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Based on observations, review of temperature and humidity logs and staff interviews. it was determined the Condition of Participation for Physical Environment is not met due to the hospital's failure to maintain humidity levels in the operating room at greater than 35 percent, failure to ensure corridor doors are latched into the frame, failure to ensure deadbolts were identified on corridor doors, failure to ensure exit discharge pathways to the public way were illuminated, failure to ensure alcohol based hand rubs were not stored over carpeted areas and failure to ensure sprinkler maintenance was performed. This affected all patients, staff and visitors. The census at the time of the survey was nine.


Findings include:

The hospital failed to ensure corridor doors latched into the frame when tested. Please refer to A-710.

The hospital failed to ensure exit discharges had a continuous surface from the exit discharge to the public way. Please refer to A-710.

The hospital failed to ensure deadbolts were identified on corridor doors and eight exit discharges lacked the appropriate lighting to eliminate leaving the area in darkness in the event of failure of a single bulb. Please refer to A-710.

The hospital failed to ensure humidity levels in the operating rooms were maintained at greater than 35 percent. Please refer to A-710.

The hospital failed to ensure sprinkler reports for one off-site was completed timely and exits were clearly labeled and identified in a second off-site facility. Refer to A710.

The hospital failed to ensure alcohol based hand rubs were not located directly over carpeting in non sprinklered areas of the building. Refer to A716.



The hospital failed to ensure all equipment used for patient care was checked for safety to ensure it was in a safe, operating manner. This equipment was found in Operating Rooms 2 and 3. Please refer to A-701.

Based on review of the medical records, review of the hospital's policy/procedure titled "Patient Fall Prevention and Management with Toileting Program" and staff interview and confirmation, it was determined the hospital failed to ensure the Registered Nurses (K and L) conducted a basic medical assessment was completed after Patient #23 fell prior to moving the patient. The hospital failed to ensure the nursing staff followed physician orders to monitor Patient #24's orthostatic (position) blood pressure twice a day. The hospitals census was nine.
Findings include:
The medical record for Patient #23 was reviewed on 08/04/10. Patient #23 was admitted on 08/02/10, with a diagnosis of a ventral hernia. On 08/02/10, Patient #23 underwent a scheduled surgical repair of a ventral hernia. Patient #23 had a history of coronary artery disease, diabetes, hypertension and arthritis. During the observation conducted on 08/04/10 at 1:20 PM, on the Medical Surgical Unit, the surveyor heard someone shouting " help, help!. " Staff K and L responded to the patient's room. On arrival to the room the surveyor noted that Patient #23 was lying on his/her back on the floor. The family member present in the room stated that Patient #23 had fallen while attempting to ambulate to the bathroom. When questioned by the nursing staff, the family member stated the patient had struck his/her head. Patient #23 was helped into a sitting position on the floor by the nursing staff K and L prior to completing an assessment for injury. Patient #23 was not questioned regarding pain nor was Patient #23 assessed for his/her neurological status prior to movement by the nursing staff K and L.
A review of the hospital's policy/procedure titled, "Patient Fall Prevention and Management Protocol with Toileting Program", revealed after a fall the patient should be assessed for injury, the assessment should include range of movement, level of consciousness, pain, bruises and lacerations. The policy stated that the patient should be assessed for vital signs and mental and neurological status. These findings were confirmed with Staff J on 08/04/10 at 5:00 PM.
The medical record for Patient #24 was reviewed on 08/04/10. Patient #24 was admitted on 08/03/10, with diagnoses of dehydration, hypotension (low blood pressure) and near syncope (fainting). On admission, the physician ordered that Patient #24 was to have vital signs monitored every shift and orthostatic blood pressure measurements (supine, sitting, then standing) twice daily. (Orthostatic vital signs are used to check for orthostatic (postural hypotension, which may occur when a change in the patient ' s position causes the blood pressure to drop rapidly). On 08/03/10 at 4:12 PM, a blood pressure was taken while the patient was in a sitting position. At 10:00 PM the blood pressure for Patient #24 was taken when the patient was lying down. On 08/04/10 at 5:53 AM, Patient #24 ' s blood pressure was checked while he/she was lying down. This was confirmed with Staff A on 08/04/10 at 10:30 AM, the registered nurses did not take the patient's orthostatic blood pressure measurements twice daily as ordered by the physician.

Based on observations during tour of the operating rooms and staff interview, it was determined the facility failed to ensure that all equipment used for patient care was checked for safety to ensure it was maintained in a safe operating manner. This equipment was found in Operating Room 2 and 3. The hospital census was 9 patients. As of July 1, 2010 there have been 1,087 surgical cases completed at the hospital.
Findings include:
A tour of the operating rooms was conducted on 08/03/10 at 1:20 PM. During the tour it was noted that 2 of 3 operating rooms had equipment that was in use that lacked evidence the equipment had been safety checked to ensure the equipment was performing adequately and preventative maintenance had been completed according to the manufacturer's recommendations.
In operating room 2 there were two electrical surgical devices that lacked preventative maintenance stickers. In operating room 3 there was a pain management pump with a preventative maintenance sticker dated 11/09/04. Interview with Staff J on 08/05/10 at 12:55 PM., revealed these three pieces of equipment were purchased in 2008 and no preventative maintenance had been completed on on the equipment since the date of purchase.

Based on observations, staff interviews and review of fire safety information, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association in regard to building construction type, corridor doors, exit discharge pathways to the public way, deadbolts on corridor doors, discharge egress lighting, humidity levels in operating rooms, sprinkler maintenance and placement of alcohol based hand rubs. This affected all patients, staff and visitors. The census at the time of the survey was nine.

Findings include:

The hospital failed to meet the provisions of the Life Safety Code of the National Fire Protection Association in the following areas:

The hospital was communicating with CMS in regard to the building construction type and lack of sprinklers in certain parts of the building, which were identified as a concern on the 05/14/10 Life Safety Code Survey. Refer to K12.

The hospital failed to ensure corridor doors latched into the frame when tested. Refer to K18.

The hospital failed to ensure exit discharges a continuous surface from the exit discharge to the public way and deadbolts were identified on corridor doors. Refer to K38.

The hospital failed to ensure eight exit discharges had appropriate lighting to eliminate darkness at the exits in the event of failure of a single bulb. Refer to K45.

The hospital failed to ensure humidity levels in the operating rooms met the Life Safety Code requirements. Refer to K78.

The hospital failed to ensure sprinkler reports for one off-site was completed timely, exits were clearly labeled and identified as exits in a second off-site facility. Refer to K130.

the hospital failed to ensure alcohol based hand rubs were not located directly over carpeting in nonsprinklered areas of the building. Refer to A716 and K211.

Based on observations and staff interviews the hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association in regard to alcohol based hand rub container placement and sprinkler maintenance. This affected all patients, staff, and visitors. The census at the time of the survey was nine.


Findings include:

During the survey on 08/03/10-08/05/10, the hospital failed to meet the provisions of the Life Safety Code of the National Fire Protection Association in the following areas:

Alcohol based hand rub containers were located directly over carpeting in nonsprinklered areas of the building. Refer to K211.