The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LITTLETON ADVENTIST HOSPITAL, CENTURA HEALTH 7700 S BROADWAY LITTLETON, CO 80122 Feb. 22, 2011
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on review of the facility's policies/procedures and logs, tour, and staff interviews, it was evidenced that the facility failed to ensure proper temperature controls within the Operating Rooms (ORs). Specifically, the facility did not maintain a log of temperatures, the OR staff had free will to change the temperatures at any time, and there was not policy in place in regards to temperature control within ORs. This failure created the potential for a negative patient outcome.

The findings were:

Tour of the facility's 2nd floor Surgical Services Department and 3rd floor Gynecology Operating Room (OR) area conducted 2/21/11 began at approximately 8:30 a.m. When the Surgical Services Director was asked about the temperature and humidity log, s/he stated it was automatic and that the Facilities Department logged it. No log was found within the ORs.

Review of the OR humidity logs was conducted on 2/21 at approximately 1:00 p.m. Humidity was checked in each OR daily and a log was maintained of such. When asked about the temperature log, the Director of Quality Management stated, at approximately 2:25 p.m., "Facilities thought OR was doing it and OR thought facilities was." The Director stated there was not a policy in regards to temperature monitoring with Operating Rooms.

An interview with the Facilities Director was conducted on 2/22/11 at approximately 8:25 a.m. When asked about temperature monitoring within the ORs, s/he stated, "The way we've handled it: we have a common set point of 68 degrees. We have given them allowance to move up or down depending on the case...if it is an infant or a trauma...we aren't always able to do it for them. We recently upgraded our controllers to give them digital thermostats in the ORs...We currently have no capability to trend or record (temperatures) automatically for long periods of time..." When asked what AORN recommends for OR temperatures, the Director stated, "68-73 degrees...but many physicians have other preferences...we do have cooling vests (for surgeons)..."

"Infection Prevention in the Surgical Setting," 2001, by Gruendemann and Mangum, page 22, stated the following, in pertinent part:
"The temperature of the OR should be maintained between 68 degrees F and 75 degrees F...Keeping the OR temperature in this range may help to inhibit bacterial growth. This range is one that most patients can tolerate, and one that is also comfortable for personnel. Certain patients...require a warmer environment for the purpose of preventing hypothermia. Each OR should have its own controls for adjusting the temperature...Room temperatures of 68 F to 76 F...inhibit bacterial growth. Except in extenuating circumstances, such as an emergency situation or when the room temperature is raised to accommodate a patient at risk for alteration in body temperature, procedure rooms that cannot be maintained at these ranges should not be used. Room temperatures and humidity levels that vary from the recommended norm may lead to alterations in the patient's body temperature, and also to discomfort and stress to the surgical team. Supplies and equipment necessary for regulating temperature and humidity are available..."

In summary, the facility did not ensure that temperature in its Operating Rooms was maintained within acceptable standards to inhibit bacterial growth and prevent infection, and promote patient comfort. The facility did not have acceptable standards, such as from the Association of Operating Room Nurse or the American Institute of Architects, incorporated into hospital policy.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interviews, review of facility policies/procedures, and medical record review the facility failed to ensure hospital personnel completed a discharge evaluation on a timely basis so that appropriate arrangements for post-hospital care could be made before discharge and avoid unnecessary delays in discharge in six (Sample records #1, #7, #14, #16, #19, #20) of 20 sample medical records.

The findings were:

Review of the facility's policies/procedures revealed the following, in pertinent parts:
"Case Management and Utilization Review Discharge Planning...
...II. Discharge Planning
A. The process of discharge planning begins upon admission for all patients and is coordinated by the designated case manager/social worker. The case manager/social worker utilizes the initial information to communicate with all disciplines and physicians involved in the patient's care to ensure that post-hospitalization needs are promptly identified and a plan implemented...
...F. The case manager/social worker documents the ongoing discharge planning progress in the Case Management DC Assessment/Plan Intervention in MEDITECH..."

An interview with the Manager of Case Management conducted on 2/22/2011 at approximately 8:00 a.m. revealed assessments and plans by the social workers and nurses who work for case management are expected to document in the patient's record within 48 hours of admission and that all patients should have discharge planning documented in their medical record.

An additional interview with the Manager of Case Management conducted on 2/22/2011 at approximately 10:20 a.m. revealed all patients should have discharge planning documented in their charts even if the patient is determined to be safe at home with no identified discharge needs at that time.

A review of 20 medical records conducted from 2/21/2011 through 2/22/2011 revealed the following, in pertinent parts:

1. Sample patient #1 was an adult admitted on [DATE] at approximately 4:30 p.m. from an assisted living facility with cellulitis, pulmonary hypertension, chronic kidney disease, anemia, and dementia. The case management department first documented on the patient on 5/1/2011 at approximately 5:47 PM (4 days after admission). The note stated, "Met with [patient] and also called son...regarding [discharge] plan. [Patient] is resident at [Assisted Living Facility] and son states [Skilled Nursing Facility] bed will be available on Monday. Referral made...Son aware may need to have other [Skilled Nursing Facility] choices. Case management to follow." The next documented interaction was 2 days later on 5/3/2010 at approximately 3:54 PM. which stated, "Patient has been accepted and will be leaving at 4:30 to go to [a different skilled nursing facility]. Worker set up transport...and the patient's son...is aware that the patient is leaving..."

2. Sample patient #14 was an adult patient admitted on [DATE] at approximately 2:33 p.m. for near syncope and fall. A review of the patient's medical record on 2/21/2011 at approximately 11:30 a.m. revealed the patient's record did not contain any documentation from case management or include any discharge planning documentation. An interview with the Director of Cardiac Services and Critical Care, conducted at the time of record review, revealed the discharge planing was "not documented right now" and that "discharge planning starts at admission". A progress note written by physical therapy on 2/19/2011 at approximately 4:10 p.m. revealed the following, in pertinent parts, "...Recommend home physical therapy at discharge." A subsequent review of the medical record on 2/22/2011 revealed a Case Management Assessment note written on 2/21/2011 at approximately 5:31 p.m. that stated, "per rounds today, PT rec home PT, hsc (patient receive home physical therapy,home care services) alerted to plan." No additional notes from Case Management or from the Home Care Services personnel were in the medical record and the patient was discharged on [DATE] at approximately 6:34 p.m. A progress note written by physical therapy on 2/21/2011 at approximately 10:00 a.m. stated, in pertinent part, "...Patient declines home physical therapy." An interview with the Manager of Case Management on 2/21/2011 at approximately 10:20 a.m. revealed sample patient #14's chart should have contained a note from the home care personnel or a follow-up note from the Case Management department, but confirmed the note was not present.





3. Sample patient #7 was admitted to the facility on [DATE] with chest pain and discharged on [DATE]. During the patient's admission, a cardiac catheterization was performed. A review of the medical record revealed there were no case management notes documented during the entire admission.

4. Sample patient #16 was admitted to the facility on [DATE] with pneumonia and was still an inpatient. The medical record was reviewed on the medical surgical unit on 2/21/11 and it was noted there were no documented case management notes. The Case Manager for this patient came to the unit during the medical record review and stated s/he had documented in another electronic system regarding this patient. However, s/he had failed to move the documentation over into the facility's electronic medical record. The manager further stated that because of this oversight, the staff caring for the patient would not know the discharge plan.

5. Sample patient #19 was admitted to the facility on [DATE] with a head injury and was still an inpatient. The medical record was reviewed on the surgical unit on 2/21/11 and it was noted there were no documented case management notes. The Case Manager for this patient came to the unit during the medical record review and stated that this patient had been admitted late on 2/18 (a Friday) and there were only two case managers for the entire weekend which was the normal staffing. Furthermore, the patient was considered a "low risk" patient which meant he/she would not have a case manager.

6. Sample patient #20 was admitted to the facility on [DATE] with an intracranial bleed and was still an inpatient. The first documented case management note was on 2/16/11, a delay of four days. There was no explanation as to the delay in discharge planning.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on tour of the facility, review of facility logs, staff interview, and review of facility's policies/procedures, the facility failed to ensure policies governing surgical care were designed to assure the achievement and maintenance of high standards of medical practice and patient care. Specifically, the facility did not have physical barriers limiting air flow movement between unrestricted and semi-restricted spaces within two Operating corridors. In addition, the Post Anesthesia Care Unit failed to complete daily documentation which evidenced that checks had been completed on the pediatric Code Blue cart. These failures created the potential for a negative patient outcome.

The findings were:

1. Separation of unrestricted and restricted areas:

Tour of the facility's 2nd floor Surgical Services Department conducted 2/21/11 began at approximately 8:30 a.m. Tour of the facility's four "old" Operating Rooms (OR), numbers 7, 8, 9, and 10, revealed the west entrance, near OR number seven, into the semi-restricted space from the unrestricted hallway was two doors. One of the doors was propped open and a tape red line was on the floor. When the Director of Surgical Services was asked about the propped door s/he stated, "Typically they are open." Further tour revealed the north entrance, near OR number ten, had an adjacent long hallway. The Director stated the hallway led to the staff lounge, back to the unrestricted area, and the Gastrointestinal (GI) Lab. A taped red line was on the floor in the semi-restricted area prior to the start of the unrestricted hallway. The Director stated the red line and sign posted designated the separation. There was no physical barrier between the semi-restricted space outside the four ORs and the unrestricted space where GI patients and staff in street clothes may have been walking. When asked what types of procedures occurred in the four ORs, the Director stated overflow surgeries were sometimes conducted in ORs seven and eight, urology procedures were conducted in OR number ten, and surgical pacemakers placements were always done in OR number nine.

Tour of the facility's 3rd floor Gynecology Operating Room area was conducted at approximately 11:30 a.m. Tour revealed the area had three Operating Rooms and an adjacent Post Anesthesia Care Unit (PACU) area which had four bays. Entrance into the OR area through double doors revealed the main entrance to the PACU area to the right and a staff dressing room to the left. Just beyond both of those rooms was a tape red line on the floor and thereafter were the three ORs. When the GYN OR Nurse Manager was asked if the PACU area was semi-restricted, s/he stated, "Essentially it is unrestricted because we'll have family in the PACU." There was no physical barrier between the semi-restricted space outside the three ORs and the unrestricted space where family could be walking by in street clothes.

An interview with the Facilities Director and the Director of Quality Management was conducted on 2/22/11 at approximately 8:25 a.m. The Facilities Director stated the dressing room in the Gynecology OR area was for surgeons. S/he stated the dressing room could be accessed through the physician lounge instead of through the main OR entrance and that ideally all staff would enter in the back through the lounge and come out the OR side. The Director of Quality Management stated that family could possibly enter into the Gynecology PACU through the pre-operative room, which connected to the PACU area as well as the unrestricted hallway outside the double doors, instead of through the main OR entrance.

An additional interview with the Facilities Director was conducted on 2/22 at approximately 10:15 a.m. When asked about air pressure testing within the OR areas, s/he stated, "Unfortunately they only test from the hall into the OR rooms, not from the sterile corridor to outside..." S/he also stated this testing was done by outside vendors. Review of outside vendor's documentation of testing revealed it was last done in June, 2010. The testing revealed each OR room in the hospital had positive pressure to the adjoining hallway, however there was no evidence as to the pressure readings from the semi-restricted to the unrestricted spaces, specifically those transitions which were without physical barriers and instead only had taped red lines on the floor.

Review of the facility's policy titled "Traffic Patterns in the Operating Room" was done on 2/22. The policy stated the following, in pertinent part:
...PROTOCOL AND GUIDELINES
I. Surgical Suite Areas
A. The surgical suite is divided into three designated areas.
1. The unrestricted areas include the central nursing station, which is established to monitor the entrance of patients, personnel, and materials; the main hallways, which lead to the lockers; the hallways leading to the lounge; and the lounge. Traffic is not limited in the unrestricted areas.
2. The semi-restricted ares include the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to the restricted areas of the surgical suites. Traffic in this area is limited to authorized personnel and patients. There are red lines on the floor to mark these areas...
III. Movement
A. Movement of personnel from unrestricted areas to either semi-restricted or restricted ares should be through a transition zone. A transition zone exists when one can enter the area in street clothing and exit into the semi-restricted or restricted zone in surgical attire. The LAH operating room locker rooms serve as transition zones between the outside and inside of a surgical suite..."

2. Crash cart checks:

Tour of the facility's Surgical Services Department was conducted on 2/21/11. At approximately 9:30 a.m., the Post Anesthesia Care Unit (PACU) was toured and revealed that the 2nd floor's only pediatric crash cart had an incomplete log. The log was titled "Daily Code Cart Checklist." The log evidenced documentation for the following days in the February: 1, 2, 5, 6, 7, 18, 20, and 21. The other days of the month were without any documentation. The January log evidenced documentation for the following days: 4, 5, 6, 7, 8, 9, 10, 11, 12, 18, 22, 24, 26, 28, and 31. The documentation on both months indicated the cart had been checked, equipment was in proper working order, and items within were not expired. There was no further indication on the logs that the PACU had been closed the other days where documentation was not complete. Upon notification of the findings, the PACU Charge Nurse stated, "We had it (the pediatric crash cart check and the adult crash cart check) on the same checklist before and I'm wondering if they (the staff) didn't know there were two (checklists)."

Upon further review with the Director of Quality Management on 2/22/11 at approximately 2:10 p.m., s/he stated "We recently changed over our crash carts and some of the staff got confused and stopped doing what they used to do..."

The policy "Code Blue" was reviewed on 2/21/11. It stated the following, in pertinent part:
"...PROTOCOL AND GUIDELINES...
IX. Code Blue Carts...
D. Daily Code Cart Checks
1. When a patient care area is open, each code cart is to be checked at least every 24 hours.
2. If an area is closed more that 24 hours, the code cart must be checked immediately upon opening and the checklist must indicate which days the area was closed.
3. All areas are to use the Daily Code Cart Checklist. (See Attachment 3.)
4. The how to do a Daily Code Cart Check is a guide to performing checks. (See Attachment 2.)..."
Attachment 1 of the policy stated that an adult and a pediatric crash cart were within the PACU.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observations, review of the facility's policies and procedures and staff interview, the facility failed to follow acceptable standards of practice in the storage of medication. This failure created the potential for negative patient outcome.

The findings were:

The facility's policy and procedure entitled, "Multidose Medications-Solution Vials, Care and Use of" reads, in pertinent part: "An opened multi-dose vial has an expiration of 28 days from the date the vial is opened."

A tour was conducted on the surgical unit on 2/21/11 at approximately 1:00 p.m. with the Chief Nursing Officer (CNO). The contents of the medication refrigerators were inspected and revealed an influenza virus vaccine vial had been opened with an expiration date after opening of 2/2/11. Another opened influenza virus vaccine vial had an expiration date of 1/31/11.

The CNO was interviewed as the tour was in progress and stated that the nurses are responsible for disposing of the opened multidose vials that have expired. The CNO disposed of the two expired influenza vials after they were found.