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.

Based on review of policies and procedures, the hospital's grievance and complaint log and selected grievance/complaint files, the hospital failed to ensure grievances were investigated, resolved promptly, and the required information was provided in the hospital's written response. This occurred in three (Grievances # 12, 13, and 14) of four grievances/complaints selected for review.


1. Although the hospital's grievance policy provided the correct definition for grievance, the explanation of a complaint provided confusing information.

The hospital's definition for grievances was that any concern raised "...which cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation and/or requires further actions for resolution.

The hospital's definition for complaint included, "...a patient concern that is resolved within 24 hours of notification of patient issue, or post-hospital verbal communication which could have been handled the same day if staff had been made aware of the complaint at the time of the incident."

2. Grievance #14 had been classified as a complaint and no written response of the resolution was provided to the complainant. This finding was reviewed with Staff C on 08/22/14.

3. Grievances 12, 13 and 14 did not contain evidence of the steps taken to investigate the patient's concerns. Although complaint # 13 was still within the hospital's specified time frame for resolution (30 days), there was no documentation that any investigation had been conducted. The surveyors asked Staff C to see the investigation that had been completed. None was provided to the surveyors to review.

4. Grievance #12 - the written response, dated 06/28/14, provided to the complainant did not contain all the required information and did not address all of the concerns. On 07/01/14 the complainant called and stated the hospital did not address all the concerns. Written communication between staff indicated that the hospital would document and reopen the complaint as a new grievance. There was no evidence this was done. This finding was reviewed and confirmed with Staff C on the afternoon of 08/22/14.
Based on observation, staff interviews and review of hospital documentation, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases, to provide a safe and sanitary environment and minimize infections and communicable diseases in patients and staff.


1. The infection control practitioner has not ensured that infection control policies and procedures have been developed and followed for each unit/area of the hospital. (Refer to Tag A-748)

2. The disinfectants used throughout the hospital have not been reviewed and approved by the hospital's Infection Control committee through the quality program. (Refer to Tag A-749)

3. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

4. Surgical practices are not reviewed to ensure they reflect current infection control standards and safe practice, including surgical procedures offered on the obstetrics unit.

5. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases.

6. Leadership does not ensure infection control concerns and issues, or lack thereof, are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).
Based on surveyors' observations, hospital document review and interviews with staff, the hospital failed to ensure the infection control preventionist (ICP) assured hospital wide infection control policies were implemented and monitored.


1. While the infection control manual contained a form identified as a risk assessment for 2014, it did not include a review of the organisms most prevalent and likely to be incurred in the hospital and community. This identification would be needed in determining if the correct disinfectants were chosen for hospital staff use.

2. The infection control manual did not contain policies and procedures for obstetric surgical attire and cleaning. The surveyors asked if there were policies and procedures addressing this. None was provided.

When the surveyors toured the cesarean section area of the obstetrics unit on 08/20/14, the surveyors were only asked to put on isolation gowns and Staff P told the surveyors that nursing staff did not change to clean hospital laundered scrubs, but only put on the yellow isolation gowns over their scrubs worn on the unit. She told the surveyors that the patient's "significant other" could be present and would either put on an isolation gown or "bunny suit" over his/her "street clothes".

3. Review of the infection control surveillance activities did not demonstrate the ICP monitored all departments to ensure infection control policies and procedures and practices were followed.
Based on review of hospital documents, meeting minutes, and infection control activity/surveillance reports, surveyor observations, and staff interviews, the hospital failed to ensure the infection control preventionist (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment.


1. Deficient infection control practices observed by the surveyors on 08/20/14, of the surgical services areas had not been identified by the infection control program. Observations include, but not limited to:

a. The surveyors observed three laryngoscope blades and an LMA endotracheal tube with guidewire were laying dry in a sink. Staff L told the surveyors that although the instruments/equipment had been used earlier, he had not cleaned or processed the equipment. The instruments were not kept wet and secretions were allowed to dry on the instruments.

b. "Flash" autoclave logs showed entire instrument sets were being processed by the shortened cycle for use. Staff S stated this was done because they were only "cleaned" the day before and were not sterilized through a full autoclave cycle because it was the end of the day.

c. Obstretical staff observed in the cesarean section room were not wearing appropriate surgical attire.

d. Refer to Tag A-940.

2. The meeting minutes did not demonstrate review, analysis with plans of action when needed, and follow-up to ensure corrective actions implemented were effective. Infection control committee meeting agendas and minutes for 2013 and 2014 contained documentation of problems and concerns, but no meeting minutes addressed these concerns. Under the heading "Action", most of the time the only thing written was "Information only." This finding was reviewed and verified with Staff C.

a. Meeting minutes did not demonstrate analysis of employee, contract staff, physician and allied health illness and infections to ensure infections and diseases were not transmitted between patients and staff.

b. Meeting attachments recorded hospital acquired infections, but the minutes did not reflect the infections were analyzed to determine if policies or practices need to be revised or if educational opportunities needed to be instituted. For example:

i. Meeting minutes for 10/23/13 recorded daily orders for Clostridium difficile cultures, but the patient were not put into contact isolation until the results were obtained. There was no follow-up of this documented concern/problem.

ii. Meeting minutes for 04/23/14 recorded the ICU was using HCG wipes to clean patients instead of soap and water in effort to decrease hospital acquired infections on the unit. There was no follow-up to determine if the plan of action was effective.

c. "Flash" cycles were reported, but the reasons for the "flash" cycles were not identified; reviewed; analyzed to determine whether this was the recommended sterilization for each type of instruments processed this way; or plan of action recorded to decrease used. (This was not documented in any of the evidence provided to the surveyors for review.)
Based on observation, hospital document review and interview with hospital staff, it was determined the hospital failed to provide surgical services (OR) in accordance with acceptable standards of practice.


The surgical suite was toured on the morning of 08/20/14, with Staff D, E, H, I, P and Q.

A sign posted on the entry into the surgical suite stated, "Proper attire beyond this point".

Staff D stated the entry corridor of the surgical suite is unrestricted.

A nurses station was centrally located in the corridor. From the nurses station the endoscopy, cystoscopy and the semirestricted corridors were able to be seen.

An area adjacent to the nurses station contained wall mounted oxygen and suction available for patient use. Staff D stated that area is not used for patient care.

The area was used for storage. There was various items in this area such as; corrugated boxes, a bedside table and fabric cubicle dividers.

There was no physical barriers to prevent dust and other particles from the storage area from entering into the semirestricted corridor of the surgical suite.



Two endoscope rooms were located inside the unrestricted area of the surgical suite.

Two endoscope rooms were on a shared corridor with the cystoscopy surgical room.

The cystoscopy portion of the corridor is semirestricted. The endoscopy portion of the corridor is unrestricted. A red line across the floor in the shared corridor was used to designate the semirestricted from the unrestricted area.

Corrugated boxes were observed on the floor by the endoscope rooms. There was no barrier to prevent particles from the boxes entering the semirestricted area.

The endoscope decontaminate room did not contain two utility sinks. This was confirmed by Staff D during the tour.


Red lines across the floor was used to designate the unrestricted, semirestricted and restricted areas of the surgical suite.

No handwashing sink in the central sterile decontaminate and processing rooms.

Acoustic ceiling tile in the central sterile decontaminate room.

Acoustic ceiling tiles in the semirestricted area of the OR .

A wheeled fabric briefcase was seen in the semirestricted area of the OR. Staff D stated the briefcase belonged to a surgical company representative (rep).

Two different reps were observed in the semirestricted area, one carried a fabric backpack and the had a fabric messenger bag across his shoulder.

Staff O was seen entering the restricted area of the OR wearing earrings, that were uncovered, a wrist watch and several bracelets.

The door from the substerile room adjacent to OR #8, leading into the adjoining OR was propped open during a surgical case.

Corrugated boxes were seen in the central sterile supply room and central sterile processing room.

Blood splatter was seen on the floor in the unrestricted area by OR #3.

Cesarean-Section Suite:

A red line across the floor was used to designate the semirestricted from the unrestricted area.

Acoustic ceiling tile in the semirestricted area.

A fabric chair in C-Section room #1.

A fabric lounge in the semirestricted area.

Staff S was observed in the C-Section room #2 without the required surgical attire.

There was no evidence, with the exception of instrument sterilization, that the Cesarean-Section suites were incorporated into the hospitals surgical department. This was confirmed by Staff C, D, E and P.


"Flash" (unwrapped) sterilization:

Prevention and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 550 through 553, 2012 edition) Recommends that flash sterilization should be kept to a minimum. Flash sterilization should not be used as a substitute for sufficient instrument inventory. Sterilization records should include information on each load, including; the items processed; the patient receiving the item; the cycle parameters (eg, temperature, duration of cycle); the date and time cycle is run; the operator information; and the reason for flash sterilization.

Review of a hospitals policy titled, Flash Sterilization, documented, "...Flash Sterilization shall be done under the following circumstances: Emergency situation during a procedure in which an instrument is contaminated and there is no replacement item. An implantable device which the manufacturer recommends flashing only. Flash sterilization shall not be done on a routine basis unless indicated as in previous two items..."

The hospital's statistical data documenting the number of loads processed using steam, Sterrad and flash sterilization from February 1 through July 31, 2014 was reviewed on August 22, 2014.

The data revealed the hospital flashed six-hundred and ten loads during a six month time span.


During the tour Staff D stated the housekeeping staff mopped the floors in the surgical suite at the end of the surgery day.

The janitors closet for the housekeeping staff is located in the unrestricted area. The janitors closet was unkept. There was a hole in the wall and the base board. The walls were also marred with black scuff marks.

The unrestricted corridor by the janitors closet, contained plastic bags filled with mop heads, red biohazard bags, that contained additional red biohazard bags and two covered plastic carts. One cart contained clean linens and the other cart contained cleaning products.
Based on policy and procedure review and staff interview, it was determined the hospital failed to maintain current policies and procedures for the surgery department.


On 08/20/14, the hospital was asked to provide the surgery department policies and procedures.

Review of the policies revealed the Cesarean Section (C-Section) suites are not included as part of the surgical department.

There was no policies and procedures for surgical attire and cleaning for the C-Section suites. This was confirmed by Staff C on the afternoon of 08/22/14.