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 record review and interview, the facility did not ensure that 1 of 29 patients reviewed were notified of Patient Rights. This had the potential for patients to be unaware of their rights.


Based on record review of Patient 10's chart dated 12/9/11, there was no Conditions of Admission document in the chart. An interview with Administrative Staff E on 10/23/15 at 12:45 p.m., confirmed that the document was not available.
Based on observation, interview and policy review, the facility failed to ensure licensed staff developed a diabetic (medical condition resulting in high blood sugars) nursing care plan for 1 patient (Patient 4) out of 30 patients, to include insulin treatment, checking blood sugar levels and monitoring high and low blood sugar reactions. These failures could result a delay in treatment.


During an observation on 10/21/15 at 11:32 a.m., Licensed Staff I checked Patient 4's blood sugar with a point of care blood sugar testing device or glucometer. Licensed Staff I checked the identity of the patient, withdrew a tiny amount of blood from Patient 4's finger and used the device to determine a 164 mg/dl result.

Medication records dated 10/20/15 and 10/21/15 indicated Patient 4 had Lantus 15 units ordered at bedtime and received 15 units on 10/20/15 at 9:19 p.m. On 10/21/15 at 11:53 a.m., Patient 1 received 3 units Humulin (short acting insulin). The point of care lab result for 10/21/15 at 11:32 am indicated Patient 1's lab result was 164 mg/dl and the point of care normal result should have been (74-118 according to lab work documentation on 48 hour Patient Summary) indicating it was a high result.

Review of the Discharge Summary dated 10/21/15 indicated Patient 4 had Diabetes Mellitus Type 2, uncontrolled on admission, with hyperglycemia, and was started on intravenous fluids, sliding scale insulin coverage and once daily long acting insulin. The Discharge Summary indicated Patient 4 was admitted with uncontrolled diabetes mellitus with an admission A1c (blood test which shows blood sugar control over 2-3 months) of 9.1 percent (normal non diabetic level 4.5-6) and Patient 4 was on long acting insulin and sliding scale insulin every 6 hours. The summary indicated the blood sugar results ranged from 300 down to 190 mg/dl.

Review of Patient 4's care plan indicated there was no diabetic care plan which described interventions that were provided to the patient such as monitoring blood sugars, administering insulin and monitoring high and low blood sugar reaction as well as special diets and related specific instruction. There was no specific blood sugar level parameters for Patient 4.

During an interview on 10/23/15 at 1:55 p.m., Licensed Staff J stated that Patient 4 went home on 10/21/15 and stated a night nurse admitted Patient 4 on the surgery floor. Licensed Staff J stated that the nurse did a head to toe assessment of the patient when they arrive to the floor, looked at the orders and verified what is being done for the patient. Licensed Staff J stated that a plan of care should have been started after the assessment of Patient 4. Licensed Staff J stated she saw Patient 4's blood sugar was high when he came in and didn't see a diabetic care plan was added to the plan of care. Licensed Staff J stated licensed staff should monitor Patient 4's blood sugar because they did not want the blood sugar too high or low and this should be addressed in a care plan. The nurse needed to revise the care plan as needed. Licensed Staff J stated nurses need to look at the care plan per shift so they know how to care for the patient.

On 10/23/15, review of the facility policy Assessment/Re-Assessment of Patients dated 6/15, indicated the care plan (process plan in the electronic healthcare record) is department specific documentation and is individualized, based on identified problems which are relative to the patient's condition and needs. The care plan is started on admission by the registered nurse, reviewed daily and developed in collaboration with other disciplines as their assessments are completed. The care plan is maintained and revised based on the patient's response to care, treatment and services and is reviewed and updated daily. The care plan provides documentation of of interventions performed to achieve desired outcomes.
Based on observation, interview and document review, the facility failed to develop a system for controlling infections and communicable diseases of patients and personnel when:

1. Documentation of required immunizations was not found in the health files of facility healthcare workers.
2. Bronchoscopes were not processed according to facility policy.
3. One environmental services worker removed contaminated gloves before handling the door knob and push button entry code pad to a trash storage area on a nursing unit.


1. On October 22, 2015 at 1:00 p.m., during a review of employee health records, one employee file (Staff X) out of 18 employee files reviewed did not have evidence of a current Tdap immunization (a combination vaccine that protects against three potentially life-threatening bacterial diseases: tetanus, diphtheria, and pertussis (whooping cough)) or Td (tetanus and diphtheria vaccine). This was validated by the Licensed Staff U.

On 10/23/15, 9 physician files (Physician K, L, M, N, O, P, Q, R and S) did not have documentation (immunization, blood titer or statement or declination) of measles, mumps, rubella, varicella, hepatitis B, tetanus or pertussis.

During an interview on 10/23/15 at 11:58 a.m., Administrative Staff T stated that the facility tracked influenza and TB but did not require other immunizations. Administrative Staff T stated that there was a Policy/Procedure for TB testing of Physicians but not for other vaccinations.

During an interview on 10/23/15 at 12:15 p.m., Licensed Staff U stated that the facility only did influenza and TB screening as a courtesy for the medical staff.

During an interview on 10/23/15 at 2:20 p.m., Administrative Staff E stated that the medical staff bylaws and rules did not require vaccinations of physicians.

During an interview on 10/23/15 at 2:45 p.m., Administrative Staff B stated that physicians are required to have TB screening and have influenza immunization or wear face masks. Administrative Staff B stated that the expectation is that physicians be in compliance with infection control standards.

October 22, 2015 at 11:30 a.m., the facility policy entitled: Employee Immunization Screening, dated December 2013, states it is based on guidelines from the Centers for Disease Control and Prevention (CDC) and that the health record of employees and volunteers will include valid documentation of screening for immunity (immunization, blood titer or statement or declination) for measles, mumps, rubella, varicella, hepatitis B, tetanus, pertussis, and influenza.

The CDC states that those who work directly with patients or handle material that could spread infection should get appropriate vaccines to reduce the chance that they will get or spread vaccine-preventable diseases. The CDC further states that healthcare workers include physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff.

2. During an observation and interview Licensed Staff W and Administrative Staff G, on 10/21/15 at 11:00 a.m., a pediatric bronchoscope hung in a locked case on the Pediatric Cart in the Emergency Department. Licensed Staff W removed the pediatric bronchoscope (a viewing instrument used to look at airways) from the case. The instrument had a tag attached to it. The tag indicated the date the instrument was processed and the "Beyond Use" date. Licensed Staff W stated that the "Ready to Use Tag" indicated the date of processing and the beyond use date. The date on the tag was 9/3/15 and the beyond use date was 9/17/15. Licensed Staff W stated the bronchoscope should be reprocessed.

During an observation and interview with Administrative Staff F and Administrative Staff G on 10/21/15, at 11:25 a.m., in the Surgical Department, the Thoracic Cart, ( used to contain instrument used for lung and chest cases) had a closed container sitting on the top that contained a bronchoscope. The container did not have a processed date or a beyond use date marked on it. When the container was opened, the bronchoscope did not have a tag that indicated the date of processing or the beyond use date. Administrative Staff F stated that a date should have been put on the container or the instrument.

The facility policy titled "Endoscope Cleaning and High Level Disinfection", dated 10/15, indicated "Place tag on clean endoscope with initials and beyond use date. All scopes not used will be reprocessed on or before the 14th day".

3. During an observation on 10/21/15 at 11:55 a.m., of the telemetry nursing unit, an environmental cleaning staff member (Staff V) was wearing gloves, holding a filled trash bag and handled the door knob of the trash storage room and dumped a trash bag in a trash container. Staff V still had the same gloves on and closed the door to the trash room, handling the door knob.

During an interview on 10/21/15 at 12:00 p.m., Staff V stated that she punched the numbers on the entry code pad above the door handle to gain entry to the trash room and stated that she sometimes wore the same gloves that she used to put trash in bags, in the patient room, and take the bags to the trash room.

During an interview on 10/23/15 at 10:00 a.m., Administrative Staff D stated, staff should, after cleaning a room, remove gloves and use hand sanitizer before leaving the patient room. The Infection Control Nurse stated that Environmental Service Staff are "afraid" and keep the gloves on to protect them but agreed that this could lead to cross contamination between dirty to clean surfaces.

On 10/23/15, review of Daily And Terminal Cleaning Of Patient Rooms policy/procedure dated 11/13, indicated housekeeping attendants should wear vinyl gloves when cleaning all patient rooms and bathrooms. Gloves should be discarded after each patient room is cleaned. Review of the facility Hand Hygiene policy dated 7/14 indicated gloves should be removed before leaving each patient's room. The policy indicated that gloves are never worn when moving from room to room and gloves are not worn in public area such as hallways and elevators.
Based on interview and document review, the facility failed to secure a current, documented medical history and physical examination before a surgery or procedure when a medical record did not contain documentation of a history and physical


1. On October 22, 2015 at 2:14 p.m. during a review of medical records, the medical record of Patient X, who underwent a colonoscopy, did not contain documentation of a history and physical. This was validated by Administrative Staff D.