2 anesthesia carts observed.

Findings include:

1. During tour of the obstetric department beginning at 3:15 p.m. on 10/16/12 and accompanied by Nursing Director #1, an opened 5 ml. single dose vial of Xylocaine 2% was observed in the anesthesia cart located in the hall.

Based on observation and staff interview, the facility failed to maintain a clean environment for 2 of 5 units toured.

Findings include:

1. During tour of the surgery department beginning at 2:40 p.m. on 10/16/12 and accompanied by Nursing Director #1 and RN #1, the anesthesia machine work surface was observed to be grossly soiled with dried substances and had a penny in the soiled area. The work surface had equipment on it and ready for a surgery to be performed on 10/17/12.

2. During tour of the obstetric department (OB) beginning at 3:15 p.m. on 10/16/12 and accompanied by Nursing Director #1, mouse droppings were observed in a drawer containing broth packets and graham crackers in the patient nutrition pantry.

3. RN #1 indicated the following in interview during the tour of the surgery department:
(A) The equipment on the anesthesia work surface was for a procedure on 10/17/12.
(B) Cleaning of the anesthesia work surface was "probably" the responsibility of nursing.

4. Nursing Director #1 verified the presence of mouse droppings in the nutrition pantry drawer during tour of the OB department.

Based on blood transfusion policy review, transfusion document chart reviews and staff interview, the facility failed to assure that blood transfusion administrations were performed in accordance with approved medical staff policies and procedures for ten of ten patients.

Finding(s) included:
1. On 10/16/12 at 9:45 a.m., review of the blood administration policy, "Blood and Blood Component Transfusion", reviewed 11/08/11, read:
"The patient's full set of vitals are documented on the Transfusion
Record at the following intervals:
Pre-transfusion
1 hour post-transfusion"

2. On 10/16/12 at 9:45 a.m., review of ten patients receiving blood units, twenty of these received-units did not have complete documentation, per policy, on the Blood Transfusion Record form. Each of the following twenty units was missing both pre and 1 hour post-transfusion vital documentation:

Patient #1
--Unit was administered on 10/10/12 at 1155 and completed at 1405
--Unit was administered on 10/10/12 at 1445 and completed at 1715
Patient #2
--Unit was administered on 10/08/12 at 1749 and completed at 2025
--Unit was administered on 10/08/12 at 2120 and completed at 2345
Patient #3
--Unit was administered on 10/03/12 at 1045 and completed at 1315
--Unit was administered on 10/03/12 at 1420 and completed at 1720
Patient #4
--Unit was administered on 10/01/12 at 2215 and completed at 0058
--Unit was administered on 10/02/12 at 0125 and completed at 0340
Patient #5
--Unit was administered on 10/28/12 at 2250 and completed at 0050
--Unit was administered on 10/29/12 at 0120 and completed at 0330
Patient #6
--Unit was administered on 9/28/12 at 1340 and completed at 1600
--Unit was administered on 9/28/12 at 1655 and completed at 1915
Patient #7
--Unit was administered on 9/26/12 at 1420 and completed at 1645
--Unit was administered on 9/26/12 at 1725 and completed at 1930
Patient #8
--Unit was administered on 9/18/12 at 1345 and completed at 1545
--Unit was administered on 9/18/12 at 1600 and completed at 1850
Patient #9
--Unit was administered on 9/12/12 at 1700 and completed at 1945
--Unit was administered on 9/12/12 at 2000 and completed at 2250
Patient #10
--Unit was administered on 9/12/12 at 1713 and completed at 2030
--Unit was administered on 9/12/12 at 1310 and completed at 1630

3. On 10/16/12 at 10:30 a.m., staff member #6 indicated that the above-listed patients had received blood units without benefit of complete documentation, per policy, as required.

Based on document review, observations, and staff interview, the infection control committee failed to ensure polices were followed for appropriate cleaning and storing of laryngoscope blades and failed to implement a policy requiring surfaces to be cleaned between patients for the emergency department (ED).

Findings include:

1. Facility policy titled "Laryngoscopy Blade" approved by the Infection Control Committee and last reviewed/revised 8/3/10 states under procedure after cleaning steps: "............3. Store in sealed plastic bag or in plastic container."

2. Facility policy titled "Cleaning Emergency Department" approved by the Infection Control Committee and last reviewed/revised 7/17/12 only requires cleaning of surfaces with germicidal solution on a daily basis. The policy states on page 1 under procedure: "Housekeeping personnel on a daily basis will:.................Damp dust counters, furniture, telephones and receivers, etc. to include all horizontal surfaces, with the hospital approved germicidal solution."

3. During tour of the ED beginning at 1:35 p.m. on 10/16/12 and accompanied by nursing director #1 and RN #2, the following was observed in room #2 which was clean and unoccupied.
(A) A dried red/rust colored substance was observed on the top surface of the I.V. pump.
(B) A dried red/rust colored substance was observed on the arm of the light over the bed.
(C) RN #2 was able to wipe the substance off when requested by surveyor to do so.

4. During tour of the surgery department beginning at 2:40 p.m. on 10/16/12 and accompanied by nursing director #1 and RN #1, the following was observed:
(A) Clean laryngoscope blades were stored uncovered on a stand within inches of the scrub sink.

5. RN #1 indicated during tour of the surgery department that the laryngoscope blades are placed there for the anesthesia provider who will come and get a blade as he/she needs them in the operating rooms.

Based on document review and staff interview, the facility failed to have evidence of a completed transfer certification form for 1 of 2 transfers from the emergency department (ED).

Findings include:

1. Facility policy titled "Transfer of Patients" effective 7/25/12 states on page 4 under "TRANSFER CERTIFICATION FORMS": "**TRANSFER CERTIFICATION FORMS MUST BE COMPLETED PRIOR TO TRANSFER. A COPY OF THE CERTIFICATION FORM MUST BE SENT WITH THE PATIENT........"

2. Review of patient #N22 medical record indicated the following:
(A) He/she was transferred from the ED on 10/9/12.
(B) The medical record lacked a transfer certification form.

3. Staff member #2 verified in interview at 4:00 p.m. on 10/16/12 that the record did not contain the transfer certification form.