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.

SANDHILLS REGIONAL MEDICAL CENTER 1000 WEST HAMLET AVENUE HAMLET, NC 28345 Aug. 7, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on hospital policy/procedure review, Medicine Services Committee meeting minutes review, medical record reviews, staffing sheet reviews, personnel file reviews, hospital investigative documentation reviews, Behavioral Health staff interviews, Administrative staff interviews, tours and observations, the hospital failed to have an effective Governing Body by failing to ensure a safe patient environment.

The findings include:

1. The hospital staff failed to ensure the patient's right for a safe environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.13 Patient Rights Condition: Tag A 115.

2. The hospital failed to provide nursing supervision ensuring a safe environment by failing to staff the Behavioral Health unit to meet the needs of the Behavioral Health patients.

~cross refer to 482.23 Nursing Services Condition: Tag A 385.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on hospital policy/procedure review, Medicine Services committee meeting minutes review, medical record reviews, staffing sheet reviews, personnel file reviews, hospital investigative documentation reviews, Behavioral Health staff interviews, Administrative staff interviews, tours and observations, the hospital staff failed to protect and promote each patient's rights by failing to have a safe patient environment for the Behavioral Health patients.

The findings include:

The hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

~cross refer to 482.13(c)(2) Patient Rights: Care in Safe Setting: Tag A 144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy/procedure review, Medicine Services Committee meeting minutes review, medical record reviews, staffing sheet reviews, personnel file reviews, hospital investigative documentation reviews, Behavioral Health staff interviews, Administrative staff interviews, tours and observations, the hospital staff failed to ensure a safe patient environment by failing to have processes and systems in place for the monitoring and supervision of Behavioral Health patients.

The findings include:

Review of the facility's observation levels policy revised June 2014 revealed no evidence of one to one observation specifics. Review of policy revealed, "...the attending physician is always contacted to give a specific order for the level of monitoring ..."

Review of current facility's observation levels policy effective July 2014 revealed, "...one to one (staff member constantly with the patient not less than arm's length away, and documents at 15-minute intervals) ...".

Review of the Medicine Services Committee meeting minutes dated 01/13/2014 revealed "For the inpatient unit the PRIDE model of practice does not provide BHI (Behavioral Health Inpatient) staff and Code Black Responders with the needed skills to handle violent behavior in a manner that is safe for staff, patient, and visitors. Our staff needs to be trained in the techniques of Nonviolent Crisis Intervention (CPI) for safely defusing anxious, hostile, or violent behavior at the earliest possible stage".

Closed medical record review of Patient #1 revealed a [AGE] year old female presented to the emergency department (ED) as an involuntary commitment (IVC) on 07/22/2014. Record review revealed the patient was admitted on [DATE] at 1508 with a diagnosis of suicidal ideation and schizoaffective disorder. Record review revealed the Behavioral Health Patient Rights Acknowledgement contract for Patient #1 dated 07/22/2014 at 2135 documenting "while you are in treatment in our facility, you retain the right to be free from ...physical and sexual abuse. An environment that is safe ..." Review of the psychiatrist notes dated 07/25/2014 at 0915 revealed patient was oriented to person, time, and place. Further review of the psychiatrist notes revealed the patient's mood was still labile and depressed. Review of Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented with observations every 30 minutes. Further review of the Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented from 0700 to 0730 resting in the patient's room, at 0800 eating food/snack in the day room, at 0830 to 0900 awake and cooperative in the day room, at 0930 in group in the day room, at 1000 to 1130 in the day room and at 1200 eating food/snack in the day room. Review of the progress notes dated 07/26/2014 at 1250 revealed Patient #1 informed LPN #1 that EST #1 approached the patient for sex. Record review revealed the LPN #1 informed the charge nurse on duty and the psychiatrist on call. Review of the psychiatrist notes dated 07/26/2014 at 1330 revealed Patient #1 informed the psychiatrist about the incident with EST #1. Record review revealed the psychiatrist documented the assessment, "patient's mood/effect were anxious. Speed was clear and articulate. Thought process were good".
Record review of the nursing progress notes dated 07/26/2014 at 2020 the patient informed the local police department onsite regarding the incident with EST #1. Review of the Medical Screening Exam dated 07/26/2014 at 1545 revealed Patient #1 was escorted by the hospital staff to the ER for a forensic (rape kit) evaluation. Record review revealed the forensic (sexual assault kit) evaluation was done by an ER physician. Record review revealed at 1720 "...patients states she was forced into sexual encounter ...patient denies changing clothes ...states cleaning staff forcibly had sex with her. Case is being investigated, law enforcement involved. Brought to the ER to complete rape kit. Patient is fully cooperative, mildly anxious...".

Closed medical record review of Patient #16 revealed a [AGE] year old female admitted on [DATE] at 1941 for dementia with psychosis and Alzheimer's disease. Review of the Nurse's notes dated 07/25/2014 at 1820 revealed documentation the patient was hitting doors with her shoes, was 1:1 observation (one staff assigned to patient #16 for continuous monitoring), was throwing water and fighting staff. Review of Nurse's notes dated 07/26/2014 at 0700 revealed documentation the patient was yelling and hitting staff. Review of Nurse's notes at 0930 the patient was up in wheelchair. Review of Special Precautions Flow sheet dated 07/26/2014 revealed patient was documented observation every 15 minutes and from 0700 to 1200 patient was documented resting in the patient's room.

Closed medical record review of Patient #17 revealed a [AGE] year old male admitted on [DATE] for psychosis. Review of physician order dated 07/26/2014 at 0630 revealed "one on one needed for patient d/t (due to) safety of himself and others". Review of Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented observation every 15 minutes. Further review of the Special Precautions Flow sheet dated 07/26/2014 revealed from 0700 to 1145 patient was documented resting in the patient's room. At 1200 the patient was documented eating food/snack in the day room. Further review of the Special Precautions Flow sheet revealed patient was documented as an every 15 minute safety check instead of individual or 1:1 (one on one) as ordered.

Review of the Behavior Health Unit assignment sheet dated 07/26/2014 from 0700 to 1900 revealed current census of 9 patients (including Patient #1, #16, #17), staffing with one Registered Nurse (RN), one Licensed Registered Nurse (LPN), and one Certified Nursing Assistant (CNA). Further review of the assignment sheet revealed there was no evidence of which staff was assigned to which patient and which staff was assigned on one to one observation.

Review of the Environmental Service Technician (EST) #1's personnel file revealed he had been employed at the facility since 08/03/2009. File review revealed the facility changed the Environmental Services as contract staff in 2012, as the result EST #1's status changed to contract staff on 05/06/2012. File review revealed EST #1 was assigned to the emergency room (ER) and the Behavioral Health Unit. File review revealed documentation of an investigation on 10/31/2012 when a Behavioral Health patient's family member reported to the facility regarding EST #1 suggesting "sexual proposition". Further review revealed allegations that EST #1 made inappropriate comments to their female family member and another psychiatric patient during a recent hospitalization . Investigative documentation review revealed EST #1 stated he gave his personal phone number to one of the female psychiatric patients.

Review of facility investigative documentation revealed a written statement by Patient #1 that she was in her bedroom on July 26, 2014. Documentation revealed EST #1 came into the patient's bedroom to clean and he asked her to get in the corner by the closet. EST #1 asked to show him her genitals/breasts. Documentation revealed "I said no. He kept telling me to over and over again. He said come on just show me once, so I did show him" genitals. He then asked her to show him her breasts. Documentation revealed EST #1 left the room and "I was glad he was outside my room messing with a mop. He came back in my room and told me to go to the bathroom. I said no I'm scared, he kept begging me to so I did". Documentation revealed EST #1 pulled out his genital and told the patient to "touch it and" place her mouth on his genital. Further review revealed "I said I was scared so he pushed my head down and made" her put her mouth on his genital. EST #1 next told the patient to bend over, "I was scared so I did what he said". EST #1 removed the patient's pant, and proceeded to perform a sexual act. Documentation revealed EST #1 told the patient not to tell anyone because the facility "would kick" the patient out and "never let" the patient "come back". EST #1 left the patient's bedroom and returned with "a rag and told me to wipe off". EST #1 returned again to the room and " asked me if I did I said yes. and he said good were (we are) kool (cool) then and he left."

Interview with LPN #1 on 08/07/2014 at 1045 revealed on 07/26/2014 the unit had 2 geriatric patients (#16, #17) that had altered mental status. The male geriatric patient (#17) had a physician order for 1 to 1. The interview revealed Patient #16 urinated on the floor and wetting herself. The interview revealed Patient #16 required 2 staff members because the patient had shuffling gait making it difficult for one person to assist the patient. Interview revealed while the LPN and CNA were in Patient #16's bedroom they removed the patient's soiled clothing, cleaned the patient, and put on clean clothing. The interview revealed one staff (RN) was left on the floor with 8 patients including the 1 to 1 observation patient. The interview revealed the door to the nursing station was opened and the RN could view the 1 to 1 observation patient. The interview revealed the 1 to 1 observation patient was not within arms length per the facility policy.

Interview with CNA #1 on 08/07/2014 at 1200 revealed on 07/26/2014 she floated to the Behavioral Health Unit at approximately 0700 assigned to monitor "keep eyes with these two patients (#16, #17)". Interview revealed there was no 1 to 1 assignment on the unit on 07/26/2014. Interview revealed Patient #16 and Patient #17 sat in the hallway so staff could keep an eye on the two patients (#16, #17). Interview revealed at approximately 1120 another patient told the staff that Patient #16 had an accident in the hallway. Interview revealed she was asked by LPN #1 to assist her in cleaning the patient. Interview revealed CNA #1 and LPN #1 were in Patient #16's bedroom until 1150, "right before lunch" (Lunch was served at 1200). Interview revealed on 07/26/2014 CNA recalled observing EST #1's housekeeping cart parked near the area he was cleaning.

Interview with the Behavioral Health (BH) Director #1 on 08/06/2014 at 1100 revealed he had been the BH Director since February 2013. Interviewed revealed based on his experience and his own assessment of the unit, he requested additional staff and training for the staff since April or May 2013. The interview revealed he had observed inappropriate holds by the staff restraining patients. The interview revealed the staff were trained in the "PRIDE" (Prevention, Intervention, De-escalation of aggressive behaviors) program and it was used more for group and nursing homes. The interview revealed he had requested staff training in CPI (Crisis Prevention Intervention). Interview revealed the requested training was also added after Patient #1's incident on 07/26/2014. The interview revealed the staff had not had CPI training but a tentative schedule was August 12, 2014 and August 14, 2014. Interview revealed the requested additional staff was added after Patient #1's incident on 07/26/2014. The interview revealed the facility had a consultant group come in to evaluate the Behavioral Health Unit the week 07/21/2014. The interview revealed an exit conference was conducted and recommendation were made to increase the number of staff and to increase the safety monitoring check from every 30 minutes to every 15 minutes. Interview revealed prior to the incident the BH Director would spot check the staff's compliance with the 30 minute safety checks. Interview revealed after the incident the unit implemented the process of every 15 minute safety checks and patients were to be out of their rooms during cleaning. The interview revealed he had checked the documentation that the staff were completing the every 15 minute forms. The interview revealed he had not observed the staff performing the 15 minute checks. The interview revealed he did not have any documentation of monitoring the processes placed after the incident with Patient #1.

Observations during tour of the Behavioral Health Unit on 08/05/2014 at 1500 revealed Patients in the large day room in group session, patients walking in the hall and patients in the bedrooms. Observation revealed all bedroom doors open. Staff conducting the 15 minute safety checks were observed. Interview during tour/observation with CNA #2 at 1510 revealed she was conducting the safety checks. Review of CNA #2's documentation during the interview revealed the 1515 check documented as completed. Interview revealed it was "ok" to predocument the safety check. The interview revealed she did not remember the time she had conducted the 1500 safety check. Observation revealed the staff conducting the 15 minute safety check were conducting it in the same pattern every time. CNA #2 was observed staring each time in the day room and proceeding to the patient rooms consecutively.

Interview with The Behavioral Health Director and the Behavioral Health Charge Nurse on duty on 08/05/2014 at 1520 revealed the staff are not to predocument any documentation, it is not the hospital policy. The interview revealed "real" time is to be documented and not predocumented. The interview revealed the staff always start the safety checks at the large day room and proceed to each patient room according the numeric order of the sheets placed on the clip board. The interview revealed the safety checks are to be completed in the same pattern every time.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on hospital policy/procedure review, Medicine Services Committee meeting minutes review, medical record reviews, staffing sheet reviews, hospital investigative documentation reviews, Behavioral Health staff interviews, Administrative staff interviews, tours and observations, the hospital failed to provide nursing supervision ensuring a safe environment by failing to staff the Behavioral Health unit to meet the needs of the Behavioral Health patients.

The findings include:

The hospital staff failed to ensure a safe environment by failing to staff the Behavioral Health unit to meet the needs of the Behavioral Health patients.

~cross refer to 482.23(b)(3) RN Supervision of Nursing Care: Tag A 395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy/procedure review, Medicine Services Committee meeting minutes review, medical record reviews, staffing sheet reviews, hospital investigative documentation reviews, Behavioral Health staff interviews, Administrative staff interviews, tours and observations, the hospital staff failed to ensure a safe patient environment by failing to staff the Behavioral Health unit to meet the needs of the Behavioral Health patients.

The findings include:

Review of the facility's observation levels policy revised June 2014 revealed no evidence of one to one observation specifics. Review of policy revealed, "...the attending physician is always contacted to give a specific order for the level of monitoring ..."

Review of current facility's observation levels policy effective July 2014 revealed, "...one to one (staff member constantly with the patient not less than arm's length away, and documents at 15-minute intervals) ...".

Review of the Medicine Services committee meeting minutes dated 01/13/2014 revealed "For the inpatient unit the PRIDE model of practice does not provide BHI (Behavioral Health Inpatient) staff and Code Black Responders with the needed skills to handle violent behavior in a manner that is safe for staff, patient, and visitors. Our staff needs to be trained in the techniques of Nonviolent Crisis Intervention (CPI) for safely defusing anxious, hostile, or violent behavior at the earliest possible stage".

Closed medical record review of Patient #1 revealed a [AGE] year old female presented to the emergency department (ED) as an involuntary commitment (IVC) on 07/22/2014. Record review revealed the patient was admitted on [DATE] at 1508 with a diagnosis of suicidal ideation and schizoaffective disorder. Record review revealed the Behavioral Health Patient Rights Acknowledgement contract for Patient #1 dated 07/22/2014 at 2135 documenting "while you are in treatment in our facility, you retain the right to be free from ...physical and sexual abuse. An environment that is safe ..." Review of the psychiatrist notes dated 07/25/2014 at 0915 revealed patient was oriented to person, time, and place. Further review of the psychiatrist notes revealed the patient's mood was still labile and depressed. Review of Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented with observations every 30 minutes. Further review of the Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented from 0700 to 0730 resting in the patient's room, at 0800 eating food/snack in the day room, at 0830 to 0900 awake and cooperative in the day room, at 0930 in group in the day room, at 1000 to 1130 in the day room and at 1200 eating food/snack in the day room. Review of the progress notes dated 07/26/2014 at 1250 revealed Patient #1 informed LPN #1 that EST #1 approached the patient for sex. Record review revealed the LPN #1 informed the charge nurse on duty and the psychiatrist on call. Review of the psychiatrist notes dated 07/26/2014 at 1330 revealed Patient #1 informed the psychiatrist about the incident with EST #1. Record review revealed the psychiatrist documented the assessment, "patient's mood/effect were anxious. Speed was clear and articulate. Thought process were good".
Record review of the nursing progress notes dated 07/26/2014 at 2020 the patient informed the local police department onsite regarding the incident with EST #1. Review of the Medical Screening Exam dated 07/26/2014 at 1545 revealed Patient #1 was escorted by the hospital staff to the ER for a forensic (rape kit) evaluation. Record review revealed the forensic (sexual assault kit) evaluation was done by an ER physician. Record review revealed at 1720 "...patients states she was forced into sexual encounter ...patient denies changing clothes ...states cleaning staff forcibly had sex with her. Case is being investigated, law enforcement involved. Brought to the ER to complete rape kit. Patient is fully cooperative, mildly anxious...".

Closed medical record review of Patient #16 revealed a [AGE] year old female admitted on [DATE] at 1941 for dementia with psychosis and Alzheimer's disease. Review of the Nurse's notes dated 07/25/2014 at 1820 revealed documentation the patient was hitting doors with her shoes, was 1:1 observation (one staff assigned to patient #16 for continuous monitoring), was throwing water and fighting staff. Review of Nurse's notes dated 07/26/2014 at 0700 revealed documentation the patient was yelling and hitting staff. Review of Nurse's notes at 0930 the patient was up in wheelchair. Review of Special Precautions Flow sheet dated 07/26/2014 revealed patient was documented observation every 15 minutes and from 0700 to 1200 patient was documented resting in the patient's room.

Closed medical record review of Patient #17 revealed a [AGE] year old male admitted on [DATE] for psychosis. Review of physician order dated 07/26/2014 at 0630 revealed "one on one needed for patient d/t (due to) safety of himself and others". Review of Special Precautions Flow sheet dated 07/26/2014 revealed the patient was documented observation every 15 minutes. Further review of the Special Precautions Flow sheet dated 07/26/2014 revealed from 0700 to 1145 patient was documented resting in the patient's room. At 1200 the patient was documented eating food/snack in the day room. Further review of the Special Precautions Flow sheet revealed patient was documented as an every 15 minute safety check instead of individual or 1:1 (one on one) as ordered.

Review of the Behavior Health Unit assignment sheet dated 07/26/2014 from 0700 to 1900 revealed current census of 9 patients (including Patient #1, #16, #17), staffing with one Registered Nurse (RN), one Licensed Registered Nurse (LPN), and one Certified Nursing Assistant (CNA). Further review of the assignment sheet revealed there was no evidence of which staff was assigned to which patient and which staff was assigned on one to one observation.

Review of facility investigative documentation revealed a written statement by Patient #1 that she was in her bedroom on July 26, 2014. Documentation revealed EST #1 came into the patient's bedroom to clean and he asked her to get in the corner by the closet. EST #1 asked to show him her genitals/breasts. Documentation revealed "I said no. He kept telling me to over and over again. He said come on just show me once, so I did show him" genitals. He then asked her to show him her breasts. Documentation revealed EST #1 left the room and "I was glad he was outside my room messing with a mop. He came back in my room and told me to go to the bathroom. I said no I'm scared, he kept begging me to so I did". Documentation revealed EST #1 pulled out his genital and told the patient to "touch it and" place her mouth on his genital. Further review revealed "I said I was scared so he pushed my head down and made" her put her mouth on his genital. EST #1 next told the patient to bend over, "I was scared so I did what he said". EST #1 removed the patient's pant, and proceeded to perform a sexual act. Documentation revealed EST #1 told the patient not to tell anyone because the facility "would kick" the patient out and "never let" the patient "come back". EST #1 left the patient's bedroom and returned with "a rag and told me to wipe off". EST #1 returned again to the room and " asked me if I did I said yes. and he said good were (we are) kool (cool) then and he left."

Interview with LPN #1 on 08/07/2014 at 1045 revealed on 07/26/2014 the unit had 2 geriatric patients (#16, #17) that had altered mental status. The male geriatric patient (#17) had a physician order for 1 to 1. The interview revealed Patient #16 urinated on the floor and wetting herself. The interview revealed Patient #16 required 2 staff members because the patient had shuffling gait making it difficult for one person to assist the patient. Interview revealed while the LPN and CNA were in Patient #16's bedroom they removed the patient's soiled clothing, cleaned the patient, and put on clean clothing. The interview revealed one staff (RN) was left on the floor with 8 patients including the 1 to 1 observation patient. The interview revealed the door to the nursing station was opened and the RN could view the 1 to 1 observation patient. The interview revealed the 1 to 1 observation patient was not within arms length per the facility policy.

Interview with CNA #1 on 08/07/2014 at 1200 revealed on 07/26/2014 she floated to the Behavioral Health Unit at approximately 0700 assigned to monitor "keep eyes with these two patients (#16, #17)". Interview revealed there was no 1 to 1 assignment on the unit on 07/26/2014. Interview revealed Patient #16 and Patient #17 sat in the hallway so staff could keep an eye on the two patients (#16, #17). Interview revealed at approximately 1120 another patient told the staff that Patient #16 had an accident in the hallway. Interview revealed she was asked by LPN #1 to assist her in cleaning the patient. Interview revealed CNA #1 and LPN #1 were in Patient #16's bedroom until 1150, "right before lunch" (Lunch was served at 1200). Interview revealed on 07/26/2014 CNA recalled observing EST #1's housekeeping cart parked near the area he was cleaning.

Interview with the Behavioral Health (BH) Director #1 on 08/06/2014 at 1100 revealed he had been the BH Director since February 2013. Interviewed revealed based on his experience and his own assessment of the unit, he requested additional staff and training for the staff since April or May 2013. The interview revealed he had observed inappropriate holds by the staff restraining patients. The interview revealed the staff were trained in the "PRIDE" (Prevention, Intervention, De-escalation of aggressive behaviors) program and it was used more for group and nursing homes. The interview revealed he had requested staff training in CPI (Crisis Prevention Intervention). Interview revealed the requested training was also added after Patient #1's incident on 07/26/2014. The interview revealed the staff had not had CPI training but a tentative schedule was August 12, 2014 and August 14, 2014. Interview revealed the requested additional staff was added after Patient #1's incident on 07/26/2014. The interview revealed the facility had a consultant group come in to evaluate the Behavioral Health Unit the week 07/21/2014. The interview revealed an exit conference was conducted and recommendation were made to increase the number of staff and to increase the safety monitoring check from every 30 minutes to every 15 minutes. Interview revealed prior to the incident the BH Director would spot check the staff's compliance with the 30 minute safety checks. Interview revealed after the incident the unit implemented the process of every 15 minute safety checks and patients were to be out of their rooms during cleaning. The interview revealed he had checked the documentation that the staff were completing the every 15 minute forms. The interview revealed he had not observed the staff performing the 15 minute checks. The interview revealed he did not have any documentation of monitoring the processes placed after the incident with Patient #1.

Observations during tour of the Behavioral Health Unit on 08/05/2014 at 1500 revealed Patients in the large day room in group session, patients walking in the hall and patients in the bedrooms. Observation revealed all bedroom doors open. Staff conducting the 15 minute safety checks were observed. Interview during tour/observation with CNA #2 at 1510 revealed she was conducting the safety checks. Review of CNA #2's documentation during the interview revealed the 1515 check documented as completed. Interview revealed it was "ok" to predocument the safety check. The interview revealed she did not remember the time she had conducted the 1500 safety check. Observation revealed the staff conducting the 15 minute safety check were conducting it in the same pattern every time. CNA #2 was observed staring each time in the day room and proceeding to the patient rooms consecutively.

Interview with The Behavioral Health Director and the Behavioral Health Charge Nurse on duty on 08/05/2014 at 1520 revealed the staff are not to predocument any documentation, it is not the hospital policy. The interview revealed "real" time is to be documented and not predocumented. The interview revealed the staff always start the safety checks at the large day room and proceed to each patient room according the numeric order of the sheets placed on the clip board. The interview revealed the safety checks are to be completed in the same pattern every time.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations during tour, work order review, and staff interview the hospital's staff failed to maintain the wall and ceiling surfaces within the Surgical Operating Room (OR) Suite in a manner to ensure safety and quality.

The findings include:

Observations during tour on 08/07/2014 at 1145 of the Surgical OR Suite revealed the following:
1. Pre-Operative (Op) Bay #1 - large red-brown (water) stain on 1 ceiling tile adjacent to H/AC vent, located above the patient care area.
2. Pre-Op Bay #2 - large red-brown (water) stain on 2 ceiling tiles, located above the patient care area.
3. Pre-Op Area - excessive black wear marks on wall surfaces and/or multiple penetrations with exposed sheetrock noted on wall surfaces in Pre-Op Bay #2, #3, #4, #5, #6, #7, and #8.
4. Pre-Op Nursing Station - large tear in wall surface with exposed drywall paper on rear wall above counter top.
5. Sub-Sterile Core hallway - excessive black wear marks on wall surfaces and/or multiple penetrations with exposed sheetrock noted on wall surfaces.
6. Sub-Sterile Core hallway - exposed dry wall patches adjacent to door frame of the central sterile storage room doorway.
7. OR #2 - electrical box where old thermostat and humidity monitor was removed is not fully covered allowing access to electrical box and exposed dry wall.

Review of "Work Order " dated 04/28/2014 revealed "Problem: Ceiling Tiles Stained" Status "Pending."

Interview during tour with OR Director #1 revealed a work order was submitted for the ceiling tiles to be replaced (04/28/2014). Interview revealed the walls and ceiling in the operating rooms had been recently repainted. Interview revealed multiple verbal request have been made over the past year to have the walls repaired and painted in Pre-Op. Interview revealed a written work order had not been submitted for repainting the walls in Pre-Op. Interview confirmed the above observations.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based upon hospital policy and procedure review, 2013 Perioperative Standards and Recommended Practices by the Association of periOperative Registered Nurses (AORN), observations during tour and staff interview the hospital's surgical operating room (OR) staff failed to follow standards of practice for the use of internal chemical indicators/integrators during steam sterilization of paper-plastic pouch packaging (peel packs)

The findings include:

Review of current hospital policy "Sterilization/Instruments, Implants, Drills, Shunts, Etc." Policy #: 701.S.9, revised 01/08, revealed "PURPOSE To destroy all microorganisms by reliable standardized methods using heat, gases or chemicals. ...7. Trays are assembled, wrapped with fused or bonded double-layer, disposable, nonwoven wrapper and fastened with indicator tape with steam indicator strip located inside. ...Single instruments and other small items may be placed in heat sealed packets. ..."

Review of the "2013 Perioperative Standards and Recommended Practices Last revised: November 2006. Copyright 2013 AORN, Inc." (provided by OR Director #1) revealed "Recommended Practices for Selection and Use of Packaging Systems for Sterilization", page 509 "Recommendation IX A chemical indicator/integrator should be placed inside each package and an external chemical indicator affixed outside each package to be processed. ...2. Internal chemical indicators should be specific to the sterilization process. Class III (single parameter indicators), Class IV (multi-parameter indicators), or Class V (chemical integrators) may be used. ...4. The internal chemical indicator/integrator should be placed in the geometric center of the package, not on top, to verify that air has been removed and that the sterilant has penetrated into the center of the pack or set. The indicator should be visible to the user when the package is opened so the user can see that the indicator has changed before touching the contents. ..."

Observation during tour of the Surgical OR Suite on 08/07/2014 at 1350 revealed in OR #1, a cabinet containing surgical supplies and equipment. Observation revealed the following: 1. Metal Stopcock sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 06 August 2014. 2. Metal Stopcock sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 20 June 2014. 3. Metal Bridge sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 14 March 2014. Observation at 1400 in OR #2 revealed a cabinet containing surgical supplies and equipment. Observation revealed a Metal Mouth Retractor sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 23 June 2014. Observation at 1405 in the Central Sterile Storage Room revealed shelves/bins containing surgical supplies and equipment. Observation revealed the following: 1. Metal Debakey Forceps sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 04 August 2014. 2. Metal Long Curved Mayo Scissors sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 30 July 2014. (Observation revealed a Metal Long Kelly Clamp sealed inside paper-plastic pouch packaging (peel pack). Observation revealed a visible internal chemical indicator/integrator present inside the peel pack. Observation revealed a label indicating the instrument was sterilized on 25 July 2014 - 5 days prior to the Mayo Scissors). 3. Metal Heaney Needle Driver sealed in paper-plastic pouch packaging (peel pack). Observation revealed no visible internal chemical indicator/integrator. Observation revealed an external chemical indicator/integrator only. Observation revealed a label indicating the instrument was sterilized on 14 July 2014.

Interview during tour of the Surgical OR Suite on 08/07/2014 at 1350 with OR Director #1 revealed the hospital follows AORN standards. Interview revealed there have been changes made with instrument sterilization processes after a visit by Corporate Quality staff in July 2014. Interview revealed prior to the visit the OR staff only used an internal indicator/integrator in paper wrapped instrument packs and in the metal instrument trays. Interview revealed the OR staff did not use an internal indicator/integrator in "peel packs." Interview revealed the OR staff started using a new internal indicator/integrator in peel packs August 1st. Interview revealed a new policy has been developed regarding sterilization of instruments but the policy has not been approved by the Chief Nursing Officer as of 08/07/2014. Interview revealed staff are supposed to be using the new internal indicator/integrator for each peel pack. Interview confirmed the instrument peel packs observed did not contain an internal indicator/integrator. Interview confirmed the staff did not place an internal indicator/integrator in the two instruments peel packs sterilized after August 1st. Interview confirmed the instruments in the peel packs observed were available for staff use.