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.

CATAWBA VALLEY MEDICAL CENTER 810 FAIRGROVE CHURCH RD HICKORY, NC 28602 March 14, 2014
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on observations as referenced in the Life Safety Report of survey completed March 13, 2014, the hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

Building 01
1. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, door to True Beam room requires excessive force to open door in an emergency - force exceeds 30lbf to open door in the closed position. Door is located off corridor near Radiation Therapy.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

2. Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the means of egress from the following area was not assured: a. There are two storage cages located in the pipe access level that are equipped with pad lock that would prevent an individual from exiting the the area if the door was locked.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

Building 02
3. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the exit access is not assured due to the following:
a. The use of momentary contact switch beside doors equipped with special locking arrangements - located near room 3136.
b. The use of momentary contact switch beside door equipped with special locking arrangements - located at smoke barrier between connecting breezeway and existing main hospital.
c. The use of deadbolt locks located above 48 inches from finished floors on doors to the following rooms:
1. Room 3134
2. Room 3136

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038.

Building 04
4. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. A remote fire alarm annunciator panel for the Fire Alarm Control Panel (FACP) was not provided for in the an area where it would be heard in case of emergency during hours of operation.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

5. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. There was not an Emergency HVAC Shutdown switch located in the area for use in case of an emergency.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review, and staff interview, the hospital failed to prevent as needed (PRN) restraint orders for 1 of 3 sampled patients that were restrained (Patient #22).

Findings include:

Review on 03/12/2014 of the hospital policy "Restraints/Restrictive Interventions" (review date 11/27/2013) revealed "PRN and standing orders are prohibited."

An open medical record review on 03/13/2014 for patient # 22 revealed the patient was admitted on [DATE] with a diagnosis of hypertension and abnormal LFTs (Liver Function Tests). The review of the patient's medical records indicated that the patient was restrained in the hospital's critical care unit with bilateral soft wrist restraints on 03/06/2014 through 03/13/2014. Review of a written physicians order on 03/10/ 2014 at 1540 revealed "May apply bilateral wrist restraints" (as needed PRN) that was written as a verbal order by a critical care unit registered nurse that was obtained from a hospital physician. The order was found to be documented on the hospitals "Physicians orders"form.

Interview on 03/13/2014 at 1110 with the critical care unit director revealed that "as needed PRN" restraints should not be written as a restraint order. The interview revealed this patient was restrained on the unit related to a history of "Delirium Tremors" that indicated the need for restraints. The interview also revealed the nursing staff did document the PRN order and should not have done so. The interview confirmed the finding.
VIOLATION: ADEQUACY OF LABORATORY SERVICES Tag No: A0582
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient record review, facility policy review and staff interview, the facility failed to ensure laboratory personnel followed through with a work-up after a patient was identified for a potential blood transfusion reaction for 1 of 2 patient's with a potential blood infusion reaction (#17).

The findings include:

Facility policy review on 03/13/2014 revealed Policy TRM-022 last reviewed 02/05/2013 which stated, "Transfusion of blood and components is ordinarily a safe and effective way to correct hematologic deficits, but untoward results may occur. The time between suspicion of a transfusion reaction and the investigation and initiation of appropriate therapy should be as short as possible. . . Types of Transfusion Reactions: . . . Febrile Non[DIAGNOSES REDACTED] Reaction (FNH) - A FNH reaction is defined by a temperature rise of 1 {degree}C {Celsius}or more occurring in association with transfusion and without any other explanation. . . Evaluation of Suspected Transfusion Reactions: Any adverse symptoms or physical sign occurring during transfusion of blood or its components should be considered as a potentially life-threatening reaction and the following actions must be taken: . . . Report the suspected transfusion reaction to blood bank personnel immediately. The blood bag, administration set and IV solutions must be sent to the Blood Bank along with a copy of the transfusion documentation form. The extent of the work-up depends on the patient's symptoms and the initial findings. . . "

Medical record review for Patient #17 revealed an admission date of [DATE] with diagnoses of [DIAGNOSES REDACTED]. The second unit of PRBCs was started 02/05/2014 at 1845 (6:45 PM). Temperature, blood pressure, pulse, respirations, oxygen saturation level and a pain assessment was conducted at the time of the transfusion initiation. Vital signs were again obtained 15 minutes later at 1900 (7:00 PM). The PRBC transfusion was stopped at 1900 due to a potential transfusion reaction identified by a temperature of 101.5. Vital signs were checked again 15 minutes later at 1915 (7:15 PM). The temperature at 1915 was 98.8.

Review of the nursing documentation for 02/05/2014 at 1900 (created 02/05/2014 at 1942) revealed the RN (registered nurse) documented the elevated temperature, stopped the blood transfusion, notified the physician and administered Tylenol 650 mg (milligrams) per the physician order. Continued review revealed the RN had notified the Blood Bank and "Blood Bank stated to bring blood back to lab."

Interview on 3/14/14 at 1325 with the RN responsible for the blood transfusion revealed the RN had taken the blood bag and tubing to the Blood Bank at the end of her shift. The RN stated the Blood Bank personnel was at dinner. The RN stated the lab personnel told her to leave the blood bag and tubing in the lab and the Blood Bank personnel would pick it up after his break.

Interview on 3/14/14 at 1320 with the Blood Bank Supervisor revealed the Blood Bank did not receive the blood bag and tubing and was not aware of the potential blood transfusion reaction for Patient #17. The Blood Bank Supervisor confirmed a work-up had not been completed for the potential blood transfusion reaction.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review and staff interview, the facility failed to ensure blood transfusions were administered per the facility policy for 2 of 3 patients reviewed that recieved a blood transfusion (#17 and 18).

The findings include:

Facility policy review on 03/13/2014 revealed "PC-121" reviewed/revised 10/14/13, whcih stated, " . . . Transfusion Record: Complete all areas of transfusion record . . . Patient Progress Notes . . . Note: any pertinent information related to the blood administration or via clinical documentation complete patient note for blood/blood component administration. . . Record blood/blood component volume infused . . . record amount of Normal Saline infused. . .Re-check and record vital signs, and observe for signs of blood transfusion reaction - Fifteen minutes after initiation, - One hour after initiation, - At end of transfusion (when blood tubing mostly cleared of product), - 1 hour after transfusion completed . . . "

1. Medical record review for Patient #17 revealed an admission date of [DATE] with diagnoses of [DIAGNOSES REDACTED]. The second unit of RBCs was started 02/05/2014 at 1845 (6:45 PM). Temperature, blood pressure, pulse, respirations, oxygen saturation level and a pain assessment was conducted at the time of the transfusion initiation. Vital signs were again obtained 15 minutes later at 1900 (7:00 PM). The RBC transfusion was stopped at 1900 due to a potential transfusion reaction identified by a temperature of 101.5. Vital signs were checked again 15 minutes later at 1915 (7:15 PM). There was no evidence vital sign assessment was conducted one hour after the PRBC transfusion had been discontinued. There was also no evidence the amount of Normal Saline that had been infused was documented.

Interview with the Blood Bank Supervisor on 03/14/2014 at 1320 confirmed vital signs should be assessed and documented one hour after a blood transfusion is stopped. The Blood Bank Supervisor also confirmed the amount of Normal Saline infused before and after a blood transfusion should be documented.

2. Medical record review for Patient #18 revealed an admission date of [DATE] with diagnoses of [DIAGNOSES REDACTED]. Review of the Transfusion Records revealed the second unit of PRBCs was started on 01/03/2014 at 1340 (1:40 PM) and was completed at 1603 (4:03 PM). There was no evidence a vital sign assessment was conducted one hour post transfusion.

Interview with the Blood Bank Supervisor on 03/14/2014 at 1320 confirmed vital signs should be assessed and documented one hour after a blood transfusion is completed.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Rules and Regulations, hospital policy, closed medical record review, incident review and staff interview the hospital's medical staff failed to ensure a reportable death was referred to the County Medical Examiner for review in accordance with the Medical Staff Rules and Regulation for 1 of 1 patient deaths reviewed (Patient #23).

The findings include:

Review of the hospital's Medical Staff Rules and Regulations revealed "...L. It is the duty of members of the Medical Staff to secure meaningful autopsies whenever possible. The following represent circumstances in which an autopsy should be considered ...3. Unanticipated death ... M. The County Medical Examiner shall be notified of any death that is defined by state law to be a reportable death. The attending physician is responsible for reporting to the hospital administration all deaths that might fall under the purview of the Medical Examiner, prior to seeking autopsy permission from the deceased patient's next of kin. The following types of deaths in North Carolina are to be reported to the Medical Examiner ...12. Sudden unexpected deaths that are not reasonably related to known previous disease ..."

Review of the hospital's Policy "Medical Examiner Cases and Autopsies", review date 05/06/2013, revealed "...for all deaths determined to meet the Medical Examiners' criteria, as determined by the Medical Examiner on duty, the Medical Examiner will complete and sign a Medical Examiner's death certificate...It is the responsibility of the attending physician or the nurse to notify the Medical Examiner..."

Closed medical record review on 03/13/2014 of patient #23 revealed an [AGE] year old female admitted to the facility on [DATE] at 1733 with a diagnosis of [DIAGNOSES REDACTED]"Multiorgan System Failure".

Review of the admitting physician's (Physician #1) History and Physical (H&P) dated 01/26/2012 at 1629 revealed "History of Present Illness:...presents with a complaint of vomiting. The onset of the vomiting has been gradual and has been occurring for 1 week....Diarrhea ...the onset of the diarrhea has been sudden and has been occurring in a persistent pattern for 1 week. The stools are watery. The volume of the stools is small...Past Medical: Diabetes, Hypertension, Osteoporosis, COPD (chronic obstructive pulmonary disease), Esophageal Reflux, heart disease, bowel obstruction. " Review of the listed home medications revealed the patient was currently taking "Coumadin (4mg tablet 1 every day, taken starting 05/17/2011) Active".

Continued review revealed patient #23 was a resident at an Assisted Living Facility. Continued review revealed a list of current medications for patient #23 faxed from the Assisted Living Facility to the hospital on [DATE] at 1705. Review of the list revealed "Warfarin (Coumadin) (blood thinner) 2 mg (milligrams) tabs (tablets) take one tablet orally every day at 4pm".

Review of the "Home Medication Reconciliation/Order" form dated 01/26/2013 at 1815 revealed Coumadin was not listed as a home medication. Continued review revealed the Home Medications order form signed by Physician #1 on 01/26/2012 at 2230. Continued review revealed no physician order for Coumadin. Continued review of the orders dated 01/26/2012 at 2230 revealed no order for PT (prothrombin time) or INR (international normalized ratio) (tests for blood clotting). Review revealed a Physician order for "Lovenox 40 mg subcutaneous daily starting today. If Creatinine Clearance (test kidney function) less than 30 ml/min then pharmacy to decrease dose to 30 mg subcutaneously daily." Continued review revealed Lovenox administered on 01/27/2012, 01/28/2012, and 01/29/2012. Continued review of the orders revealed the Lovenox was discontinued on 01/29/2012 at 1330 due to hemoptysis (coughing blood).

Review of the "Consultation Report" by the Hospitalist (Physician #2) dictated on 01/26/2012 at 2308 revealed "Reason for Consultation: Acute renal failure...PAST MEDICAL HISTORY: diabetes mellitus, coronary artery disease status post - MI (myocardial infarction) and RCA (right coronary artery) stent, diastolic dysfunctional CHF (congested heart failure), [DIAGNOSES REDACTED](A-Fib), GERD (gastrointestinal reflux disease), hiatal hernia, diverticulitis, hypertension ...COPD ...incarcerated internal hernia with ischemic bowel status post-partial small bowel resection ...MEDICATIONS: see home med (medication) list ..." Review of Consulting Physician #2's list of home medications revealed Coumadin was not listed as a home medication.

Continued review revealed on 01/30/2012 at 0433 an INR (international normalized ratio) (tests for blood clotting) greater than 16 (normal 2-3). Review revealed the Critical INR results called to the hospitalist on 01/30/2013 at 0444.

Review of the Pulmonologist (Physician #3) "Consultation Report" dictated 01/31/2012 at 1107 revealed "DATE OF CONSULTATION: 01/30/2012 ...called to see her on a routine basis for scant blood in sputum, question hemoptysis...She was also noted to have an INR greater than 16. On reviewing her notes from the nursing home she was on Coumadin, which was being adjusted by her primary physician. This apparently was on board for a history of atrial fibrillation. She had already been given a dose of vitamin K (helps blood clot) by the time I had arrived ...ASSESSMENT AND PLAN: 1. Hemoptysis. Given the history as noted above this is almost certainly going to be pulmonary edema with subsequent increased risk of hemoptysis due to anticoagulation. The anticoagulation is being reversed but please see note below ...I do recommend she will be transferred to the intensive care unit (ICU) for closer observation, especially nursing care to keep her in bed and give fresh frozen plasma and vitamin K until the INR is well below 4. If she has persistent bleeding recommend reversing anticoagulation until below 1.5...This patient is at very high risk for morbidity and mortality and has very complex problems requiring complex decision making ... "

Review of Physician #1's "Discharge Summary Report" dictated 02/25/2012 at 1749 revealed "date of death : 02/03/2012. PRINCIPLE DIAGNOSES: 1. dehydration 2. nausea 3. vomiting 4. diarrhea 5. history of bowel obstruction. HOSPITAL COURSE: .. admitted with 1-week history of diarrhea and 2 days of nausea and vomiting, not getting any better. She was seen in the office and was actively vomiting in the office as well as having diarrhea. She was clinically dehydrated, and was admitted for IV hydration and further evaluation. Hospitalists were consulted at the time of admission. Medical management was initiated. Electrolytes were depleted. Patient was started on IV antibiotics and IV fluids. The nausea and vomiting resolved. The diarrhea resolved. By hospital day #3, the patient was tolerating clear liquids; however she did not fully recover, and on 01/30 was noted to have hemoptysis and acute blood loss anemia. The patient was transferred to the ICU. Pulmonology was consulted. The patient's INR at this point was greater than 16. The patient's overall condition continued to deteriorate throughout the remainder of her hospital stay and by 02/01 the patient states she just wanted comfort measures only. The family remained at the bedside, and at 0109 on 02/03/2012, the patient expired."

Review revealed "Record of Death" dated 02/03/2012 at 0341 revealed "Criteria for when an autopsy should be considered ...4 Unanticipated deaths ...8. Death in the presence of a perplexing clinical problem ... If there is any question as to whether or not a given case should be investigated by the ME (medical examiner), contact the Office of the Chief Medical Examiner (OCMED) for consultation." Continued review revealed no request for a Medical Examiner review or autopsy.

Review of an incident report dated 01/30/2012 at 1452 for Pt #23 revealed "Coumadin not listed as Home Medication on Pt (patient) (#23) medication reconciliation. Pt. INR checked on Day 4 of admission and greater than 16. Pt. transferred to CCU. Pt had med list from SNF (skilled nursing facility) and Coumadin was listed ...Home med list states meds were taken per pt. Patient also given Lovenox this admission since no one aware she was on Coumadin at home."

Interview on 03/12/2014 at 1615 with the Clinical Pharmacists revealed "If we had known she (Pt #23) was on Coumadin at home we would have followed our protocol and obtained an INR. If the INR was elevated you would not want to start the patient on Lovenox."

Telephone interview on 03/13/2014 at 1515 with Physician #1 revealed he was unable to provide an interview due to "hold harmless clause" from his malpractice insurance carrier advising him not to discuss the medical record without their representative being present.

Telephone interview on 03/14/2014 at 1430 with the Quality Improvement Manager revealed a Record of Death document is completed for all deaths. Attached to the Record of Death document is the criterion for an autopsy and a listing of the types of deaths in North Carolina to be reported to the Medical Examiner. The provider (Physician #1) is responsible for notifying the medical examiner. Interivew confirmed any unexpected deaths should be referred to Medical Examiner to determine if autopsy is necessary.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Medical Staff Rules and Regulations, closed medical record review and staff interview the hospital's medical staff failed to ensure a patients' History and Physical was completed according to the medical staff rules and regulations for 1 of 18 medical records reviewed (Patient #23).

The findings include:

Review of the hospital's Medical Staff Rules and Regulations reviewed and approved by the Board of Trustees on 01/20/2014 revealed "Histories and physical examinations are required... within 24 hours of inpatient admission...F. COMPLETION OF MEDICAL RECORDS:... 1. Medical records...must be completed by the practitioner within twenty-three (23) days after discharge or record will be considered delinquent ...3. If any record remains incomplete on any Tuesday by 30 days or more after discharge, the practitioner's admitting privileges and ability to post surgical/invasive procedure cases is suspended..."

Closed medical record review on 03/13/2014 of patient #23 revealed an [AGE] year old female admitted to the facility on [DATE] at 1733 with a diagnosis of nausea, vomiting, and diarrhea. Continued review revealed the patient expired on [DATE] at 0109. Review of the admitting physician's (Physician #1) History and Physical (H&P) dated 01/26/2012 @ 1629 revealed Physician #1's electronic signature on 04/17/2013 at 1000 (1 year, 2 months, and 14 days after expiration).

Interview on 03/13/2014 at 1440 with the Director of Health Information System revealed physician's are required to complete the patient's medical record within 30 days of the patient's discharge or death. The completion of the record includes physician's signature on the History and Physical. Interview revealed the physician electronically signed the history and physical on April 17, 2013 (1 year, 2 months, and 14 days after expiration). Interview confirmed the history and physical was not completed within 30 days of patient's discharge/expiration as required by the medical staff rules and regulations. Interview confirmed Physician #1 failed to follow the Medical Staff's rules and regulations.

Telephone interview on 03/13/2014 at 1515 with Physician #1 revealed he was unable to provide an interview due to "hold harmless clause" from his malpractice insurance carrier advising him not to discuss the medical record without their representative being present.
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observation during tour and staff interview the hospital staff failed to ensure unauthorized individuals cannot gain access to confidential health information after hours in 1 of 2 off campus outpatient services toured (Outpatient Rehabilitation Center).

The findings include:

Observation during tour on 03/14/2014 of the off-campus Outpatient Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Cardiac Rehabilitation (Rehab) services revealed outpatient medical records stored on a rolling open cart in the staff work area. The cart had two shelves with medical records and did not have a cover or door that could be locked/secured. Observation revealed there was only one door leading into the staff work area. The entrance door had locking capability.

Interview with the Department Manager during tour on 03/14/2014 revealed the department closes each day, Monday through Friday at approximately 1730. Interview revealed the patient's medical records are left on the open cart in the staff work area when the department is closed. Interview confirmed housekeeping, security, and plant operation staff have keys to the door leading into the staff work area. Interview revealed the housekeeping staff is in the building until 2000 and "could enter and access the records". Interview confirmed the patient's protected health information could be accessed by unauthorized individuals.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations as referenced in the Life Safety Report of survey completed March 13, 2014, the hospital leadership failed to have an effective governing body responsible for the functions of the hospital.

The findings include:

The hospital leadership failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross refer to 482.41 Physical Environment - Condition Tag A0700.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations as referenced in the Life Safety Report of survey completed March 13, 2014, the hospital staff failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A-0701

2. The hospital staff failed to assure the safety of patients by failing to ensure emergency power and lighting was provided to critical and appropriate areas of the hospital during outages of normal power.

~Cross-refer to 482.41(a)(1) Physical Environment Standard Tag A-0702

3. The hospital staff failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

~Cross-refer to 482.41(b)(1)(2)(3) Physical Environment Standard Tag A-0710


4. The hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

~Cross-refer to 482.41(b)(9) Physical Environment Standard Tag A-0716
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on policy and procedure reviews, "ServSafe Manager" manual review, observations during tour, and staff interviews, the hospital's dietary staff failed to carry out their respective duties in a competent manner to ensure: safe storage of chemicals and dry food products; refrigerated/frozen leftover foods were labeled, dated, and/or discarded; employee beverages were labeled and stored appropriately; cookware, storage drawers, and serving utensils were cleaned and maintained in a sanitary condition; non-approved food grade materials were not available for use in freezers; and potentially hazardous foods were not available for consumption and were maintained at safe temperatures in the Dietary Department.

The findings include:

Review of current hospital policy "Guidelines for Kitchen Sanitation" Policy No. Nutrition Care-5, dated 07/11/2013, revealed "II. Policy Detail ... 1. Food Supplies a. any food items that are not in sound condition, free from spoilage, filth, or other contamination and safe for human consumption are to be discarded and or returned to the vendor for reimbursement. 2. Food handling and Protection a. all foods are to be kept covered, properly labeled (date, name of product and date the product is good thru) and stored in a sanitary manner. ... 3. Hygiene ... j. employee drinks are allowed only in workstations as outlined in employee drink policy. 4. Sanitation of Equipment and Utensils ... b. need to air-dry all plastic and pots and pans, and do not stack on top of each other wet. ..."

Review of current hospital policy "Employee Beverages In Work Areas" Policy No. Nutrition Care-1, dated 04/18/2013, revealed "II. Policy Detail ... B. PROCEDURES: Nutrition Care Employees are to follow the procedures listed below for personal drinks within the Nutrition Care Department. 1. All beverages must have a lid and employee name on the drink. 2. All drinks must be stored in designated areas of the kitchen listed below: a. Cooks: Bottom shelf below the table where the production sheets are. b. Catering: Bottom shelf below work table away from food. c. Tray line Area: Store on lower shelves within their area on the tray line. ... g. Patient Prep Area: Bottom shelf below slicer."

Review of current hospital policy "HACCP (Hazard Analysis Critical Control Point)" Policy No. Nutrition Care 4, dated 06/17/2013, revealed "B. PROCEDURES: The following list is checked daily by the assigned employee: ... 6. Day Dot System & Dating of Product - All management staff is to make sure all prepared food is discarded after 48 hours. ... All cold food prep for patients has a day dot, and label, and be must [sic] used within the day dot color chart and or within 48 hours of the date. ..."

Review of a "SERVSAFE MANAGER 6th Edition Book," copyright 2012 provided by Dietary Management Staff revealed on Page 2.9 "Chemical Contaminants ... Prevention ... Store chemicals away from prep areas, food-storage areas, and service areas. Chemicals must be separated from food and food-contact surfaces by spacing and partitioning. Chemicals must NEVER be stored above food or food-contact surfaces." Review revealed on Page 5.5 "Packaging ... Damage ... reject cans with labels that are not intact or have bulging or swollen ends, rust, or dents." Review revealed on Page 5.8 "Storing Following good storage guidelines for food and nonfood items will help keep these items safe and preserve their quality. In general, you must label and date mark your food correctly. You must also rotate food and store it at the correct temperature. Finally, you need to store items in a way that prevents cross-contamination. Labeling ... Labeling Food for Use On-site *All items that are not in their original containers must be labeled. ... Date Marking ... ready-to-eat TCS (temperature control for safety) food must be marked if held for longer than 24 hours. It must indicate when the food must be sold, eaten, or thrown out. Ready-to-eat TCS food can be stored for only seven days if it is held at 41 degrees F (5 degrees C) or lower. The count begins on the day that the food was prepared or a commercial container was opened. ..."

Observations during tour on 03/13/2014 from 0950 to 1030 and 1115 to 1230, of the Dietary Department/Main Kitchen revealed:

In the Dry Storage Area(s):
1. Four (4) 67.6 fl. oz. (fluid ounce) containers of Purell hand sanitizer solution stored on a shelf with dry food products. 2. One (1) opened container of Karo Syrup stored on a shelf with syrup residue on the outer container surface. Interview during tour with dietary management staff revealed chemicals are not to be stored with food products. Interview reveal the Purell hand sanitizer is usually stored in the dish room. Interview revealed opened items should not be placed into the dry storage area without being cleaned. Interview revealed spillage is an attraction for pests.

In refrigeration/freezer storage areas:
1. Observation during tour of the walk-in Cook's Freezer #2, revealed shelves with one (1)leftover container of Tomato Basil Soup labeled with a preparation date 02/20/2014 and a use by date of 02/29/2014 (22 days old); one (1) left over container of Beef Stew labeled with a preparation date of 11/11/2013 and a use by date of 01/11/2014 (123 days old); and one (1) left over container of Beef Stew labeled with a preparation date of 11/06/2012 and a use by date of 01/06/2014 (128 days old). One (1) left over container of chicken chili labeled with a preparation date of 12/06/2013 and no use by date (98 days old); and a 4X4 pressure treated wood beam (non-approved food grade material) being used as a ceiling support. 2. Observation during tour of the Cook's Reach-In Refrigerator revealed one (1) opened container of cranberry dressing salad labeled with a preparation date of 03/09/2014 and no use by date (5 days old). 3. Observation during tour of walk-in Produce Refrigerator revealed one (1) opened container of pimento spread with no label indicating a preparation date or use by date. One (1) opened container of French Salad dressing and One (1) opened container of Ranch Salad dressing with dressing residue on the containers' outer surfaces. Further observation revealed One (1) opened container of carrot salad with no label indicating a preparation date or use by date. Interview during tour with dietary management staff confirmed the observations. Interview revealed leftover foods are to be labeled with a preparation date and use by date before being placed into the refrigerator or freezer. Interview revealed left over foods should be used or discarded within 48 hours. Interview revealed the left over foods placed into the cook's freezer were labeled incorrectly. Interview revealed the 4X4 pressure treated wood beam was used to support the freezer ceiling. Interview revealed a work order had been placed to repair the freezer ceiling and to remove the wood beam.

In the Food Preparation areas:
1. One (1) 46 oz. can of Tomato Juice, one (1) 6 lbs. (pounds) 10 oz. can of Mandarin Oranges, one (1) 6 lbs 8 oz. can of York Imperial Apples, being stored on a shelf across from the cook's refrigerator with dents in the cans extending into the can seals. 2. Dry food particle buildup on the inner surface of the microwave located in the salad prep area. 3. Storage drawer containing serving scoops, 2 of 3 scoops observed with dry food particles on the scoop surfaces. 1 of 3 scoops observed with clear liquid on the scoop surface. 4. Storage drawer located near the "Grill" containing cooking utensils with dry food particles on the inner drawer surface. 5. One (1) uncovered 20 oz. cup of ice tea (belonging to a staff member), not labeled, and stored on an upper countertop in food prep area. Interview during tour with dietary management staff confirmed the observations. Interview revealed dented cans should not be stored with undented cans. Interview revealed dented cans are not to be used for patient consumption. Interview revealed dented cans should be removed from stock, to be returned to the supplier or discarded. Interview revealed the microwave and storage drawers should have been free of dried food particle residue. Interview revealed utensils should not be placed into the storage drawer wet, they should be air dried, then stored.

In the Cooking areas:
1. Dry storage rack(s) near triple compartment sink and washing area with plastic cookware/containers being stored for later use to prepare food. Observation revealed visible clear liquids on the outer and inner surfaces of 2 of 5 plastic cookware/containers sampled, 2 of 3 metal pans with grease and dry food particle residue on the inner surface of the pans, and one (1) grease trap/filter with visible grease residue on exterior surfaces. Interview during tour with dietary management staff revealed the cookware on the dry storage racks were considered clean and ready for use. Interview revealed the dietary staff are to inspect the items after being washed, make sure they are clean and air dried before stacking and storing the items on the clean storage racks. Interview confirmed the observations.

On the patient tray serving line:
1. One (1) individual serving of carrot raisin salad on a patient tray. The carrot raisin salad was selected for temperature test. Observation revealed the temperature of the carrot raisin salad (cold food) was 44 degrees (F) Fahrenheit (elevated temperature). Interview during tour with dietary management staff confirmed the temperature of the carrot raisin salad. Interview revealed the carrot raisin salad was for consumption by a patient. Interview revealed the temperature of the carrot raisin salad should have been below 41 degrees F.

On the public/staff cafeteria serving line:
1. One (1) large container of coleslaw. The coleslaw was selected for temperature test. Observation revealed the temperature of the coleslaw (cold food) was 47.5 degrees F. (elevated temperature). Interview during tour with dietary management staff confirmed the temperature of the coleslaw. Interview revealed the coleslaw was available for consumption by the public and staff. Interview revealed the temperature of the coleslaw should have been below 41 degrees F.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, open and closed medical record review, incident report review, and staff interview, the hospital staff failed to investigate an adverse patient event, analyze the cause and implement corrective actions for 1 of 5 patients receiving Coumadin (#23).

The findings include:

Review of the hospital's policy "Incident Documentation and Risk Management Reports" original date 05/16/1982 with last review/revised date of 04/2012 revealed, "...B. Risk Management Reports: 1. The purposes of Risk Management Reports are: (1) to provide information to enhance the quality of patient care and assist in providing a safe environment for that care; (2) to provide a method to identify and report all unusual and/or unsafe conditions within the facility; and, (3) to provide a record of the event and a means for an investigation of cause(s). The report is NOT to place blame on individuals ...7. Once submitted, the completed report is forwarded immediately by the Risk Management reporting system to the Department Manager/Director (or designee) for review, investigation and corrective action. Documentation of proper information in the medical record and completeness of the report will also be verified by the Manager/Director. 8. The Department Manager/Director will complete the appropriate sections in the Risk Management reporting system and will close the case. The Director of Risk Management and/or Risk Analyst will review for completeness and for trending purposes. Additional corrective action will be initiated as necessary. 9. The Director of Risk Management and/or Risk analyst will refer cases to additional departments for follow-up when warranted. 10. Referrals to the Medical Staff about the event will be made via a Case Review Worksheet ..."
Review of the hospital's policy "Sentinel Event/Significant Medical Error Investigation" original date 05/15/1998, (no revised dates) review date of 01/09/2012 and 10/28/2013 revealed "POLICY: (Name of facility) will provide a process for investigating sentinel events and significant medical/health care error or undesirable trends in performance. DEFINITIONS: A. For the purposes of this policy, a 'sentinel event' is defined as an unexpected occurrence, involving death or serious physical or psychological injury, or the risk thereof, not related to the natural course of the patient's illness or underlying condition. Serious injury specifically includes major permanent loss of limb or function not related to the natural course of the patient's illness or underlying condition. The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Specific events addressed by this policy, whether or not they result in death or major permanent loss of function, include: ...B. For the purposes of this policy, 'significant undesirable performance or variation' includes the following circumstances...3. Performances that varies significantly and undesirably from recognized standards C. 'significant medical/health care errors' includes...2. Significant preventable adverse drug reactions (ADRs) and significant medication errors (ADEs) ... POLICY DETAIL: A. when a sentinel event occurs, a root-cause analysis (RCA) will be conducted. When a significant medical/health care error or undesirable trend in performance is identified and intense analysis will be performed. The completion of a thorough root cause analysis or intense analysis will be completed within 45 days of the event or the discovery of the event. E. The root cause analysis will: ...focus on systems and processes, not on individual performance ...identify changes that could be made in systems and processes, through either redesign or development of new systems or processes, that would improve the level of performance and reduce the risk of a particular serious adverse event occurring in the future; and result in an action plan. F. The action plan will: identify strategies that the organization intends to implement to reduce the risk of similar events occurring in future; and address responsibility for implementation, oversight, time lines, and strategies for measuring the effectiveness of the actions ...G...15. Provide reports to senior leadership and others as indicated ..."

Closed medical record review on 03/13/2014 of patient #23 revealed an [AGE] year old female admitted to the facility on [DATE] at 1733 with a diagnosis of [DIAGNOSES REDACTED]"Multiorgan System Failure".

Review of the admitting physician's (Physician #1) History and Physical (H&P) dated 01/26/2012 at 1629 revealed "History of Present Illness:...presents with a complaint of vomiting. The onset of the vomiting has been gradual and has been occurring for 1 week....Diarrhea ...the onset of the diarrhea has been sudden and has been occurring in a persistent pattern for 1 week. The stools are watery. The volume of the stools is small...Past Medical: Diabetes, Hypertension, Osteoporosis, COPD (chronic obstructive pulmonary disease), Esophageal Reflux, heart disease, bowel obstruction." Review of the listed home medications revealed the patient was currently taking "Coumadin (4mg tablet 1 every day, taken starting 05/17/2011) Active".

Continued review revealed patient #23 was a resident at an Assisted Living Facility. Continued review revealed a list of current medications for patient #23 faxed from the Assisted Living Facility to the hospital on [DATE] at 1705. Review of the list revealed "Warfarin (Coumadin) (blood thinner) 2 mg (milligrams) tabs (tablets) take one tablet orally every day at 4pm".

Review of the "Home Medication Reconciliation/Order" form dated 01/26/2013 at 1815 revealed Coumadin was not listed as a home medication. Continued review revealed the Home Medications order form signed by Physician #1 on 01/26/2012 at 2230. Continued review revealed no physician order for Coumadin. Continued review of the orders dated 01/26/2012 at 2230 revealed no order for PT (prothrombin time) or INR (international normalized ratio) (tests for blood clotting). Review revealed a Physician order for "Lovenox 40 mg subcutaneous daily starting today. If Creatinine Clearance (test kidney function) less than 30 ml/min then pharmacy to decrease dose to 30 mg subcutaneously daily." Continued review revealed Lovenox was administered on 01/27/2012, 01/28/2012, and 01/29/2012. Continued review of the orders revealed the Lovenox was discontinued on 01/29/2012 at 1330 due to hemoptysis (coughing blood).

Review of the "Consultation Report" by the Hospitalist (Physician #2) dictated on 01/26/2012 at 2308 revealed "Reason for Consultation: Acute renal failure...PAST MEDICAL HISTORY: diabetes mellitus, coronary artery disease status post - MI (myocardial infarction) and RCA (right coronary artery) stent, diastolic dysfunctional CHF (congested heart failure), [DIAGNOSES REDACTED](A-Fib), GERD (gastrointestinal reflux disease), hiatal hernia, diverticulitis, hypertension ...COPD ...incarcerated internal hernia with ischemic bowel status post-partial small bowel resection ...MEDICATIONS: see home med (medication) list ..." Review of Consulting Physician #2's list of home medications revealed Coumadin was not listed as a home medication.

Continued review revealed on 01/30/2012 at 0433 an INR (international normalized ratio) (tests for blood clotting) greater than 16 (normal 2-3). Review revealed the Critical INR results called to the hospitalist on 01/30/2013 at 0444.

Review of the Pulmonologist (Physician #3) "Consultation Report" dictated 01/31/2012 at 1107 revealed "DATE OF CONSULTATION: 01/30/2012 ...called to see her on a routine basis for scant blood in sputum, question hemoptysis...She was also noted to have an INR greater than 16. On reviewing her notes from the nursing home she was on Coumadin, which was being adjusted by her primary physician. This apparently was on board for a history of atrial fibrillation. She had already been given a dose of vitamin K (helps blood clot) by the time I had arrived ...ASSESSMENT AND PLAN: 1. Hemoptysis. Given the history as noted above this is almost certainly going to be pulmonary edema with subsequent increased risk of hemoptysis due to anticoagulation. The anticoagulation is being reversed but please see note below ...I do recommend she will be transferred to the intensive care unit (ICU) for closer observation, especially nursing care to keep her in bed and give fresh frozen plasma and vitamin K until the INR is well below 4. If she has persistent bleeding recommend reversing anticoagulation until below 1.5...This patient is at very high risk for morbidity and mortality and has very complex problems requiring complex decision making ... "

Review of Physician #1's "Discharge Summary Report" dictated 02/25/2012 at 1749 revealed "date of death : 02/03/2012. PRINCIPLE DIAGNOSES: 1. dehydration 2. nausea 3. vomiting 4. diarrhea 5. history of bowel obstruction. HOSPITAL COURSE: ...Patient was started on IV antibiotics and IV fluids. The nausea and vomiting resolved. The diarrhea resolved. By hospital day #3, the patient was tolerating clear liquids; however she did not fully recover, and on 01/30 was noted to have hemoptysis and acute blood loss anemia. The patient was transferred to the ICU. Pulmonology was consulted. The patient's INR at this point was greater than 16. The patient's overall condition continued to deteriorate throughout the remainder of her hospital stay and by 02/01 the patient states she just wanted comfort measures only. The family remained at the bedside, and at 0109 on 02/03/2012, the patient expired."

Review of an incident report dated 01/30/2012 at 1452 for Pt #23 revealed "Coumadin not listed as Home Medication on Pt (patient) (#23) medication reconciliation. Pt. INR checked on Day 4 of admission and greater than 16. Pt. transferred to CCU. Pt had med list from SNF (skilled nursing facility) and Coumadin was listed ...Home med list states meds were taken per pt. Patient also given Lovenox this admission since no one aware she was on Coumadin at home."

Interview on 03/12/2014 at 1615 with the Clinical Pharmacist revealed "If we had known she (Pt #23) was on Coumadin at home we would have followed our protocol and obtained an INR. If the INR was elevated you would not want to start the patient on Lovenox." Continued interview revealed Coumadin is identified as one of the high risk medications and the Pharmacist assists the physician in dosage adjustments based upon INR lab results. Continued interview revealed all incidents involving medications are to be referred to pharmacy for evaluation and follow up. Continued interview revealed the pharmacy was unaware of the incident involving Coumadin for patient #23. Interview confirmed the facility failed to investigate an adverse patient event, analyze the cause and implement corrective actions.

Interview on 03/13/2014 at 1235 with the Nursing Director of the Surgical Unit revealed the incident report involving Coumadin for patient #23 was filed by the Care Coordinator of the CCU after patient #23 was transferred to that unit and it was discovered by the nursing staff the patient's home medication reconciliation was incomplete. Continued interview revealed there was a list of the patient's home medications faxed from the assisted living facility. The home medications included "Coumadin" which the patient was taking on a daily basis. Interview revealed the admission RN failed to list Coumadin as one of patient #23's home medication. Continued interview revealed the Director spoke with the admission RN regarding the omission and reminded her to "be more careful". Interview confirmed no additional follow up or action by the Nursing Director of the Surgical Unit. Interview confirmed the facility failed to investigate an adverse patient event, analyze the cause and implement corrective actions.

Interview on 03/13/2014 at 1315 with the Director of Risk Management revealed the incident involved the omission of Coumadin from patient #23's list of home medications. Interview revealed the incident had been referred to the Surgical Unit Nursing Director for investigation and follow-up. Interview revealed the Risk Manager was not involved in the investigation or follow-up. Interview revealed the incident was not referred to pharmacy for investigation or follow-up. Interview revealed the investigation by the Surgical Unit Nursing Director was considered complete and the file was closed. Interview revealed an intense analysis was not completed. Interview confirmed the facility failed to investigate an adverse patient event, analyze the cause and implement corrective actions.

Interview on 03/13/2014 at 1500 with Administrative Staff revealed Coumadin is listed as "High Risk, High Alert Medication. Continued interview revealed the incident was not referred for Medical Peer Review.

Telephone interview on 03/13/2014 at 1515 with Physician #1 revealed he was unable to provide an interview due to "hold harmless clause" from his malpractice insurance carrier advising him not to discuss the medical record without their representative being present.

Interview on 03/14/2014 at 1430 with the Quality Improvement Manager revealed all incidents involving medication are forwarded to Pharmacy for investigation and follow-up. Interview revealed the incident involving Coumadin for Patient #23 was not sent to pharmacy for investigation or follow-up. Interview confirmed the facility failed to investigate an adverse patient event, analyze the cause and implement corrective actions.
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
Based on observations as referenced in the Life Safety Report of Survey completed March 13, 2014, the hospital staff failed to assure the safety of patients by failing to ensure emergency power and lighting was provided to critical and appropriate areas of the hospital during outages of normal power.

The findings include:

Building 01
1. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, there is no emergency lighting for rear exit discharge of MRI Unit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

2. Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
a. By observation exit discharge illumination was observed as noncompliant: specific findings include that the facility could not verify that all exit discharge lighting was connected to emergency power. Lighting must be arranged to provide light from the exit discharge leading to the public way. The walking surfaces within the exit discharge shall be illuminated to values of at least 1 ft-candle measured at the floor. Failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candles in any designated area. NFPA 101 7.8.1.1, 7.8.1.3, and 7.8.1.4.
b. Exit discharge illumination was not provide for at the Same Day Surgery stairwell door.
c. Exit discharge Illumination was not provided for at the ambulance parking bay rear corridor exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

3. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, exit and directional signs are incomplete due to the following:

a. Lack of exit sign at intersecting corridors - located on first floor area leading to Oncology Unit.

b. Lack of exit directional sign for ninety degree corridor area leading from MRI to Day Surgery.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

4. Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
a. Exit and directional signage was not provided in the corridor located outside plant operations located on lower level to the stairwell located outside sterile processing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.

5. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, the emergency power system is noncompliant due to the following:
a. Staff interviews revealed improper load testing of emergency power system. There was no loss of normal power to automatic transfer switches of the essential electrical system during scheduled thirty minute load test as required by NFPA 99.
b. Emergency power system required greater than ten seconds to restore power during loss of normal power to emergency system transfer switches.
c. During initial test of emergency power system, there was no power restored to critical care areas of hospital after over 90 seconds of elapsed time.
d. Life Safety Branch lighting systems can be switch off by wall mounted corridor light switch - located in service corridor leading to main electrical switchgear room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 106.

Building 02
6. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the essential electrical system is incomplete due to the following:

a. LS Branch panelboard ELW3 contains a smoke guard system not permitted on the Life Safety Branch of the essential electrical system - located in Pavilion electrical room on third floor.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 106.

Building 03
7. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, exit discharge lights connected to emergency power source are not functioning at exit discharges.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

Building 04
8. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. The wall pack emergency lights located in the front corridor and one at the front entrance when tested did not operate.
b. Emergency lighting was not provided for in the main area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 046.

9. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. An emergency exit directional sign is needed in the main area leading individuals to the rear exit stairwell.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 047.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations as referenced in the Life Safety Report of Survey completed March 13, 2014, the hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

The findings include:

Building 01
1. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the door to critical care waiting room is less than forty inches in width. Door is approximately thirty six inches - located in Critical Care South Unit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

2. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, vertical chases are incomplete due to the following:
a. Unsealed penetrations in chase located in pharmacy area.
b. Fire curtain obstructed to tray conveyor chase - located on lower level pharmacy by tray cart.
c. Lack of guardrail protection at each floor level of tray conveyor chase.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 020.

3. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, hazardous areas are incomplete due to the following:
a. Lack of sprinkler(s) for volunteer storage room - room exceeds 100 square feet in area. room is located on first floor.
b. The trash room door located in the kitchen was not self closing.
c. The dry storage room door was held open preventing the door from closing.
d. The corridor door to sterile processing (L057) lower level did not have positive latching.
e. The door to material management storage room was not a rated door.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

4. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, exits are not assured due to the following:
a. Incomplete electromagnetic locking arrangement on exit access door from PACU to OR corridor - system installed is not equipped with motion sensor as required for access controlled egress door.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

5. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, the fire alarm system audible/visual signaling devices did not function properly during test - units in third floor corridor did not function at the same time.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

6. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, sprinkler coverage was incomplete due to the following:
a. In the material management storage room (Lower Level) the lower duct works was blocking the overhead sprinkler head.
b. The facility utilizes Special Locking devices on required egress/exit doors - The facility is basically 100% sprinklered with the following exceptions:
By observation sprinkler heads were missing in the following areas;
1. Morgue Shower room
2. Rear Kitchen walk-in refrigeration units
3. Electrical closet in kitchen next to cookline.
4. Mechanical room, kitchen area next to rear entrance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 056.

7. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, maintenance of the automatic sprinkler system is incomplete due to the following:
a. Heat sensitive element of pendent sprinkler is covered by lint and debris - located in ED waiting area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

8. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the seventh floor laundry chute was not verified to have a sprinkler installed at the top of the chute.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

9. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, sprinkler tamper alarm incomplete due to the following:
a. The sprinkler tamper alarm located on 6th floor north stairwell was equipped with an unapproved tamper alarm.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

10. Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the mechanical systems are noncompliant due to the following:
a. Nonlisted mechanical duct used at ceiling level in main dining room - the material doesn't meet UL duct classifications required in health care facilities.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

11. Based on observation, on March 11, 2014 at approximately 2:30 PM onward, the following deficiencies were noted:
a. On the cook lines there is an oven and other equipment cooking equipment located on the cook line that were not properly located under the hood.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 069.

12. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, there are exposed element, high temperature portable space heaters used in the following areas:
a. Office beside fastrack area on first floor.
b. Pharmacy office
c. VP office located in administration area.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 070.

13. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, the means of egress clearance is incomplete due to the following:

a. Impediments by mechanical equipment in floor area to MRI - located beside anesthesia on call room.

b. Impediments in means of egress - corridor area near TrueBeam room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 072.

14. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the fifth floor respiratory department had nitrous oxide cylinders that were not individually chained.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 076.

15. Based on observation, on March 12, 2014 at approximately 2:00 AM onward, the facility electrical system is incomplete due to the following:

a. Lack of weatherproof receptacle with ground-fault interrupter protection for outlets serving Lipo Truck - located beside MRI exit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

16. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the document review noted that the NCDOL inspection report on 3/4/2014 had incomplete items including: cleaning oil from the car top and stop the leak at the drive machine.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 160.

Building 02
17. Based on observation, on March 13, 2014 at approximately 1:45 PM onward, there is a gap between the meeting edge of the inactive and active door leafs to room #260.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 018.

18. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the call room number 3134 does not have sprinkler pass through mesh at the top of the shower curtain.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 202.

19. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, there are no smoke damper installed in the ductwork that penetrate the smoke wall above the cross corridor doors that lead into the "C" section suite.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 104.

Building 03
20. Based on observation, on March 13, 2014 at approximately 2:00 AM onward, there is no fireproofing of structural beams supporting steel deck - located above gas fired boiler room.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

21. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, exit discharge is incomplete to the publicway - side exit located near front entrance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032.

22. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, the facility fire alarm system is incomplete due to the following:
a. Lack of labeling of normal power circuit breaker serving the main fire alarm control panel - circuit and panelboard must be identified on fire alarm control panel.
b. Lack of smoke detector located in vicinity of main fire alarm control panel.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 051.

23. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, there is no service access opening for fire dampers located between boiler room and adjacent spaces - dampers are located in mechanical ducts at rated wall penetrations.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 067.

24. Based on observation, on March 13, 2014 at approximately 5:00 AM onward, there are no knockout covers for missing circuit breakers in electrical panelboard GRB.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 147.

Building 04
25. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. The corridor door to the oxygen/storage room located on the rear exit hall was not self closing.
b. The mechanical room room corridor door located on the rear hall by stairwell was not self closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 029.

26. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. The stairwell corridor door located next to the mechanical room did not close and latch and was dragging on the floor preventing the door from closing.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 034.

27. Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the third floor call room number 3134 does not have the proper mesh on the shower curtain that will allow proper sprinkler cover for that space.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.

28. Based on observation on March 13, 2014 at approximately 6:00 AM onward the following deficiencies were noted:
a. The underground pit for the sprinkler backflow preventer that is also equipped with electronically supervised tamper alarms did not have a drain or other methods to keep the pit dry or from being flooded. At the time of the survey there was approximately 6 inches of water in the pit.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 062.
VIOLATION: ALCOHOL-BASED HAND RUB DISPENSERS Tag No: A0716
Based on observations as referenced in the Life Safety Report of survey completed March 13, 2014, the hospital staff failed to ensure that alcohol based hand rub (ABHR) dispensers were located away from an ignition source.

The findings include:

Building 01
Based on observation, on March 11, 2014 at approximately 1:45 PM onward, the fifth floor small nurses station chart area near room 522 had an alcohol based hand rub dispenser installed over an ignition source the light switch in that area.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K 211.