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.

MEDINA MEMORIAL HOSPITAL 200 OHIO STREET MEDINA, NY March 21, 2013
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on document review and interview, the facility does not ensure standards for safe medication administration are developed and implemented related to CDC standards of practice for limiting the use of multidose vials in patient care areas to prevent potential contamination.

Findings include:

Review on 3/12/13 of the CDC "Questions about Multi-dose Vials" (last updated 2/9/11) revealed if multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use.

Interview on 3/12/13 at 10:10 AM with Certified Registered Nurse Anesthetist Staff #21 revealed during operating room procedures, he will draw up medications from multidose vials housed in the anesthesia cart during a procedure and return the multidose vial back into the anesthesia cart to be used on another case.

This finding was verified with Operating Room (OR) Nurse Manager Staff #25 on 3/12/13 at 10:10 AM.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, the hospital does not ensure the medical record contains complete information regarding patient progress and discharge plans, as evidenced for Patient #42.

Findings include:

Medical record review on 3/20/13 for Patient #42 revealed no evidence a discharge summary was completed, although the patient was discharged on [DATE].

This finding was verified with VP of Patient Care Services Staff #3 on 3/21/13 at 2:30 PM.
VIOLATION: GOVERNING BODY Tag No: A0043
The governing body failed to ensure that the hospital is compliant with all Conditions of Participation, as noted in the area of Physical Environment as it relates to medical gas alarms (Tag #A724), and in the area of Infection Control (Tag #A749).

See findings under Condition Tag #A700, and its associated Tags #A702, A710, A724 and A726.

See findings under Condition Tag #A747, and its associated Tag #A749.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on policy and procedure review, document review and interview, the facility does not ensure that each QAPI project uses a quality indicator that is based on evidence that it will improve health outcomes, and the projects are presented to the governing body for approval of the frequency and detail of data collection.

Findings include:

Review on 3/12/13 of policy "Organizational Performance Improvement Plan" (effective 10/11) revealed subjects for ongoing measurement through quality indicators may include staff perception of current performance and opportunities for improvement, and processes related to changes in evidence based outcomes.

Review on 3/12/13 of "Performance Improvement Board" minutes for 2012 revealed projects such as Fall Safety, Skin Care and Nutrition/Patient food tray accuracy according to diet prescription. The narrative for these three projects referenced benchmarks, but there was no documentation indicating from where these benchmarks were drawn. No project summation could be located for the projects, documenting planning items such as title, purpose/reason for choice, project benchmark and what it is based on, frequency and method of data collection. Although information from these projects was reported to the governing body during meetings in 2012, it was not clear when the indicators were presented to the governing body for approval of the frequency and detail of data collection, as required.

This finding was confirmed with Director of Performance Improvement/Risk Management/Infection Control (PI/RM/IC) Staff #2 on 3/14/13.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, nursing services does not ensure ongoing assessment of needs, as evidenced for Patients #37 and 38.

Findings include:

Medical record review on 3/20/13 for Patient #37 revealed the following:
- In the discharge summary dated 1/21/13 at 1928, the physician documented "the patient had a run of 16-beat non-sustained VT ([DIAGNOSES REDACTED]) last evening that I was not made aware of."
- No evidence was found in the record to indicate nursing services documented the episode in the nursing notes, that a telemetry strip was obtained and/or reviewed or that a physician was notified.

Medical record review on 3/20/13 for Patient #38 revealed the following:
- The medication reconciliation form (a tool used to track a patient's medications upon admission, transfer, and discharge) dated 1/12/13 at 1540 indicates to continue the administration of Rapaflo 8 mg orally daily.
- A nursing note dated 1/13/13 at 0830 indicates Patient #38 was asked to call his wife to bring in the 0900 medication that the pharmacy doesn't have.
- The medication administration record indicates on 1/13/13 at 1010 the dose of Rapaflo 8 mg was "omitted" as the medication is not available at the pharmacy; the patient is going to call. On 1/15/13 at 1000, Rapaflo 8 mg was administered for the first time.
- No evidence was found that indicated the physician was notified Rapaflo was unavailable and/or the physician placed the medication on hold.

These findings were verified with Vice President (VP) of Patient Care Services Staff #3 on 3/21/13 at 2:30 PM.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on policy and procedure review, observation and interview, the facility does not have a policy in place that ensures outdated, unusable drugs and biologicals are not available for patient use.

Findings include:

Review on 3/14/13 of policy 1.12 "Floor Stocked Medications" (last reviewed 11/11) revealed the policy refers to medications only and not other supplies with expiration dates.

Observation on 3/14/13 at 10:15 AM of the medical/surgical medication room revealed a pediatric emergency kit. The kit had approximately 6 separate pockets containing supplies. There was an expiration date on each of the pockets indicating the supplies were in date; however, inspecting inside three of the pockets revealed IV start kits expired in 12/11 and 22/24 gauge needles expired in 11/11 and 3/12.

Observation on 3/14/13 at 10:50 AM of the medical/surgical IV cart revealed one purple top phlebotomy tube expired 5/11.

Observation on 3/14/13 at 11:45 AM in the emergency department revealed the following:
- Trauma room #2 chest tube tray had one 14 gauge IV catheter expired 12/11, two 2.0 silk sutures expired 1/12, one 60 cc syringe packaging that was yellow, appearing compromised, and three gray top phlebotomy tubes expired 2/12.
- The storage room had seven gray top phlebotomy tubes expired 12/12.

All expired supply findings were verified on 3/14/13 with Nurse Educator Staff #5 at the time of inspection.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, document review and interview, this Condition is not met as evidenced that medical gas alarms for oxygen, medical air and vacuum were observed to be disabled in the Ambulatory Surgery Center and in the Emergency Department on 3/13/13. A determination of Immediate Jeopardy was declared on 3/13/13 at 3:40 PM.

On 3/13/13 at 4:30 PM, the Immediate Jeopardy was abated. The facility provided a signed letter of attestation by Vice President of Patient Care Services Staff #3 indicating a plan of action to physically monitor and document the PSI levels and alarms hourly. New alarm panels were installed and functional on 3/15/13 for the Ambulatory Surgery Center and 3/21/13 for the Emergency Department.

See findings under Tag #A724, and associated Tags #A702, A710 and A726.
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
Based on observation and interview, the battery-powered emergency lighting unit in one of two operating rooms did not illuminate when the test button was pressed.

Findings include:

During tour of operating room #2 with Facilities Staff #8 on 3/14/13 at 2:30 PM, the test button for the battery-powered lighting unit was pressed, but the lights did not illuminate.

This finding was verified with Facilities Staff #8 at the time of inspection.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on observation, document review and interview, the hospital does not ensure all aspects of Life Safety Code are met, as evidenced by the following: 1.) the hospital does not ensure that the sprinkler system is fully inspected; 2.) the hospital does not ensure that the hospital campus non-smoking policy is effectively enforced.

Findings include:

Findings #1:
During facility tour with Facilities Staff #8 on 3/14/13, it was observed that there was a sprinkler head in the walk-in freezer located in the kitchen.

Review on 3/14/13 of the quarterly sprinkler reports, dated 12/19/12, 9/14/12, 12/6/12 and 3/6/12, revealed the reports did not identify the sprinkler system, which protects the freezer in the kitchen, as either one of the two: containing antifreeze--section (5)(d) of the report indicated "N/A", or a dry system--section (6) of the report indicated "0" dry systems as part of the sprinkler system.

Interview on 3/18/13 of Facilities Staff #8 revealed he could not identify what type of sprinkler system was in the walk-in freezer.

This finding was verified with Chief Operating Officer (COO) Staff #15 on 3/18/13.

Findings #2:
During facility tour with Facilities Staff #8 on 3/18/13 at 1:30 PM, there were approximately 100 cigarette butts at the outside entrance to the emergency department in the grass. At the main entrance to the hospital, there approximately 50 cigarette butts in the grass.

Interview with COO Staff #15 on 3/18/13 revealed there is a campus wide no smoking policy, and those persons who choose to smoke do so in the designated area across the street.

This finding was verified with COO Staff #15 on 3/18/13.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, document review and interview, the hospital does not ensure an acceptable level of safety and quality, as evidence by the following: 1.) the hospital does not maintain medical gases at typical operating pressure; 2.) the hospital does not ensure medical gas area alarms are operational; 3.) the hospital does not have all medical gas zone shutoff valves labeled; 4.) the hospital does not maintain plumbing and plumbing fixtures to ensure safety and quality; 5.) the facility does not maintain all rooms clean and in good repair.

Findings include:

Findings #1:
During facility tour with Facilities Staff #8 on 3/13/13 at 10:00 AM, it was observed that the medical air gauge at the zone valve shutoff box for emergency department room #1 indicated that it was at 42 pounds per square inch gage (psig). It was observed that the medical air gauge at the zone valve shutoff box for emergency department room #2 indicated that it was at 44 psig.

During facility tour with Facilities Staff #8 on 3/13/13 at 12:00 PM, it was observed that the medical air gauge at the zone valve shutoff box for the operating room suites indicated that it was at 46 psig.

Review on 3/13/13 at 12:40 PM of the "Annual Medical Gas System Evaluation" report performed by Upstate Analytical Services L.L.C., dated 2/7/13 revealed "typical operating pressure" to be between 50-55 psi. Testing conducted on 45 of 45 station outlets indicated that the psig was 46.

Interview on 3/13/13 with VP of Patient Care Services Staff #3 and Facilities Staff #8 at 1:00 PM revealed they did not know the alarm set points and did not know if it was the intent of the facility to have the medical air set below typical operating pressure for operational purposes.

These findings were verified with Facilities Staff #3 on 3/13/13 at 2:00 PM.

Findings #2:
Review on 3/13/13 at 12:40 PM of the "Annual Medical Gas System Evaluation" report, performed by Upstate Analytical Services L.L.C., dated 2/7/13, revealed that the medical gas area alarms were disabled in the Emergency Department and the Ambulatory Surgery Unit.

These findings were verified with Facilities Staff #3 on 3/13/13 at 2:00 PM.

Findings #3:
During facility tour with Facilities Staff #8 on 3/18/13 at 1:00 PM, it was revealed that the medical gas zone shutoff valve box that serves the ultrasound area, and the zone shutoff valve box that serves the mammography area, were not labeled.

This finding was verified with Facilities Staff #8 at the time of inspection.

Findings #4:
During facility tour with Facilities Staff #8 on 3/15/13 at 10:00 AM, the following was observed in the housekeeping washroom:
- The hot water pressure relief valve on the hot water tank was leaking. A plastic pan was underneath it and a hose was connected to the pan to convey the water to the drain. There was water on the floor in the area.
- A hot water supply line was leaking from the water spigot.

These findings were verified with Facilities Staff #8 at the time of inspection.

Findings #5:
During facility tour on 3/13/13 with Facilities Staff #8 at 10:10 AM, the following was observed in "ED-1" (emergency department room #1):
- There was an eight inch by five inch piece of flooring located at the threshold, that was patched with concrete. The concrete was cracking and breaking up, rendering it porous and not cleanable.
This finding was verified with Facilities Staff #8 at the time of inspection.

Findings #6:
During facility tour with Facilities Staff #8 on 3/13/13 at 10:15 AM, the following was observed in "ED-2":
- At the door jamb, a six inch long by two inch wide area on the wall was missing drywall.
- An eight inch by eight inch piece of plastic was covering an area on the wall, where Staff #8 stated there had previously been a clock.
- There was dirt on the floor.
These findings were verified with Facilities Staff #8 at the time of inspection.

During facility tour with Facilities Staff #8 on 3/18/13 at 1:00 PM, the following was observed in the morgue:
- There were two small metal filing cabinets on the floor with pathology slides in the drawers and on top of the cabinets.
- In the corner near the door, there was a wood mop handle, an empty latex glove box, many plastic bags, newspaper inserts, a telephone and four full Bud Light beer cans.
These findings were verified with Facilities Staff #8 at the time of inspection.

During facility tour with Facilities Staff #8 on 3/18/13 at 1:15 PM, the following was observed in the vacuum pump room:
- Three floor buffers and five mop buckets were stored in the room with the vacuum compressors and steam boiler components. The handle of one of the mop buckets was directly against the face of a pressure gauge, which was part of the steam equipment.
This finding was verified with Facilities Staff #8 at the time of inspection.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation, document review and interview, the hospital does not ensure there is proper ventilation and temperature controls in the facility, as evidenced by the following: 1.) the hospital does not maintain the operating rooms and the post-surgical recovery area between 30 to 60 per cent (%) humidity; 2.) the hospital does not have a practice to ensure that temperature and humidity are maintained in the endoscopic procedure room; 3.) the hospital does not ensure that exhaust components of the ventilation system are operated to ensure rooms requiring direct exhaust to the outside of the facility are maintained.

Findings include:

Findings #1:
During facility tour with Facilities Staff #8 on 3/14/13 at 2:00 PM, the digital humidity monitor in "OR #1" indicated the humidity was 22%. The digital humidity monitor in "OR #2" read 20%.

During facility tour with Facilities Staff #8 on 3/14/13 at 3:00 PM, the digital humidity monitor in the "PACU" indicated the humidity was 22%.

Review on 3/14/13 of the "Surgical Services Temperature and Humidity Log" revealed that on nine of ten days in March 2013, the humidity was below 30% in OR #1, OR #2 and the PACU. The log stated that "recommended relative humidity is 30% to 60%. (AORN 2010)".

These findings were verified with Facilities Staff #8 on 3/14/13.

Findings #2:
During facility tour with Facilities Staff #8 on 3/14/13 at 2:40 PM, it was revealed that there was no monitor device for temperature and humidity for the endoscopic procedure room.

This finding was verified with OR Nurse Manager Staff #25 on 3/14/13.

Findings #3:
During facility tour with Facilities Staff #8 on 3/18/13 at 12:45 AM, it was observed that the environmental services closet, near pharmacy, did not have an exhaust vent in the room. The room was equipped with a diffuser grill in the ceiling that allowed air from the room to enter plenum space and circulate; per regulation, air from this room shall not be circulated to other parts of the facility.

This finding was verified with Facilities Staff #8 on 3/18/13.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on policy and procedure review, interview, document review and observation, this Condition is not met, as evidenced that the facility does not have a policy which addresses the required frequency and method to clean glucometers located on patient care units, thereby causing facility practice to vary on different patient units.

See findings under Tag #A749.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on policy and procedure review, interview, document review and observation, the hospital does not have an effective infection control system, as evidenced by the following: 1.) the hospital does not have a policy which addresses the required frequency and method to clean glucometers located on patient care units, thereby causing facility practice to vary on different patient units; 2.) the infection control officer has not developed, implemented, and evaluated measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital; 3.) staff do not follow acceptable infection control practices related to hand hygiene and glove use.

Findings include:

Findings #1:
Review on 3/14/13 of policy 20-GL-9-D-7 "Glucometer, Documentation and Verification of Point of Care Testing" (last reviewed 10/11) and the "Annual Glucose Monitoring Competency Checklist" (undated) revealed no evidence of the frequency required, or how to clean the glucometer machine.

Interviews with registered nurses (RNs) from 3/11/13 to 3/14/13 revealed the frequency the unit glucometer is cleaned for the following units: RN Staff #36- weekly or as necessary in the PSU2, RN Staff #37- every shift on the medical/surgical floor, RN Staff #24- every day and after each use in the medical rehabilitation unit, and RN Staff #38- every day in the emergency department.

Findings #2:
Review on 3/18/13 of the Infection Control committee meeting minutes dated 11/29/12, 12/28/12 and 3/1/13 revealed no evidence the following areas are incorporated into ongoing infection control surveillance monitoring: equipment sterilization, routine environmental/equipment cleaning, medication administration techniques or employee health/immunization/exposure status.

This finding was confirmed with Director of PI/RM/IC Staff #2 and Infection Control Practitioner Staff #9 on 3/18/13 at 2:00 PM.

Findings #3:

Observation in patient care areas revealed the following:
- On 3/11/13 at 3:00 PM in PCU2 room, Respiratory Therapy Staff #35 used hand sanitizer, donned clean gloves and extubated a patient. She proceeded to remove her stethoscope from around her neck, listen to the patient's lungs and return the stethoscope around her neck (no hand hygiene or new gloves donned after extubation, or touching her stethoscope). She disposed of the ventilator tubing and removed her gloves; no hand hygiene was performed. She donned clean gloves and used her tablet computer. She removed her gloves (no hand hygiene was performed) and exited the room proceeding to obtain a nebulizer medication vial from a drawer in the medication cart. She poured the medication into the mask, administered the nebulizer treatment, performed hand hygiene and exited the room.
- On 3/13/13 at 12:12 PM in the emergency department, Patient Care Technician Staff #39 performed hand hygiene, disconnected the IV tubing from an intravenous lock and disposed of the tubing. Using the same gloves, she took gauze from a cart nearby and removed the IV in the patient's forearm.