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.

MARSHFIELD MEDICAL CENTER 611 ST JOSEPH AVE MARSHFIELD, WI 54449 Nov. 3, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility staff failed to provide Medicare eligible patients the second IMM notice within 2 days of discharge from the hospital in 8 of 18 (Pt. #7, 8, 13, 43, 44, 47, 48, and 49) MR's reviewed out of a total universe of 46 MR's reviewed.

Findings include:


Per review on 10/28/2014 at 10:30 a.m. of pt. #7's MR revealed hospitalization dates of 7/30/14 through 8/2/2014. The first IMM was signed on 7/30/2014. There was no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Per review on 10/28/2014 at 1:05 p.m. of pt. #8's MR revealed hospitalization dates of 9/10/2014 through 9/13/2014. The first IMM was signed on 9/10/2014. There was no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Per review on 10/28/2014 at 3:10 p.m of pt. #13's MR revealed hospitalization dates of 9/22/2014 through 9/27/2014. The first IMM was signed on 9/23/2014. There was no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

The findings for pt. #7, 8, and 13 were verified with Dir PCS S at time of record review.





Pt. #43's MR, reviewed on 10/28/2014 at 1:35 p.m., contains a signed IMM on the date of admission of 5/30/2014. Pt. #43 was discharged on [DATE], there is no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Pt. #44's MR, reviewed on 10/28/2014 at 2:15 p.m., contains a signed IMM on the date of admission of 9/8/2014. Pt. #44 was discharged on [DATE], there is no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Pt. #47's MR, reviewed on 10/28/2014 at 3:00 p.m., contains a signed IMM on the date of admission of 8/17/2014. Pt. #47 was discharged on [DATE], there is no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Pt. #48's MR, reviewed on 10/28/2014 at 3:05 p.m., contains a signed IMM on the date of admission of 9/6/2014. Pt. #48 was discharged on [DATE], there is no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

Pt. #49's MR, reviewed on 10/28/2014 at 3:10 p.m., contains a signed IMM on the date of admission of 8/7/2014. Pt. #49 was discharged on [DATE], there is no documentation that the facility delivered a follow up IMM within 48 hours of discharge.

The findings for Pt's. #43, #44, #47, #48 and #49 were verified at the time of the review with MD CC.

Per review on 10/28/14 at 4:15 p.m. of policy titled, "Issuance of the Important Message from Medicare", policy number: 740.04.04, dated 5/20/2013 stated under 1.c. "Case Management will explain and obtain the patient's signature (or that of his/her representative) within 48 hours or as near to discharge as possible and return the original document to the patient's medical record."

In an interview with Dir of Patient Care Services (PCS) S on 10/28/2014 at 10:30 a.m., Dir PCS S was unaware of the current practice.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the facility failed to modify the patient plan of care to reflect the use of restraints in 1 of 1 restrained patients (Pt. #44) out of total of 46 MR reviewed.

Findings include:

Pt. #44's MR, reviewed on 10/28/2014 at 2:15 p.m., revealed the use of restraints for medical necessity on Pt. #44 from 7:50 p.m. on 9/9/2014 to 3:50 a.m. on 9/10/2014. Pt. #44's plan of care does not include documentation related to the use of restraints.

Facility policy "Restraints, Use of on All Patient Care Units" #607.00.01 dated 3/19/2014, reviewed on 10/28/2014 at 2:45 p.m. does not address modification of the patient plan of care in conjunction with the use of restraints.

Per interview with Dir F on 10/29/2014 at 9:45 a.m., Dir F did not know if staff had been educated to update the care plan when using restraints on a patient.

Per interview with Mgr T on 10/29/2014 at 11:00 a.m., Mgr T was not aware whether or not staff was expected to reflect the use of restraints on a patient's plan of care.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the facility staff failed to reassess patients pain after pain medication was provided in 8 out of 20 MRs of patients with documented pain (pt. #6, 10, 11, 13, 16, 17, 18, and 43) out of a total of 46 MRs reviewed.

Findings include:


Per review on 10/28/2014 at 9:15 a.m. of pt. #6's MR revealed on 8/26/2014 between 11:01 PM and 12:00 a.m. a Tylenol 650 mg was given for mild pain. Documentation indicated between 1:01 a.m. and 4:00 a.m. "nonverbal signs absent, sleep". Respiratory rate was documented as 12 between 12:01 a.m. and 1:00 a.m. but quality was not recorded.

Per review on 10/28/2014 at 1:50 p.m. of pt. #10's MR revealed on 9/16/2014 at 12:02 p.m. Oxycodone 10 mg was given for mild pain. No indication noted that pt. was sleeping, respiratory rate was documented at 2:49 p.m., quality was not recorded. At 3:00 p.m. pain was re-assessed as mild. At 10:00 p.m. a medication was given. At 11:59 p.m. documentation indicated "nonverbal signs absent, sleep". Respiratory rate and quality was not evaluated. On 9/19/2014 at 2:00 a.m. a pain medication was given, at 4:00 a.m. documentation indicated "sleep". Respiratory rate and quality was not evaluated. On 9/22/2014 at 8:00 p.m. pain medication, oxycodone 5 mg was given, at 10:00 p.m. documentation indicated "nonverbal present, sleep". Respiratory rate and quality were not assessed.

Per review on 10/28/2014 at 2:25 p.m. of pt. #11's MR revealed on 7/14/2014 at 8:14 p.m. pain medication, acetaminophen, 650 mg was given for mild pain. At 10:00 p.m. documentation indicated "nonverbal signs absent, sleep". Respiratory rate and quality was not evaluated. On 7/15/2014 at 10:07 p.m. pain medication, acetaminophen 650 mg was given for mild pain. At 10:07 p.m. documentation indicated"nonverbal absent, sleep". Respiratory rate and quality were not evaluated.

Per review on 10/28/2014 at 3:10 p.m. of pt. #13's MR revealed on 9/26/2014 at 9:37 p.m. pain medication, acetaminophen 650 mg was given for mild pain. At 11:47 p.m. documentation indicated "nonverbal absent, sleep". Respiratory quality was not evaluated.

The findings for pt. #6, 10, 11, and 13 were verified with Dir PCS S at time of record review.





A MR review was conducted on Pt. #16's closed OB MR on 10/28/2014 at 10:35 a.m. accompanied by RN AA and PI Specialist J who confirmed the findings during the MR review. Pt. #16 was given pain medication on 7/14/2014 at 3:40 a.m. Pain was not reassessed until 8:00 a.m.

A MR review was conducted on Pt. #17's closed OB MR on 10/28/2014 at 10:50 a.m. accompanied by RN AA and PI Specialist J who confirmed the findings during the MR review. Pt. #17 was given pain medication on 9/11/2014 at 3:45 a.m. Pain was not reassessed until 8:25 a.m. On 9/12/2014 Pt. #17 was given pain medication at 8:40 p.m. There was a physical assessment documented at 9:15 p.m., however pain was not assessed during this time and there was no other pain reassessment to coincide with the intervention.

A MR review was conducted on Pt. #18's closed OB MR on 10/28/2014 at 11:20 a.m. accompanied by RN AA and PI Specialist J who confirmed the findings during the MR review. Pt. #18 received pain medication on 8/22/2014 at 10:00 a.m. Pain was not reassessed until 5:15 p.m.





Pt. #43's MR, reviewed on 10/28/2014 at 1:35 p.m., lacks pain assessment documentation between 5/30/2014 at 6:07 p.m. and 6/1/2014 at 8:00 a.m. Pain medications were administered on 5/30/2014 at 9:00 p.m. There is no documentation of a pain assessment or respiratory rate and quality on 5/30/2014 between 9:00 p.m. and 11:00 p.m. Pain medications were administered on 5/31/2014 at 9:00 a.m. There is no documentation of a pain assessment or respiratory rate and quality on 5/31/2014 between 9:00 a.m. and 11:00 a.m. Pain medications were administered on 5/31/2014 at 9:00 p.m. There was no documentation of a pain assessment or respiratory rate and quality on 5/31/2014 between 9:00 p.m. and 11:00 p.m.

The findings for Pt. #43 were verified with MD CC at the time of the review.

Per interview with Dir of Patient Care Services (PCS) S on 10/28/2014 at 10:00 a.m., Dir PCS S stated the policy changed in July of 2014 however the staff is to be completing re-assessments within two hours of pain medication being given, and if patient is sleeping respiratory rate and quality needs to be evaluated and documented.

Per review on 10/28/2014 at 1:30 p.m. of policy titled Standards of Care for Pain Management: Acute and Ambulatory Care, policy number 902.10.05, dated 7/14/2014 stated under III. D. "Reassess and document effectiveness of interventions on the pain flow sheet. 1. Reassess the patient following prn analgesic administration once a sufficient time as elapsed for the treatment to reach peak effect, not to exceed every 2 hours. E.1. If the patient is asleep after being medicated with prn analgesics, the nurse may use discretion to not awaken the patient as long as the respiratory status is WNL for the patient. Respiratory assessment will include rate and quality of respiration. Assess/reassess once a sufficient time has elapsed for medication to reach peak effect, not to exceed 2 hours. a. If respiratory status is WNL (within normal limits) and the patient does not demonstrate any behavioral signs of pain, document "nonverbal signs absent" for pain rating, document "sleep" on the sedation scale, and respiratory rate and quality on the pain flowsheet."
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observation and interview, the facility failed to ensure patient identifiable information was kept secure to maintain confidentiality in 1 of 2 areas where patient records are stored on nursing unit 7 North. This deficiency has the potential to affect all patients who received care on nursing unit 7 north.

Findings include:

During a tour of nursing unit 7 North on 10/27/14 at 12:45 PM, accompanied by Pt Care Manger FF, in the equipment storage room at the end of the hall, noted 9 boxed and 2 plastic crates which contained documents that included the patient name and room number were observed.

Per interview with Pt Care Manger FF at the time of discovery, FF stated that the boxes and crates contained past census sheets. Pt Care Manager FF stated the equipment storage room is not locked and is not monitored at all times.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on record review and interview, the facility failed to ensure all orders are dated, timed and authenticated in 17 out of 34 (pt. #6, 7, 8, 10, 11, 12, 13, 21, 23, 25, 26, 30, 31, 43, 44, 48, and 49) MR's out of a total of 46 MR's reviewed.

Findings include:

The Medical Staff Rules and Regulations, dated December 18, 2013, were reviewed on 10/28/2014 at 9:30 a.m. The Rules state in part on page 10, #27. Standing (Routine) Orders, "A Practitioner's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record and subject to the usual dating, timing, and authentication requirements....C. General Conduct of Care, #2. Verbal/Telephone Orders, "Inpatient verbal/telephone orders must be authenticated within 48 hours of receipt. The signature must include the date and time of the signature."

Per review on 10/28/2014 at 10:00 a.m. of policy titled, "Physician Orders", policy number: 902.05.01, dated 7/9/2013, under 9., "All orders must include date, time, signature, and, title/credentials." Under D. 6. a., "A provider needs to sign the telephone order and document the date and time of the signature within 48 hours of the telephone order being written."

In an interview with Dir of Patient Care Services (PCS) S on 10/28/2014 at 10:00 a.m., Dir of Patient Care Services (PCS) S stated, "Physicians should be signing, dating and timing telephone order within 48 hours of the order being written."

Per review on 10/28/2014 at 9:15 a.m. of pt. #6's MR revealed a telephone order (TO) written on 8/24/14 at 9:30 a.m. authenticated by physician without a date or time. TO written on 8/24/14 at 10:10 p.m. was not signed by a physician. TO written on 8/24/2014 at 10:40 p.m. was not signed by a physician. TO written on 8/25/2014 at 10:05 a.m. was not signed by a physician. TO written on 8/25/2014 at 12:09 p.m. was not signed by a physician.

Per review on 10/28/2014 at 10:30 a.m. of pt. #7's MR revealed TO's written 7/31/2014 at 2:55 p.m. and 8/1/2014 at 7:35 a.m. and were signed by a physician dated 8/11/2014 at 2:30 p.m. Physician order written on 8/2/2014 was not timed.

Per review on 10/28/2014 at 1:05 p.m. of pt. #8's MR revealed an order written on 9/12/14, no time is documented.

Per review on 10/28/2014 at 1:50 p.m. of pt. #10's MR revealed orders written on 9/21/2014 at 8:30 a.m., 9/16/2014 at 2:15 p.m., and 3:30 p.m. were not signed by a physician.

Per review on 10/28/2014 at 2:25 p.m.of pt. #11's MR revealed orders written on 7/11/2014 at 10:10 a.m. was not signed by physician. TO's written on 7/1/2014 at 7:30 p.m. and 11:00 p.m. were signed by a physician dated 8/11/2014 at 1:10 a.m.

Per review on 10/28/2014 at 2:50 p.m. of pt. #12's MR revealed an order written on 7/16/2014 at 12:45 p.m., signed by a physician dated 8/1/2014.

Per review on 10/28/2014 at 3:10 p.m. of pt. #13's MR revealed orders written on 9/23/2014 at 4:35 p.m.and on 9/25/2014 3:20 p.m. were not signed by a physician.

The findings for pt. #6, 7, 8, 10, 11, 12, and 13 were verified with Dir of PCS S at time of record review.






Review on 10/28/14 at 11:10 a.m. of Pt #23's, accompanied by Dir of Quality CC who confirmed the findings during the record review. MR revealed verbal orders written by the RN on 7/8/14 at 8:20 a.m., 9:10 a.m., 9:50 a.m., 10:50 a.m., 12:30 a.m. and 12:50 a.m. These orders were not authenticated by the physician until 9/15/14 at 10:52 a.m. Dir of Quality CC confirmed the findings during the record review.

Review on 10/28/14 at 1:30 p.m. of Pt #25's, accompanied by Dir of Quality CC who confirmed the findings during the record review, MR revealed telephone orders written by the RN on 7/15/14 at 9:30 p.m.. These orders were not authenticated by the physician until 8/14/14 at 6:00 p.m.

Review on 10/28/14 at 2:00 p.m.of Pt #26's, accompanied by Dir of Quality CC who confirmed the findings during the record review, MR revealed telephone orders written by the RN on 7/22/14 at 1:07 p.m. These orders were not authenticated by the physician until 8/25/14 at 5:00 p.m.





A MR review was conducted on Pt. #21's closed NB MR on 10/28/2014 at 12:15 p.m. accompanied by RN AA and PI Specialist J who confirmed the findings during the record review. Pt. #21 has a Standing Physician Order Set for the NB nursery which was initiated by the RN on 8/20/2014 at 3:00 p.m. The MD's signature on the last page of the order set does not include a date or time for when it was signed.

A MR review was conducted on Pt. #30's closed NICU MR on 10/28/2014 at 1:30 p.m. accompanied by RN Supvr II, Dir M and PI Specialist J who confirmed the findings during the record review. Pt. #30 has pre-printed MD orders for neonatal transport that were initiated as a TO. There is no date and time accompanying the MD's signature for when these orders were authenticated.

A MR review was conducted on Pt. #31's closed NICU MR on 10/28/2014 at 2:17 p.m. accompanied by RN Supvr II, Dir M and PI Specialist J, who confirmed the findings during the record review. Pt. #31 has a Standing Order set for admission to the NICU that was initiated by the RN. There is no date or time accompanying the MD's signature on page 2 of the order set for when these orders were authenticated.





Pt. #43's MR, reviewed on 10/28/2014 at 1:35 p.m., contains a telephone order on 6/1/2014 at 8:00 a.m. The order is signed by the physician without a date or time.

Pt. #44's MR, reviewed on 10/28/2014 at 2:15 p.m., contains a telephone order for restraints on 9/9/2014 at 7:50 p.m., a telephone order on 9/10/2014 at 4:11 a.m., and telephone orders on 9/12/2014 at 4:15 p.m. and 5:00 p.m. These orders are not authenticated by a physician's signature.

Pt. #48's MR, reviewed on 10/28/2014 at 3:05 p.m., contains telephone orders on 9/8/2014, 9/9/2014 and 9/10/2014. These orders are not authenticated by a physician's signature.

Pt. #49's MR, reviewed on 10/28/2014 at 3:10 p.m., contains telephone orders on 8/8/2014 and 8/9/2014. These orders are signed by the physician on 8/22/2014, more than 48 hours after the telephone orders were obtained.

The findings for Pt. #43, 44, 48, and 49 were verified with MD CC at the time of the review.
VIOLATION: SECURE STORAGE Tag No: A0502
Based on observation, record review, and interview this facility failed to ensure that 1 of 1 emergency carts on the Pediatric unit was locked which had the potential to affect all 20 patients.

Findings include:

During a tour of the Peds unit on 10/27/2014 at 12:15 p.m. accompanied by PI Dir K and Peds RN Supvr L, the emergency medication cart was found to have a break away lock that was not intact. This finding was witnessed by Dir K and Supvr L.

Review of the assignment sheets for the 3 days prior to the survey, where documentation of the emergency cart checks is captured, revealed that the cart was not checked on the night shift of 10/25/2014 or 10/26/2014.

In an interview with Supvr L at the time of this finding, Supvr L stated that the expectation on this unit is that the emergency cart is checked every shift. Supvr L did not know when the emergency cart was last used and stated that it should have been checked on the night shift but it was not documented.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, the facility failed to ensure biologicals were appropriately removed and not available for use for patients after the biologicals expiration date in1 of 5 patient care rooms observed in the ED (Rm #14).


On 10/27/14 at 12:20 PM an observation ED room #14 accompanied by RN, Patient Safety Manager Staff B, and ED RN, Staff Manager Staff C in an upper supply cabinet there was a 2 fluid ounce Povidone Iodine scrub care antiseptic bottle open/used/expired as of 09/14, a 4 fluid ounce bottle of Hydrogen Peroxide 3% solution open/used/expired as of 04/14, and an 8 fluid ounce bottle of Chlorhexidine Guconate 4% solution antiseptic open/used and unable to visually read entire expiration date.

These observations were verified by RN, Patient Safety Manager Staff B, and ED RN, Staff Manager Staff C at the time of discovery.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, record review and interview, this facility failed to maintain equipment to ensure the safety of patients and staff as evidenced by, 1. The dialysis unit staff failed to follow facility policy regarding temperature setting limits and reporting malfunctions in 1 of 1 blanket warming machine located in the dialysis room, and 2. 1 of 1 blanket warmers in the OB unit-cesarean section corridor, does not have a thermostat to monitor the temperature. This deficiency could have potentially affected the 8 patients who were scheduled to receive dialysis treatment on 10/28/2014, there were no patients undergoing cesarean section at the time of the observation.

Finding include:

Per review on 10/28/2014 at 7:30 a.m. of policy titled Blanket Warmers: Temperature, Maintenance and Cleaning, policy number 902.07.03, dated 10/18/2013 stated in part under I. A. The temperature setting on blanket warmer cabinets is limited to 130 degrees Fahrenheit.

Per observation on 10/27/2014 at 8:00 a.m. of a blanket warmer in the Dialysis Unit, signage on door indicated temperature setting should not exceed 130 degrees. Temperature dial was noted to be set at 170 degrees. Temperature gauge indicated a temperature of 220 degrees. Findings were confirmed with Contracted Dialysis Facility Administrator (DFA) N and Dir of Patient Care Services S during the observation.

Per interview with DFA N on 10/28/2014 at 8:00 a.m. DFA N stated "I don't know why it would be set at a higher temperature, it must have been bumped. The staff should be monitoring the temperatures daily."





A tour of the OB unit was conducted on 10/27/2014 at 1:15 p.m. accompanied by PI Dir K and OB Mgr M. It was observed that the blanket warmer in the corridor outside of the cesarean section OR did not have a thermostat and the temperatures were not being monitored.

In an interview with Mgr M at the time of the observation, Mgr M stated that they are aware a thermostat is needed and there is a proposal for a new one.
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation, record review and interview this facility failed to monitor temperatures of food refrigerators and freezers in the nursing department kitchenettes of 7 of 10 kitchenettes observed (3 North (N), 5N, 7N, 8N, Rehabilitation unit, OB and Peds). Failure to monitor refrigerator/freezer temperatures in patient care areas has the potential to affect all patients in the facility, including the 259 (averaged) patients present during the on-site dates of the survey.

Findings include:

Facility policy "Managing Food Safety" #502.04.26 dated 5/14/11 states in part: "4. Temperatures of all refrigeration and freezer units are recorded twice daily. Readings below or above the allowed range are reported to the supervisor...Temperature charts are maintained in the directors office for one year." This policy was reviewed on 10/28/2014 at 11:00 a.m.

Review on 10/28/2014 at 11:00 a.m. of policy "Storage of Patient Food In Floor Refrigerators and Temperature Record Keeping" #502.04.13 dated 7/18/11 documents the following procedure for temperature monitoring: "3. Each refrigerator/freezer is monitored by a log tag that is placed in each unit. The log tag is reviewed by FNS [Food & Nutrition Services] staff when stocking. A red alarm light will also pulsate if the temperature falls outside the appropriate range. Any staff observing this red light should report the problem to facilities management for repair. All log tag information will be downloaded and reviewed every month..."

During an observation of the nursing unit 3N on 10/27/2014 at 11:45 a.m., there was no temperature log available for the 3N kitchenette refrigerator.

During an observation of the nursing unit 8N on 10/27/2014 at 3:30 p.m., the temperature log of the 8N kitchenette refrigerator revealed the temperature had last been documented on 9/1/2014. During an interview with Mgr H at the time of the observation, Mgr H stated that dietary staff is responsible for maintaining the temperature log of the refrigerator.

Dir Z confirmed during an interview on 10/28/2014 at 10:05 a.m. that dietary staff is responsible for refrigerator temperatures on the floors. Dir Z stated that daily refrigerator temperatures had not been documented due to the use of refrigerator "log tag" system that had been implemented on the nursing unit food refrigerators. The log tags are an automated monitoring device that is housed within the refrigerator. The log tags monitor the temperature every 30 minutes and are green when temperatures are within pre-set limits. If the refrigerator temperature rises above set thresholds every 30 minutes 3 times, the log tag turns red. Both dietary staff and nursing staff on the floors are trained to report if a log tag is observed to be red when using the refrigerator.

Dir Z further stated that it was decided not to pursue daily manual monitoring of the refrigerator temperatures with the log tag system.





During observation of the refrigerator for patient use on the nursing unit 5N on 10/27/2014 at 12:15 p.m., Director of Patient Care Services (DPCS) S stated unit staff do not monitor the refrigerator temperatures.

Per observation of the refrigerator for patient use on the rehabilitation unit with DPCS S on 10/27/2014 at 1:30 p.m., there was no record of refrigerator temperatures.





During a tour of nursing unit 7N on 10/27/14 at 12:45 p.m. the refrigerator for patient use was observed to not have a temperature log. In an interview with Pt Care Manager FF at the time of observation, FF stated unit staff do not monitor the refrigerator temperatures and that it is the responsibility of Food Services Department.





A tour of the Peds unit was conducted on 10/27/2014 at 12:15 p.m. accompanied by PI Dir K and Peds RN Supvr L who confirmed the following observation: In the kitchenette refrigerator Supvr L (per interview completed during the observation) stated that the log tag for temperature monitoring is read one time per month by the kitchen staff, the breast milk refrigerator is not currently being monitored with the same system; and both refrigerators began daily manual temperature recording on the day of the observation (10/27/2014), prior to this day nothing has been recorded.

A tour of the OB unit was conducted on 10/27/2014 at 1:15 p.m. accompanied by PI Dir K and RN Mgr M, who confirmed there were no temperatures recorded on the log for the kitchenette refrigerator until the day of observation.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interview, this facility failed to ensure staff followed proper hand hygiene in 8 out of 19 observations (Staff A, E, N, O, Q, R, W, BB); failed to maintain a clean and sanitary environment in 16 of 25 facility departments toured (Peds, PICU, OB, Dialysis, OR, 3N, 5N6N, 7N, 8N, Sterile Processing, GI Lab, Laundry, Kitchen, MICU and ED); failed to ensure window curtains in patient care areas were clean, and failed to develop a policy specific to kitchen employee illness. These deficient practices had the potential to afafect all patients receiving care in this facility. The average census was 259 during the survey.

Findings include:

Observations of failed Hand Hygiene/glove use:
On 10-27-2014 at 1:20 p.m., accompanied by MD WW, who confirmed the following observation, PT A was observed going into pt. #1's room. PT A entered the room without performing hand hygiene (HH). PT A completed a therapy session with pt. #1 that included assisting pt. #1 with leg exercises, touching pt., and touching personal property in room. PT A finished the session and left the room without performing HH. PT A was asked when is HH performed, PT A explained when PT A returns to the office that is when hands are washed.

On 10/27/2014 at 12:15 p.m. RN E failed to perform hand hygiene prior to entering Pt. #2's room for medication administration. These findings were discussed with Mgr I who stated during an interview on 10/27/2014 at 12:20 p.m. that all staff is expected to perform hand hygiene upon entering and exiting a patient's room and that signage is posted outside each patient room to serve as a reminder to staff.

During an observation of the inpatient dialysis unit on 10/28/2014 at 8:10 a.m. RN O initiated hemodialysis for Pt. #3 on Station 4. During the initiation, RN O removed gloves after cleaning Pt. #3 dialysis port and donned a clean pair of gloves at 8:20 a.m. RN O failed to perform hand hygiene after removing gloves and prior to gloving. At 8:25 a.m., RN O secured the arterial line to the Pt. #3's port, removed gloves and donned a clean pair of gloves. RN O failed to perform hand hygiene after removing gloves and prior to gloving. At 8:29 a.m., RN O removed gloves and donned a clean pair of gloves without performing hand hygiene. RN O failed to perform hand hygiene after removing gloves and prior to gloving a total of 3 times during the initiation of Pt. #3's hemodialysis.

On 10/28/2014 at 8:45 a.m., DFA N responded to Pt. #3's machine alarm at Station 4. DFA N failed to wear gloves while touching the dialysis machine to address alarm.

On 10-28-2014 at 11:05 a.m. RN W was observed in pt. #4's room performing wound care on pt. #4's left foot. After completing the removal of the old dressing RN W performed hand hygiene, donned new gloves, set up supplies to pack the wound, moved pt. #4's drinking cups out of the way on the bedside table. Then RN W opened a pair of sterile gloves and put them on over the dirty gloves and proceeded to pack the wound. During an interview on 10/28/14 at 11:45 a.m. the above observation was described to Infection Control RN X. RN X was asked if that was a acceptable practice, RN X stated, "No, it was not. [RN W] should have removed the dirty gloves, performed HH and then put on new gloves."

During an interview with DFA (Dialysis Facility Administrator) N on 10/28/2014 at 8:35 a.m., when asked about the appropriate times to perform hand hygiene in relation to glove changes, DFA N stated "I would have to refer to the policy" for guidance on when to perform hand hygiene.

On 10/28/2014 at 10:15 a.m. an observation of MD BB performing a circumcision on Pt. #15 was completed. After prepping Pt. #15's genitalia with betadine, MD BB removed BB's clean gloves and applied sterile gloves without performing hand hygiene in between.

In an interview with IP X on 10/29/2014 at 7:34 a.m., IP X stated that the expectation in the above scenario would be for the MD to have performed hand hygiene between the glove changes.

The dialysis provider's policy "Infection Control in the Hospital Dialysis Setting" #7-03-01 dated September 2014 was reviewed on 10/28/2014 at 8:45 a.m. In regards to personal protective equipment, the policy states "9. Gloves should be worn when: ...Touching the blood lines, dialyzer or dialysis deliver system during or after a dialysis treatment..."

On 10-27-2014 at 4:20 PM a review of P&P titled Infection Control- Handwashing/Hygiene, #606.01.25, dated 4-23-2014 was completed. The P&P states in part, "D. When should hands be decontaminated with an alcohol based handrub: 1.When entering a patient's room. 6. After contact with a patient's intact skin. 9. After removing gloves, sterile or non-sterile, or other personal protective equipment. At a minimum, hands must be decontaminated upon entering and when leaving the patient's room."

Per review of the facility's contracted dialysis provider's policy "Hand Hygiene" #7-03-02 dated April 2013 on 10/28/2014 at 8:45 a.m., the policy states in part: "Hands will be washed...prior to gloving, after removal of gloves..." The policy goes on to state: "Alcohol-based hand rubs may be used: ...before gloving and after glove removal, and may be used if the gloves...have had no exposure to or contact with blood or other potentially infectious materials"





Observations of failed Clean and Sanitary Environment:

Peds:
A tour of the Peds unit was conducted on 10/27/2014 at 12:15 p.m. accompanied by PI Dir K and Peds RN Supvr L. The following observations were made and confirmed at the time of discovery by Dir K and RN L:

Rm 351: a series of reddish colored dots were found on the metal casing of an overbed lift in an empty room that RN L indicated had been cleaned by housekeeping. These dots were easily removed by RN L with a paper towel. In an interview with RN L during the tour, L stated that upon discharge, "The housekeeper should clean all surfaces in the room."

Rm 355: The vinyl covering on a reclining chair seat was not intact rendering it uncleanable.

Rm 361: There is a small patch of exposed drywall in the bathroom above the toilet creating a porous and uncleanable surface.

PICU:
A tour of the PICU was conducted on 10/27/2014 at 1:00 p.m. accompanied by PI Dir K and Peds RN Supvr L, and joined by Dir TT. The following observations were made and confirmed at the time of discovery by Dir K and RN L and Dir TT:

In a hallway desk drawer outside of Rm 333 there was an empty food container and plastic bag of Doritos. RN L stated these should not be there.

In the double room at the end of the hall, a curtain separation of the two bed area was observed and behind the curtain in the second bed was 4-5 IV poles with brain boxes (the mechanical portion of the IV monitor) being stored . These monitors were not tagged as being cleaned and were not covered. Dir TT agreed with this observation.

OB:
A tour of the OB unit was conducted on 10/27/2014 at 1:15 p.m. accompanied by PI Dir K and RN Mgr M. The following observations were made and confirmed at the time of discovery by Dir K and Mgr M:

Rm 237: The bathroom sink was found to have a chalky white residue with black flecks in it. The room was unoccupied and indicated to have been cleaned by housekeeping.

The patient refrigerator identified as BC R#2 [birth center refrigerator number 2] had a brown sticky substance on the bottom outside the lowest shelves. Mgr M stated that the Food and Nutrition department is responsible for the refrigerator.

Rm 242: The bathroom vent has a significant build up of dust on the louvers. The previous patient was discharged on [DATE].

Cesarean Section room-The cabinet with packaged supplies that is on the wall behind the anesthesia machine had the sliding door left open after the terminal clean.




The facility's policy titled, "Discharge and Transfer Cleaning," policy number 503.30.75 dated 3/25/10, was reviewed on 10/28/2014 at 7:15 a.m. The policy states in part, "After all items have been removed, disinfect the entire room starting at the right hand side of the room and moving around the entire room."

Per review on 10/28/2014 at 7:30 AM of policy titled Cleaning Guidelines, policy number 503.30.10, dated 9/2/2011 stated in part under 2. High Dusting (Monday and Thursday) 2. The high duster tool is to remove dust that is above shoulder height. This includes pictures, TV's, vents, light fixtures, ceiling corners, drapery rods, equipment, etc. The policy also details cleaning expectations of the housekeeping staff throughout the entire hospital including patient rooms and kitchenettes located on the nursing floors.

Inpatient Dialysis:
Per observation on 10/28/2014 at 8:10 a.m. of RN O initiating dialysis through a central venous catheter for pt. #3. RN O wore mask under nose throughout the process of disinfecting dialysis catheter limbs, removing caps and hooking up to tubing of blood lines.

Per interview with Dialysis Facility Administrator (DFA) N on 10/28/2014 at 8:45 a.m., DFA N was asked the expectation of the staff when wearing a mask during initiation of dialysis through a catheter, DFA N stated "whatever the policy says".

Per interview with Dialysis Clinical Care Specialist (DCCS) P on 10/28/2014 at 8:50 a.m., DCCS P stated the staff should be wearing the mask pinched at the bridge of the nose.

Per review on 10/29/2014 at 12:30 p.m. of email from Dir of Patient Care Services (PCS) S stated "The hospital does not have a specific policy regarding donning of a mask. An exposure plan in the infection control manual states the following: Masks and goggles or face shields must be worn whenever splashes, sprays, spattering or droplets of blood/body fluids may be generated. A mask must be worn to protect the mucous membrane of the nose and mouth".

5N:
Per observation on 10/27/2014 at 12:45 p.m. of clean supply room on 5 North, layer of dust noted in ceiling air vents. This was confirmed by Dir of Patient Care Services S at the time of the observation.





OR:

On 10/27/14 at 2:15 p.m. observed EVS assistant RR set a suction canister containing pink tinged body fluids, on the floor, in the clean corridor outside of OR 4. EVS assistant RR stated "I will put that (meaning the canister) in a red bag after I finish cleaning." Per interview with Dir of Peri-op DD at the time of observation, DD stated that the canister should have been bagged prior to removing it from the OR.

Per review of facility policy on 10/28/14 at 3:35 p.m., titled " Housewide Handling and Disposal of Regulated Infectious Waste" # 503.20.60 dated 9/20/12, states "All identified infectious waste will be handled in the following manner: a. Place in RED thick 2 mil bag ... b. Tie SECURELY ... d. Take waste to a dirty utility room or designated area for pickup.

Review of "Operating Room Suites" log on 10/28/14 at 4:00 p.m. revealed the following:
OR room 2 was not project cleaned in January, March, May, July or September 2014.
OR room 3 was not project cleaned in February, May, July, August or September 2014
OR room 4 was not project cleaned in January, February, March, June, July or September 2014.
OR room 5 was not project cleaned in January, February, or July 2014.
OR room 6 was not project cleaned in February, June, July or August 2014.
OR room 7 was not project cleaned in February, July, August or September 2014.
OR room 8 was not project cleaned in February, July, or September 2014.
OR room 9 was not project cleaned in February, March, May, or August 2014.
OR room 10 was not project cleaned in January, February, June, July, August, or September 2014.
OR room 12 was not project cleaned in February, July, or September 2014.
OR room 13 was not project cleaned in January, March, or July 2014.
OR room 14 was not project cleaned in February, March, May, June, August, or September 2014.
OR room 15 was not project cleaned in January, February, April, May, June, July or September 2014.

Review of facility policy on 10/27/14 at 3:20 p.m. titled "Surgical Cleaning Procedure - Project Cleaning Operating Room, Etc." # 503.40.30 dated 8/2010 states "To properly project clean all operating rooms suites in the Surgical Area. Frequency: Monthly... 3. Wash walls and ceilings with disinfectant cleaner solution using wall washer kit."

Per interview with Director of Peri-op DD on 10/28/14 at 7:10 a.m., DD stated they follow AORN standards of practice and recommends monthly cleaning of OR walls and ceilings.

Per interview with EVS assistant RR on 10/27/14 at 2:00 p.m., RR stated walls and ceilings should be done monthly but are not being done due to being short staffed.

During an interview with Dir Y on 10/28/2014 at 11:25 a.m., Dir Y stated that operating rooms are terminally cleaned daily and undergo "project cleaning" monthly. Project cleaning includes an extensive clean of the walls, ceiling and lighting tracks. The floor is flooded and "super scrubbed" as part of this process. When asked about scheduling the rooms that are due to be project cleaned, Dir Y stated there wasn't a set schedule due to the use of rooms in the OR. Per Dir Y, housekeeping staff is responsible to coordinate project clean with OR staff monthly.

On 10/27/14 at 2:20 p.m., a cautery cart was observed to be missing paint with areas of rust causing a porous non-cleanable surface, in OR 4. Dir of Peri-op DD stated, at the time of discovery, that carts should be repainted or replaced.

On 10/28/14 at 8:45 a.m., two cleaned arm boards in OR room labeled CV1 were observed to be stored on the floor. Per interview with Surgery Manager SS, at the time of discovery, SS stated the arm boards should not be kept on the floor.


7 North:
On 10/27/14 at 12:20 p.m. during a tour, accompanied by Med Dir of Quality CC, observed holes and gouges in the walls in room across from the Pyxis (medication dispensing unit) where clean supplies are stored; and holes and gouges in walls in Pyxis room across from room 721.

Sterile Processing:
On 10/27/14 at 2:50 p.m. three wheeled carts were observed to have areas of rust on them in the sterile processing area. Central Services Manager EE stated, at the time of discovery, two new carts have been ordered to replace those currently in use.

GI Lab:
During a tour of GI lab on 10/27/14 at 1:00 p.m., observed clean suction canisters being stored under the sink in GI lab room # MC3.A16. Per interview with RN GG at the time of discovery, GG stated the canisters are for patient use. Also observed clean supplies stacked/stored on countertops and open shelving. Per RN GG at the time of discovery, clean supplies are not wiped down/cleaned between patient cases and would not be able to be cleaned during the terminal cleaning process.





Laundry:
During an observation of the laundry room on 10/28/2014 at 11:50 a.m., ceiling pipes and laundry hoyers (lifts) were completely covered in a dense layer of dust over the clean linen area. The grates of an industrial sized fan that was not in use in the washer room was obstucted by dust.

An Environmental Services work schedule, revised 1/14/2007, lists the dryer area, where there is clean linen, of the laundry area to be cleaned daily. Under the section for the dryer, the work schedule states, "Make sure you put on clean dust mop and dust the ceilings and walls weekly. The pipes and vents must be kept clean."

During an interview with Dir Y on 10/28/2014 at the time of the observation, Dir Y stated that staff "routinely" air blows the laundry facilities to prevent the build up of dust and debris in the clean linen area. Dir Y stated that the cleaning of the laundry room is not scheduled, but is done as needed. Dir Y could not say when the last time the surfaces in the clean linen area had been "air blown." Dir Y was unable to produce a policy in regards to cleaning expectation in the laundry room.

Main Kitchen:
Per review on 10/28/2014 at 10:30 a.m. of facility policy "Managing Food Safety" #502.04.26 dated 5/19/11, the policy states in part: "5. Products are routinely rotated...Any items over the expiration date are discarded."

Per review on 10/28/2014 at 10:30 a.m. of facility policy "Storing Foods Under Refrigeration" #502.04.04 dated 8/3/12, the policy states in part: "7. ...during daily usage, check the date on the container and discard outdated items."

Facility policy "Food Service Sanitation" #502.04.19 dated 5/19/11 states under "Food Storage", "All foods in storage must be covered, labeled and dated." Under "Food Preparation", "Scoops, spoons, etc. are not to be left inside containers of food." This policy was reviewed on 10/28/2014 at 10:30 a.m.

ServSafe 2013 recommendations for staff illness in the kitchen are as follows: food handlers with sore throat and fever should be excluded from working with or around food; food handlers with diarrhea OR vomiting should be excluded from working with or around food and should not return to work until there is an absence of symptoms for at least 24 hours OR there is a written release from a medical practitioner.

Observations during a tour of the kitchen on 10/28/2014 at 9:05 a.m. include the following items in dry storage: an unlabeled, undated container of dry rice with scoop and handle submerged in the rice; opened, undated bags of pasta (5); opened, undated bag of rice; multiple open, undated containers of spices. The freezer contained an unsealed, unlabeled, undated bag of hot dogs and an unsealed, undated bag of sirloin steaks. The kitchen refrigerator contained opened, undated bags of shredded cheese (2); packages of deli roast beef (3) with an expiration date of 10/26/2014 and a carton of potato salad with an expiration date of 10/22/2014.

Dir Z stated that the scoop and handle "should not be" placed in the rice container and further confirmed at the time of the findings that all expired foods should be discarded and that open foods are expected to be labeled and dated.

When inquired about illness protocols for work restrictions, Food Service Worker KK stated during an interview on 10/28/2014 at 10:55 a.m. that it would be okay to return to work when the diarrhea or vomiting is "done." Food Service Worker LL stated during an interview on 10/28/2014 at 11:00 a.m. that it is okay to return to work when "feeling better" and was not aware of any guidelines as to when it would be appropriate to return to work after having diarrhea or vomiting.

During an interview with Dir Z on 10/28/2014 at 10:05 a.m., Dir Z stated that ill kitchen staff are expected to call a phone number to report symptoms. The phone number is for all hospital employees and symptoms are tracked. Per Dir Z, there are no specific staff illness policies in place for kitchen staff. Dir Z confirmed that the dietary department follows ServSafe as their standards of practice.

Infection Control Mgr X stated during an interview on 10/29/2014 at 7:30 a.m. that the facility follows CDC guidelines for work restrictions and staff is aware of the guidelines as they are posted online. Review of the facility's guidelines on 10/29/2014 at 7:50 a.m. states that staff members with acute diarrheal infections should be restricted from food handling "until symptoms resolve." Mgr X confirmed that there are no policies or training specific to ill food handlers in the kitchen.

Failure to educate kitchen staff on recommended guidelines for illness increases the potential for staff to food contamination and fails to maximize the prevention of foodborne illness within the facility.


MICU:
During an observation of the MICU on 10/27/2014 at 12:45 p.m., the supply room contained the following expired supplies: spinal biopsy needles (3) expiration date 9/2014; arterial needles (2) expiration date 1/2009; and endotracheal tube (1) expiration date 11/2012.

During an interview with Supervisor G at the time of the findings, Supervisor G stated that the "supply chain" is responsible to ensure the rotation of supplies and removal of expired supplies. Per Supervisor G, drawers and cabinets labeled with a "purple dot" serves as an indicator that the respective drawer or cabinet contains supplies that have an expiration date. The expired needles were found in a drawer not labeled with a "purple dot"; the endotracheal tube was found in another drawer not labeled with a "purple dot."


3N:
On 10/27/2014 at 12:30 p.m. tour of the 3N kitchenette revealed a collection of dust on the refrigerator, ceiling vents and ice machine. These findings were confirmed with Mgr I on 3N and Mgr H on 8N at the time of observation.

8N:
On 10/27/2014 at 3:30 p.m. observations in the 8N kitchenette revealed a collection of dust on the refrigerator, ceiling vents and ice machine. These findings were confirmed with Mgr I on 3N and Mgr H on 8N at the time of observation.

On 10-28-2014 at 10:31 a.m. accompanied by PSM B who confirmed the following observation: RN Q was observed to prepare a syringe for pt. #4's injection. RN Q removed the plastic covering off the vial and entered the vial with the needle without cleaning the rubber stopper with alcohol first.

Window Curtains:
Facility policy "Drapery/Cubicle Curtain Cleaning" #503.10.20 dated 6/1/2014, reviewed 10/29/2014 at 1:30 p.m. states that cubicle curtains will be sprayed with an IHP (Improved Hydrogen Peroxide) product at every discharge cleaning procedure. The policy additionally states "3. Window drapes or blinds in...non-patient areas will be examined weekly and cleaned (remove dust) as needed."

Per CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008, under " 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities " the guidelines recommend " d. Clean walls, blinds, and window curtains in patient-care areas when these surfaces are visibly contaminated or soiled. "

During an interview with Dir Y on 10/28/2014 at 11:25 a.m., Dir Y stated that privacy curtains in the patient rooms are disinfected between patients with a chemical disinfectant spray and are laundered every 6 month. Dir Y confirmed on 10/29/2014 at 9:40 a.m. that the facility ' s policy for curtain cleaning does not include window curtains in patient rooms and the facility does not have a policy to address window curtain cleaning in patient care areas.

Failure to clean window curtains in patient care areas increases the potential for cross-contamination of microorganisms between patients.





6N:
A tour of 6N was conducted on 10/27/14 at 11:05 AM accompanied by Dir PI Staff K and Mgr of 6 N T who confirmed the following observation: In a locked soiled utility and hazardous waste storage room found 5 individual medical drug waste receptacles attached to the wall. Each receptacle was identified for a specific drug disposal. All 5 containers were found to have covers unsecured and open which would allow access to receptacle contents.

Per interview with EVS Staff U at the time of the observation, "They had a hard time putting the bags (product) through the small yellow opening at the top, so they just left the top of the box (receptacle) open, when they get full we close them."

Per interview with EVS mgr NN 10/27/14 at 11:20 AM, stated "All containers should be locked when leaving for disposal, but should be closed at all times."

Per facility P&P "Hazardous Pharmaceutical Waste Management" #100.06.02.09, last reviewed on 09/21/12, Policy: 6) Environmental Services (EVS) will provide and manage the designated waste receptacles in Pharmacy and patient care areas. 7) The waste receptacles must be kept closed between uses."

ED:
Observation on 10/27/14 at 1:35 PM of ED soiled linen room located across from ED room #9, accompanied by ED RN Mgr Staff C and RN PSM B who confirmed the following: A large cardboard box with red biohazard Ebola waste bags under the sink. There is a potential for getting wet and creating a contaminated area. In an interview at the time of the observation, RN PSM B stated: "I know they should not be there, we just got them in and that's where they ended up."

On 10-28-2014 at 8:30 a.m., accompanied by PSM B who confirmed the following observation in ED: RN R was observed in the ED, drawing up IV Lasix from a vial. RN R removed the top from the vial and inserted the syringe needle without using alcohol on the vial stopper first.

An interview with the Mgr of Infection Prevention and Control, RN X, on 10/29/2014 at 7:34 a.m., RN X stated that this facility follows the nationally recognized professional recommendations and guidelines from the CDC, AORN, and AAMI, among others.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on a tour of the facility with several of the facility staff between October 27th to October 30th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients; the Condition of Participation is not met. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

K-tags cited were as follows:

Building #1-1978 Building:
K-12: Class of Construction
K-18: Corridors doors smoke-tight
K-29: Hazardous areas built as one-hour
K-38: Spaces open to Exit
K-41: Exit access direct to Corridor
K-56: Sprinkler system installed per NFPA 13
K-62: Testing of Automatic Sprinkler System components
K-67: Hvac system
K130: Miscellaneous items

Building #2- 1961 Building:
K-12: Class of Construction
K-18: Corridor doors
K-29: Hazardous areas built as one-hour
K-56: Sprinkler system installed per NFPA 13
K130: Miscellaneous items

These deficient practices were confirmed by observation and interviews with Staff OO (VP Hospital Operations) at the time of discovery.

Refer to the full description and findings in the specific K-tags, listed above, within the Life Safety Code survey report.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on a tour of the facility with several of the facility staff between October 27th to October 30th, 2014; this surveyor observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients; the Life Safety from Fire is not met. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

K-tags cited were as follows:

Building #1-1978 Building:
K-12: Class of Construction
K-18: Corridors doors smoke-tight
K-29: Hazardous areas built as one-hour
K-38: Spaces open to Exit
K-41: Exit access direct to Corridor
K-56: Sprinkler system installed per NFPA 13
K-62: Testing of Automatic Sprinkler System components
K-67: Hvac system
K130: Miscellaneous items

Building #2- 1961 Building:
K-12: Class of Construction
K-18: Corridor doors
K-29: Hazardous areas built as one-hour
K-56: Sprinkler system installed per NFPA 13
K130: Miscellaneous items

These deficient practices were confirmed by observation and interviews with Staff OO (VP Hospital Operations), Staff PP (Project Manager) at the time of discovery.

Refer to the full description and findings in the specific K-tags, listed above, within the Life Safety Code survey report.
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
Based on record review and interview, the facility failed to ensure the post anesthesia evaluation did not take place until the patient was recovered from anesthesia in 6 of 6 patients receiving anesthesia (Pt. #8, 22, 23, 24, 27, and 29) out of a total of 46 MR reviewed.


Finding include:

Per review on 10/28/14 at 1:10 PM of facility policy titled "Anesthesia Services Patient Care Guidelines" # 902.08.01.10 dated 11/23/11, it states under G. "A postanesthesia evaluation must be completed and documented by a qualified anesthesia provider within 48 hours following a surgery or procedure. The evaluation should include assessment of the following: 1. Respiratory function... 2. Cardiovascular function... 3. Mental status, 4. Temperature, 5. Pain, 6. Nausea and vomiting, 7. Postoperative hydration.

Per interview with Medical Director of Quality CC on 10/28/14 at 10:30 AM, Dir of Quality CC stated the anesthesia evaluation should not be done at the same time the case ends and the facility was aware of the practice and is discussing how to correct it.

Per interview with Anesthesiologist HH on 10/28/14 at 9:40 AM, Anesthesiologist HH stated the expectation for completion of the post anesthesia evaluation is for it to be completed after Phase I recovery (the immediate post anesthesia care) if the patient is going to be admitted to the floor and after Phase II (preparing the patient to go home) recovery for outpatients but ultimately it is at the discretion of the anesthesiologist.

Per record review on 10/28/2014 at 1:05 PM of pt. #8's MR revealed surgical procedure under general anesthesia on 9/10/2014, anesthesia record indicated surgery end time of 11:20 AM, anesthetic end documented at 11:55 AM and post anesthesia evaluation was completed at 11:55 AM. MR review was completed with Dir of Patient Care Services S.

Per review on 10/28/14 at 10:15 AM Pt #22's MR revealed an Anesthesia end time as 11:04 AM, the post anesthesia evaluation was completed at 11:02 AM, prior to anesthesia end time.

Per review on 10/28/14 at 11:10 AM, Pt #23's MR revealed an Anesthesia end time of 1:37 PM, the post anesthesia evaluation was completed three minutes later at 1:40 PM.

Per review on 10/28/14 at 1:00 PM, Pt #24's MR revealed an Anesthesia end time of 5:15 PM, the post anesthesia evaluation was completed simultaneously at 5:15 PM.

Per review on 10/28/14 at 2:20 PM, Pt #27's MR revealed an Anesthesia end time of 5:55 PM, the post anesthesia evaluation was completed simultaneously at 5:55 PM.

Per review on 10/28/14 at 2:30 PM, Pt #29's MR revealed an Anesthesia end time of 10:05 AM, the post anesthesia evaluation was completed 5 minutes later at 10:10 AM.

These findings were reviewed with and confirmed by the Medical Dir of Quality CC during the MR reviews.