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 observation and interview, it was determined the hospital failed to maintain a separate isolation room area in the newborn nursery for the purpose of segregation and isolation of any infant with a communicable disease in accordance with minimum design and construction standards for health care facilities. This has the potential to negatively affect the quality of care and services provided to all newborn patients.

Findings include:

1. The "Guidelines for Design and Construction of Health Care Facilities", 2010 edition states "An airborne infection isolation room shall be provided in or near at least one level of nursery care. The room shall be enclosed and separated from the nursery unit with provisions for observation of the infant from adjacent nurseries or control area(s)." During a tour of the newborn nursery area on 12/19/2012 at 9:55 a.m., it was noted there was no separate isolation room. The nurse present at the time of the tour stated the previously designated isolation room had been converted into an office "about two (2) years ago."
Based on observation and staff interview it was determined the infection control officer failed to ensure a system for the maintenance of a sanitary environment for the preparation and storage of medications and supplies was maintained on the medical/surgical unit. This failure creates the potential for environmental contamination of medications and supplies which places all patients at risk for infections.

Findings include:

1. Observations were conducted of the medication room and supply area on the Medical/Surgical (Med/Surg) Unit at 1445 on 12/17/12. The Nurse Manager of the Med/Surg Unit accompanied the surveyor during these observations. Two (2) sticky soiled areas were noted on top of medication cart #10. Two (2) sticky soiled areas were noted on the top of medication cart #9. Horizontal surfaces in the medication room (such as top of medication refrigerator, shelves containing intravenous (IV) fluids and medications and shelves in medication stock cabinet) were noted to be coated with a thick layer of dust. The medication stock cabinet lacked an outside door or cover to protect the medication trays from environmental dust and contamination.

A handwashing sink was noted just outside the medication room door. Miscellaneous patient supplies were stored on open shelves beside this sink. These shelves were visibly dusty. The shelves lacked a cover to protect the shelves/supplies from environmental dust, contamination and/or splashing from the handwashing sink.

2. These observations were shared and discussed with the Nurse Manager. She agreed with these findings.

3. These findings were reviewed and discussed with both the Chief Nursing Officer and Director of Infection Control at 0830 on 12/18/12. They acknowledged the uncovered cabinets had been previously identified as a problem during infection control rounds. They were unable to provide a projected date for correcting this issue.
A. Based on observation, review of documentation and staff interview, it was determined the hospital failed to maintain documentation of weekly checks for emergency eye wash stations.

Findings include:

1. On 12/17/12 at approximately 9:30 a.m., the emergency eye station located on the Medical Surgical unit was observed. The documentation of "weekly checks" had not been checked and signed off since 8/16/12.

2. These findings were discussed with the Medical Surgical Nurse Manager on 12/17/12 at the time of the observations, and she concurred with the findings.

B. Based on observation and interview, the hospital failed to ensure proper storage of office supplies.

Findings include:

1. During observation of a secure room used for prisoners, located on the Medical Surgical Unit on 12/17/12 at 11:00 a.m., it was discovered the two (2) closets in this room were being used to store office supplies, including copy paper. The Registered Nurse present during this tour stated: "This room is seldom used for patients and the closet is used for extra storage space."