HospitalInspections.org

A. Based on the reviews of Hospital's Contracts Policies and Procedures, a list of Contractual Services, Service Order Review/Renewal (SCOR) Form, Individual Contracts and Evaluation, Hospital Improvement Plan and staff interview, it was determined that for 9 of 9 Contracts (Archer Window Cleaning, CardioMatic, Inc., CareerStaff Management Inc, Clean Air Flow, Inc., Heartland Blood Center, Medical Staffing Network (MSN), Nurse Finders,Stericycle, and Waste Management of Illinois), the Hospital failed to ensure each contract was evaluated.

Findings include:

1. The Hospital's Policies and Procedures entitled, "Service Contract Order Renewal" was reviewed on 6/28/11 at 9:00 AM. The policy stated, "2. The user department will be asked to evaluate the performance of the current contract. 3. The user department will have the following options: Renew the contract as is, Renew the contract with changes, Do not renew, and other."

2. The Hospital List of Contractual Services was reviewed on 6/28/11 at 10:00 AM. The list included all Contractual Services with the following titled column: C/C: Hospital Code, Vendor, Coverage/Nature and Expiration Date.

3. The Hospital's Service Order Review/Renewal (SCOR) Form was reviewed on 6/29/11 at 9:10 AM. The Vice President of Support Services stated that the SCOR Form was the evaluation tool utilized to evaluate each contractual service.

4. A sample of nine (9) Hospital Contracts and their Evaluation (SCOR) Forms (Archer Window Cleaning, CardioMatic, Inc., CareerStaff Management Inc, Clean Air Flow, Inc., Heartland Blood Center, Medical Staffing Network (MSN), Nurse Finders,Stericycle, and Waste Management of Illinois) were reviewed on 6/29/11 at 9:30 AM. The areas of the SCOR Form were as follow: Service Description, Contract Cost Proposal, Term/Cancellation, Purchase Date/Price Service, Negotiations, Background/Explanation, Price/ % Changes from Previous Years, and New/Renewal/Comments. However, the SCOR Form did not include an evaluation of the services and the Hospital failed to provide documentation that evaluation had been done for each of the contractual service.

5. The Hospital's Performance Improvement Plans "Organization Indicators" for 2010 and 2011 were reviewed on 6/29/11 at 11:45 AM. The Contractual Services were not included in the Hospital-wide Organizational Quality Plan.

6. On June 29, 2011, at approximately 1:25 PM, these findings were discussed and confirmed with the VP of Support Services. The VP stated that the SCOR Form was the only tool that is used for evaluation of Contractual Services and that feedback about services are provided by each user department regarding each contract upon renewal.

A. Based on observation, review of Hospital policy, safety round records, clinical records and staff interview, it was determined that for 2 of 2 (Intensive and General) Psychiatric Units and for 8 of 8 patients (Pt's. #1 - 8) on the Intensive Psychiatric Unit and 11 of 14 patients (Pt's. #9 - 19), on the Psychiatric General Unit the Hospital failed to protect and promote patient rights.

Findings include:


1. The Hospital failed to ensure safe monitoring of patients by accurately completing patients' safety round records, as required by policy for 8 of 8 patients (Pt's. #1 - 8) on the Intensive Psychiatric Unit and 11 of 14 patients (Pt's. #9 - 19), on the Psychiatric General Unit. (A-144A).The Hospital failed to ensure a safe environment for 2 of 2 (Intensive and General) Psychiatric Units . (A-144B).


The cumulative effect of these systemic practices resulted in the Hospital's inability to maintain, protect and promote patient rights. The condition of Patient Rights was not met.

A. Based on review of Hospital policy, safety round records, clinical records, and staff interview, it was determined, that for 8 of 8 patients (Pts. #1 - 8) on the Intensive Psychiatric Unit and 11 of 14 patients (Pts. #9 - 19), on the Psychiatric General Unit, the Hospital failed to ensure safe monitoring of patients by accurately completing patients round records, as required by policy.

Findings include:

1. Hospital policy titled, "Precautions" was reviewed on 6/27/11 at 10:00 AM. The policy included,"3. Close Watch Precautions: Every fifteen minutes' observation of the patient who is assessed at moderate risk of injury to self, violence to self or others, or moderately impaired functioning."

2. On 6/27/11 at 9:25 AM, an observational tour was conducted on the Psychiatric Intensive Care Unit. The Safety Round Records were reviewed at 9:25 AM. Eight of 8 patient round sheets (Pts. #1 - 8) were each marked for "Close Watch Precautions (q 15 minutes)." However, the last documentation of each safety round record was at 8:15 AM (more than an hour without documentation).

3. On 6/27/11 at 9:35 AM, an observational tour was conducted on the Psychiatric General Care Unit and the Safety Round Records were reviewed for each patient. Eleven of 14 patient round record (Pts. #9 - 19) were marked "Close Watch Precautions (q 15 minutes)." However, the last documentation for each rounding record was at 7:45 AM, (More than 1 1/2 hours without documentation).

4. On 6/28/11 between 9:35 and 9:55 AM, the clinical records of Patients #1 - 19 were reviewed. Each record included an order for close observation (q 15 minutes):

- Pt. #1 was a 92 year old male, admitted on 6/13/11, with a diagnosis of Major Depression. A physician's order dated 6/13/11, included, "Precautions: assess for gait - uses walker." At 9:36 AM, Pt. #1's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #2 was an 83 year old male, admitted on 6/18/11, with diagnoses of Dementia with Agitation. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:37 AM, Pt. #2's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #3 was a 64 year old male, admitted on 6/24/11, with a diagnosis of Alcohol Withdrawal. A physician's order dated 6/25/11, included, "Treatments: Close Watch." At 9:38 AM, Pt. #3's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #4 was a 33 year old male, admitted on 6/18/11, with a diagnosis of Schizophrenia. A physician's order dated 6/18/11, included, "Precautions: CW." At 9:39 AM, Pt. #4's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #5 was an 88 year old female, admitted on 6/18/11, with diagnoses of Dementia with Agitation. A physician's order dated 6/19/11, included, "Precautions: Close Watch." At 9:40 AM, Pt. #5's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #6 was a 79 year old female, admitted on 6/19/11, with a diagnosis of Major Depression. A physician's order dated 6/19/11, included, "Precautions: Close Watch." At 9:41 AM, Pt. #6's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #7 was a 77 year old female, admitted on 6/18/11, with a diagnosis of Bipolar Disorder. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:42 AM, Pt. #7's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #8 was a 48 year old female, admitted on 6/23/11, with a diagnosis of OxyContin Withdrawal. A physician's order dated 6/24/11, included, "Treatments: Close Watch." At 9:43 AM, Pt. #8's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #9 was a 53 year old male, admitted on 6/21/11, with a diagnosis of Alcohol Dependency Withdrawal. An unsigned physician's order dated 6/23/11, included, "Treatments: Close Watch." At 9:44 AM, Pt. #9's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #10 was a 55 year old male, admitted on 6/25/11, with diagnoses of Alcohol Intoxication and Major Depression. A physician's order dated 6/26/11, included, "Treatments: Close Watch." At 9:45 AM, Pt. #10's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #11 was an 26 year old male, admitted on 6/19/11, with a diagnosis of Mood Disorder. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:46 AM, Pt. #11's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #12 was a 42 year old male, admitted on 6/22/11, with diagnoses of Major Depression with Suicidal Ideation and Bipolar Disorder. A physician's order dated 6/22/11, included, "Precautions: Close Watch / No Belts." At 9:47 AM, Pt. #12's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #13 was a 34 year old male, admitted on 6/22/11, with diagnoses of Substance Abuse, Major Depression with Psychosis. A physician's order without a date, included, "Precautions: Close Watch." At 9:48 AM, Pt. #13's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #14 was an 69 year old male, admitted on 6/15/11, with diagnoses of Bipolar Disorder and Manic. A physician's order dated 6/16/11, included, "Precautions: Close Watch." At 9:49 AM, Pt. #14's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #15 was a 47 year old female, admitted on 6/23/11, with diagnoses of Bipolar, Depressed, and Suicidal Ideation. A physician's order dated 624/11, included, "Precautions: CW." At 9:50 AM, Pt. #15's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #16 was a 53 year old male, admitted on 6/24/11, with diagnoses of Major Depression with Suicidal Ideation. A physician's order dated 6/12/11, included, "Precautions: Close Watch." At 9:51 AM, Pt. #16's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #17 was an 18 year old male, admitted on 6/20/11, with a diagnosis of Acute Psychosis. A physician's order dated 6/20/11, included, "Precautions: Cl. Watch." At 9:30 AM, Pt. #17's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #18 was a 68 year old female, admitted on 6/20/11, with a diagnosis of ETOH Withdrawal. A physician's order dated 6/21/11, included, "Precautions: Close Watch - No Belts." At 9:52 AM, Pt. #18's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #19 was a 54 year old female, admitted on 6/22/11, with diagnoses of Chemical Dependency and Alcohol Withdrawal. A physician's order dated 6/22/11, included, "Treatments: Close Watch." At 9:53 AM, Pt. #19's fifteen minute safety round record had not been completed since 7:45 AM.

5. On 6/28/10 at 10:00 AM, an interview was conducted with the Certified Nurses Aide (E #6) who completed the safety round records on 6/27/11 on the Psychiatric General Care Unit. E #6 stated that she did not complete the safety rounds on time yesterday, because she was assigned to perform vital signs and breakfast monitoring for 6 - 7 patients, and then she went on her break.

6. The Assistant Vice President of Nursing Behavioral Health confirmed these findings during an interview on 6/28/11 at approximately 10:45 AM. The hospital submitted on 6/28/11at 1 P.M. a revised policy, titled "Precautions"- Close Watch rounds are assigned to specific staff members for specific blocks of time. The Staff member completing their assigned rounds will hand the Close Watch rounds board with all the Close Watch round sheets to the next staff member assigned. A QA has been set up to monitor and staff education began on 6/28/11 for staff.

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B. Based on observation, review of Hospital policy, and staff interview, it was determined that for 2 of 2 (Intensive and General) Psychiatric units, the Hospital failed to ensure that the environment was safe.

Findings include:

1. An observational tour of Psychiatric Intensive Care Unit and Psychiatric General Care Unit was conducted on 6/27/11 between 9:20 AM and 11:00 AM. The following observations were made:

-The Day Room in the Psychiatric Intensive Care Unit contained a wall telephone with approximately a 6 foot phone cord. This room was not clearly visible from the nurses' station and was unlocked.

-The sitting area in the Psychiatric General Care Unit contained 2 wall telephones with each phone containing a 6 foot phone cord. Two additional wall phones were located on the Unit on the opposite side of a window to the nurses station and each had a 6 foot phone cord. During the tour, a patient was observed using one of the phones, unsupervised.

-A metal drawer bracket (approximately 18 inches long) was found in an unlocked drawer in the patients' kitchen. This area is located next to the sitting area on the Psychiatric General Unit and is accessible by unsupervised patients.

2. The Hospital's Policy, entitled, "Contraband and Locker Items", was reviewed on 6/27/11 at approximately 11:00 PM. The policy required that "...Items to be stored and used in locker room or with supervision:...cords over 12 inches long..."

3. The above findings were confirmed with the Assistant Vice President of Nursing/ Behavioral Health on 6/27/11 at approximately 11:15 AM.

A. Based on observation, review of Hospital Policy and staff interview, it was determined for 1 of 9 operating rooms (OR's) inspected (#8), the Hospital failed to ensure confidentiality of medical record.

Findings include:

1. On 6/28/11, at approximately 8:00 AM, OR #8 was inspected. An identification sticker (Pt's name and medical record number) from a previous procedure was observed attached to a computer.

2. The Hospital policy titled, "Confidentiality of Patient Health Information" was reviewed on 6/30/11 at 9:30 AM. The policy included, "It is the policy of Palos Community Hospital that all patient care information shall be regarded as confidential and available only to authorized users."

3. The above finding was confirmed with the Assistant Vice President, Nursing Special Care Units during an interview on 6/30/11 at approximately 1:00 PM.

A. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 3 (Pt. #21) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure physicians' orders for restraints were renewed daily per policy.

Findings include:

1. The Hospital policy titled, "Restraint Policy" was reviewed on 6/27/11 at 3:30 PM. The policy included, "A written renewal order is issued no less than once each calender day ...".

2. The clinical record of Pt. #21 was reviewed on 6/27/11 at 2:10 PM. Pt. #21 was a 78 year old male admitted on 6/1/11 with the diagnosis of Gangrene Both Feet - Peripheral Vascular Disease. The clinical record included physician orders for restraints dated 6/17/11 - 6/19/11 and three separate restraint orders dated 6/22/11. The clinical record lacked a physician order for restraints for 6/20/11, 6/21/11 and 6/23/11.

However, the daily nursing "Restraint Record for Acute Med/Surg Patients" dated 6/20/11, 6/21/11 and 6/23/11 indicated that Pt. #21 was in restraints.

3. The above finding was confirmed with the Assistant Vice President of Nursing Medical Surgical Services and the Assistant Vice President of Nursing Orthopaedic Services on 6/27/11 at approximately 3:15 PM, during an interview.

A. Based on a review of the Hospital's 3rd and 4th Nursing Unit Floors "Organizational Indicators", Occurrence Reports for year 2011, Trend Analysis Data for 3 of 3 years (2009, 2010 and 2011), and staff interview, it was determined that the Hospital failed to ensure falls data was used to identify changes for improvement.

Findings include:

1. On 6/30/11 at approximately 12:15 PM, the Hospital's "Organizational Indicators" were reviewed. The indicators for patient falls included, " Evaluate the effectiveness of all fall reduction activities including assessment, interventions and education."

2. On 6/30/11 at approximately 12:30 PM, Occurrence Reports for the 3rd and 4th Nursing Unit Floors for January 2011 through April 2011 regarding patient falls were reviewed with the following findings:

* The third floor nursing unit there had 38 patient falls.

* The 4th floor nursing units had 24 patient falls.

3. On 6/30/11 at approximately 12:40 PM the Facility's "In Patient Falls Trend Analysis" for 2009, 2010 and 2011 was reviewed with the following findings:

* January 2009 - December 2009: Falls = 196
* January 2010 - December 2010: Falls = 201
* January 2011 - April 2011: Falls = 88

There was no documentation to evidence that any analysis, evaluation or implementation of fall reduction activities were conducted to improve patient safety.

4. The above findings were discussed with Vice President of Nursing on 6/30/1 at approximately 2:45 PM.


B. Based on a review of Medication Errors report for 3 of 3 months in 2011 (March, April and May 2011), it was determined that the Hospital failed to ensure evaluation of dispensing errors by pharmacy

Findings include:

1. On 6/30/11 at approximately 2:45 PM, pharmacy medication errors of March, April and May 2011 Occurrence Reports were reviewed. On April 15, 2011 the pharmacy sent 8 mg (milligrams) of Coumadin to the nursing unit instead of 4 mg as ordered. On May 1, 2011 the pharmacy sent a 2 mg tablet of Requip to the nursing unit instead of 6 mg as ordered.

2. The Director of Pharmacy was interviewed on 6/30/11 at approximately 2:30 PM. The Director stated that individual pharmacy dispensing mistakes are evaluated in the department meeting minutes. However upon review of the minutes for 2011 the above medication errors were not mentioned or evaluated.

3. The above finding was discussed with the Director of Pharmacy during an interview on 6/30/11 at approximately 3:00 PM.

A. Based on review of the Hospital's Medical Staff Bylaws, Rules and Regulations, an attestation letter from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Bylaws, Rules and Regulations were reviewed on 6/29/11 at 9:30 AM. The Rules and Regulations included, "A chart is considered delinquent 30 days following the patients discharge."

2. An attestation letter presented on 6/29/11 at 10:30 AM by the Director, Quality Assessment & Patient Review Systems indicated that as of survey date 6/29/11, there were 1,916 medical records incomplete (delinquent) greater than 30 days post discharge.

3. The above finding was confirmed with the Director, Health Information Management during an interview on 6/29/11 at approximately 10:30 AM.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on June 28 - 29, 2011, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Sample Validation Survey conducted on June 28 - 29, 2011, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the (3) CMS Forms 2567, dated June 29, 2011.

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A. Based on observation and staff interview, it was determined that for 2 of 2 (3 oz.) bottles of sterile water observe, the Hospital failed to ensure that the sterile water had not expired.

Findings include:

1. On 6/27/11, at approximately 9:30 AM, a tour was conducted in the infant nursery. A drawer of 1 of 2 supply carts contained 2 (3 oz) bottles of infant sterile water with an expiration date of 3/2011.

2. The above findings were confirmed with the VP of Special Care Areas on 6/27/11 at approximately 10:00 AM.


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B. Based on observation, staff interview, and review of Hospital policy, it was determined that for 2 of 2 operating rooms (OR) (OR #4 and 7) observed, the Facility failed to ensure a sanitary environment.

Findings include:

1. An observational tour of Operating Rooms #4 and #7 was conducted on 6/28/11 between 6:30 AM and 8:00 AM. The following observations were made:

- At approximately 6:40 AM in OR #4 , 2 of 2 detachable arm rests for the surgical table contained tape residue on the surfaces. Seven of 9 rolling carts contained brown stains on the wheels (removable by wiping with Surgical Tech present). The floor contained brownish yellow stains around the surgical cart (removable by rubbing with Surgical Tech present).

- At approximately 6:50 AM in OR #7, the base of the surgical table and the electric cord contained tape residue.

2. The Hospital policy, entitled "Environmental Cleaning in the Surgical Setting", was reviewed on 6/28/11 at approximately 11:15 AM. This policy required "...Patients will be provided a safe and visibly clean surgical environment..."

3. The above findings were confirmed with the OR Clinical Nurse Manager on 6/28/11 at approximately 8:30 AM.

A. Based on Hospital Policy review, observation and staff interview, it was determined that for 3 of 3 employees observed (E#s 1, 2 and 3). it was determined that the Hospital failed to ensure adherence to the use of Personnel Protective Equipment (PPE)

Findings include:

1. On 6/28/11 at approximately 2:30 PM, the Hospital Policy titled," Isolation Precautions (section 10)" was reviewed. The policy included, "Perform hand hygiene...immediately after glove removal...put on gown, overlapping well in the back to cover clothing..."

2. On 6/27/11 at approximately 2:00 PM, an observational tour was conducted in the Coronary Care Unit and the following were noted:

- E#1 exited a contact isolation room 355-5 at approximately 2:05 PM, without performing hand hygiene immediately after glove removal. E#1 was also storing disposable gloves in her pocket.

- E#2 exited contact isolation room 355-5 at approximately 2:20 PM without performing hand hygiene immediately after glove removal.

E#3 was observed in contact isolation room 355-5 wearing a protective gown that had fallen off her back and was dragging on the floor while she was attempting to draw blood cultures.

3. The above findings were verified by the VP of Special Care Areas during an interview on 6/27/11 at approximately 3:30 PM.

B. Based on an observational tour and staff interview, it was determined that the Hospital failed to ensure clean supplies were maintained to prevent potential contamination for 1 of 1 Nursery and 2 of 9 Operating suites (OR #s 7 and 8).

Findings include:

1. On 6/27/11 at approximately 9:40AM, the adjunct nursery was toured. A box of opened surgical gloves was observed stored on a small biohazard container.

2. The above finding was verified by the VP of Special Care during an interview on 6/27/11 at approximately 9:45 AM.

3. On 6/28/11, at approximately 6:40AM, an observational tour was conducted of the surgical suites. OR rooms #7 and 8 contained approximately 10 blue cloth towels that were stored directly on the top of a biohazard container.

4. The above findings were verified by the Clinical Nurse Manager during an interview on 6/28/11 at approximately 6:50 AM.

C. Based on Hospital policy review, an observational tour and staff interview, it was determined that the Hospital failed to ensure sanitary conditions in 1 of 1 cook preparation area, 1 of 1 nutrition supplement preparation area and 1 of 1 dry food storage area.

Findings include:

1. On 6/29/11 at approximately 12:00 PM, Hospital Policy titled," Cleaning Procedures- Index S" was reviewed. The policy included, "To provide sanitary conditions for food to be stored, prepared and served: Stainless steel counters are cleaned daily..."

2. On 6/29/11 at approximately 12:15 PM, Hospital policy titled,"Ware Washing" was reviewed. The policy included,"...items are thoroughly washed....items are air dried...sanitized and dried items are returned to specific storage places..."

3. On 6/29/11 between 9:10 AM and 11:30AM, an observational tour of the dietary department was conducted. The following were observed:

* Ten (10) of approximately thirty 6-8 oz plastic glasses were observed in the nutritional supplement preparation area. The 10 glasses were wet with water thus promoting potential bacterial growth.

* One of one deep fryer contained cooking oil that was brown/black in appearance with floating particles. The label on the fryer indicated that the cooking oil was last changed on 5/12. The cover over the deep fry baskets contained dark brown colored liquid. The two deep fry baskets contained brown colored particles.

* The "party grill" was dark with burnt particles.

* Four of 4 boxes of packaged cookies were stored on a dusty metal shelf in the nutrition preparation area.

* Forty three (43) of 62 spice bottles, located in the dry storage area, contained dust.

* Four (4) of 4 bottles of apple cider, in the dry storage area, were dusty.

4. The above findings were verified with the Clinical Nutrition Supervisor during an interview on 6/29/11 at approximately 10:50 AM.

A. Based on Hospital policy review, an observational tour of the operating room suites (OR#s 1-9) and staff interview, it was determined that for 1 of 1 opened surgical packs observed (OR# #5), the Hospital failed to ensure the opened surgical packs were continuously monitored.

Findings include:

1. On 6/28/11 at approximately 1:30 PM, Facility policy titled,"Maintaining A Sterile Field" was reviewed. The policy included," A sterile field will be constantly monitored and maintained."

2. On 6/28/11 at approximately 6:50 AM, the surveyor observed laparoscopy packs opened and unattended in OR #5. According to the Clinical Nurse Manager, the packs were opened at 6:40 AM.

3. The above finding was confirmed with the Clinical Nurse Manager during an interview on 6/28/11 at approximately 6:50 AM


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B. Based on review of Hospital policy, observation,and staff interview it was determined that for 2 of 6 (E#4 and 5) staff members present in the Operating Room (OR), the Hospital failed to ensure adherence to the dress code policy for the operating room.

Findings include:

1. The Hospital policy, entitled "Dress Code for Surgical Environment", was reviewed on 6/27/11 at approximately 3:00 PM. The policy required "...Surgical head covers or hoods that confine all hair will be worn by all personnel entering the surgical environment...All persons entering restricted areas of the surgical environment will wear a mask...The mask will cover both mouth and nose and be secured in a manner that prevents venting..."

2. An observational tour of OR #4 was conducted on 6/28/11 between 6:30 AM and 8:00 AM. The following was observed during the tour:

- At approximately 7:05 AM, in OR #4, where sterile instruments were open, E #4 entered OR #4 with his face mask held in place with his hand and mask was untied.

Approximately 2 inches of hair to back of E #4's head was not covered by surgical head cover.

- At approximately 7:55 AM, E #5 entered OR #4 with her face mask held in place with her hand and mask was untied. Scrubbed personnel and open sterile items were present in OR #4 at this time.

3. The above findings were confirmed with the OR Clinical Nurse Manager on 6/28/11 at approximately 8:30 AM.

A. Based on review of Hospital policy, safety round records, clinical records, and staff interview, it was determined, that for 8 of 8 patients (Pts. #1 - 8) on the Intensive Psychiatric Unit and 11 of 14 patients (Pts. #9 - 19), on the Psychiatric General Unit, the Hospital failed to ensure safe monitoring of patients by accurately completing patients round records, as required by policy.

Findings include:

1. Hospital policy titled, "Precautions" was reviewed on 6/27/11 at 10:00 AM. The policy included,"3. Close Watch Precautions: Every fifteen minutes' observation of the patient who is assessed at moderate risk of injury to self, violence to self or others, or moderately impaired functioning."

2. On 6/27/11 at 9:25 AM, an observational tour was conducted on the Psychiatric Intensive Care Unit. The Safety Round Records were reviewed at 9:25 AM. Eight of 8 patient round sheets (Pts. #1 - 8) were each marked for "Close Watch Precautions (q 15 minutes)." However, the last documentation of each safety round record was at 8:15 AM (more than an hour without documentation).

3. On 6/27/11 at 9:35 AM, an observational tour was conducted on the Psychiatric General Care Unit and the Safety Round Records were reviewed for each patient. Eleven of 14 patient round record (Pts. #9 - 19) were marked "Close Watch Precautions (q 15 minutes)." However, the last documentation for each rounding record was at 7:45 AM, (More than 1 1/2 hours without documentation).

4. On 6/28/11 between 9:35 and 9:55 AM, the clinical records of Patients #1 - 19 were reviewed. Each record included an order for close observation (q 15 minutes):

- Pt. #1 was a 92 year old male, admitted on 6/13/11, with a diagnosis of Major Depression. A physician's order dated 6/13/11, included, "Precautions: assess for gait - uses walker." At 9:36 AM, Pt. #1's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #2 was an 83 year old male, admitted on 6/18/11, with diagnoses of Dementia with Agitation. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:37 AM, Pt. #2's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #3 was a 64 year old male, admitted on 6/24/11, with a diagnosis of Alcohol Withdrawal. A physician's order dated 6/25/11, included, "Treatments: Close Watch." At 9:38 AM, Pt. #3's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #4 was a 33 year old male, admitted on 6/18/11, with a diagnosis of Schizophrenia. A physician's order dated 6/18/11, included, "Precautions: CW." At 9:39 AM, Pt. #4's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #5 was an 88 year old female, admitted on 6/18/11, with diagnoses of Dementia with Agitation. A physician's order dated 6/19/11, included, "Precautions: Close Watch." At 9:40 AM, Pt. #5's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #6 was a 79 year old female, admitted on 6/19/11, with a diagnosis of Major Depression. A physician's order dated 6/19/11, included, "Precautions: Close Watch." At 9:41 AM, Pt. #6's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #7 was a 77 year old female, admitted on 6/18/11, with a diagnosis of Bipolar Disorder. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:42 AM, Pt. #7's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #8 was a 48 year old female, admitted on 6/23/11, with a diagnosis of OxyContin Withdrawal. A physician's order dated 6/24/11, included, "Treatments: Close Watch." At 9:43 AM, Pt. #8's fifteen minute safety round record had not been completed since 8:15 AM.

- Pt. #9 was a 53 year old male, admitted on 6/21/11, with a diagnosis of Alcohol Dependency Withdrawal. An unsigned physician's order dated 6/23/11, included, "Treatments: Close Watch." At 9:44 AM, Pt. #9's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #10 was a 55 year old male, admitted on 6/25/11, with diagnoses of Alcohol Intoxication and Major Depression. A physician's order dated 6/26/11, included, "Treatments: Close Watch." At 9:45 AM, Pt. #10's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #11 was an 26 year old male, admitted on 6/19/11, with a diagnosis of Mood Disorder. A physician's order dated 6/18/11, included, "Precautions: Close Watch." At 9:46 AM, Pt. #11's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #12 was a 42 year old male, admitted on 6/22/11, with diagnoses of Major Depression with Suicidal Ideation and Bipolar Disorder. A physician's order dated 6/22/11, included, "Precautions: Close Watch / No Belts." At 9:47 AM, Pt. #12's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #13 was a 34 year old male, admitted on 6/22/11, with diagnoses of Substance Abuse, Major Depression with Psychosis. A physician's order without a date, included, "Precautions: Close Watch." At 9:48 AM, Pt. #13's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #14 was an 69 year old male, admitted on 6/15/11, with diagnoses of Bipolar Disorder and Manic. A physician's order dated 6/16/11, included, "Precautions: Close Watch." At 9:49 AM, Pt. #14's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #15 was a 47 year old female, admitted on 6/23/11, with diagnoses of Bipolar, Depressed, and Suicidal Ideation. A physician's order dated 624/11, included, "Precautions: CW." At 9:50 AM, Pt. #15's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #16 was a 53 year old male, admitted on 6/24/11, with diagnoses of Major Depression with Suicidal Ideation. A physician's order dated 6/12/11, included, "Precautions: Close Watch." At 9:51 AM, Pt. #16's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #17 was an 18 year old male, admitted on 6/20/11, with a diagnosis of Acute Psychosis. A physician's order dated 6/20/11, included, "Precautions: Cl. Watch." At 9:30 AM, Pt. #17's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #18 was a 68 year old female, admitted on 6/20/11, with a diagnosis of ETOH Withdrawal. A physician's order dated 6/21/11, included, "Precautions: Close Watch - No Belts." At 9:52 AM, Pt. #18's fifteen minute safety round record had not been completed since 7:45 AM.

- Pt. #19 was a 54 year old female, admitted on 6/22/11, with diagnoses of Chemical Dependency and Alcohol Withdrawal. A physician's order dated 6/22/11, included, "Treatments: Close Watch." At 9:53 AM, Pt. #19's fifteen minute safety round record had not been completed since 7:45 AM.

5. On 6/28/10 at 10:00 AM, an interview was conducted with the Certified Nurses Aide (E #6) who completed the safety round records on 6/27/11 on the Psychiatric General Care Unit. E #6 stated that she did not complete the safety rounds on time yesterday, because she was assigned to perform vital signs and breakfast monitoring for 6 - 7 patients, and then she went on her break.

6. The Assistant Vice President of Nursing Behavioral Health confirmed these findings during an interview on 6/28/11 at approximately 10:45 AM. The hospital submitted on 6/28/11at 1 P.M. a revised policy, titled "Precautions"- Close Watch rounds are assigned to specific staff members for specific blocks of time. The Staff member completing their assigned rounds will hand the Close Watch rounds board with all the Close Watch round sheets to the next staff member assigned. A QA has been set up to monitor and staff education began on 6/28/11 for staff.

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B. Based on observation, review of Hospital policy, and staff interview, it was determined that for 2 of 2 (Intensive and General) Psychiatric units, the Hospital failed to ensure that the environment was safe.

Findings include:

1. An observational tour of Psychiatric Intensive Care Unit and Psychiatric General Care Unit was conducted on 6/27/11 betwe

A. Based on a review of the Hospital's 3rd and 4th Nursing Unit Floors "Organizational Indicators", Occurrence Reports for year 2011, Trend Analysis Data for 3 of 3 years (2009, 2010 and 2011), and staff interview, it was determined that the Hospital failed to ensure falls data was used to identify changes for improvement.

Findings include:

1. On 6/30/11 at approximately 12:15 PM, the Hospital's "Organizational Indicators" were reviewed. The indicators for patient falls included, " Evaluate the effectiveness of all fall reduction activities including assessment, interventions and education."

2. On 6/30/11 at approximately 12:30 PM, Occurrence Reports for the 3rd and 4th Nursing Unit Floors for January 2011 through April 2011 regarding patient falls were reviewed with the following findings:

* The third floor nursing unit there had 38 patient falls.

* The 4th floor nursing units had 24 patient falls.

3. On 6/30/11 at approximately 12:40 PM the Facility's "In Patient Falls Trend Analysis" for 2009, 2010 and 2011 was reviewed with the following findings:

* January 2009 - December 2009: Falls = 196
* January 2010 - December 2010: Falls = 201
* January 2011 - April 2011: Falls = 88

There was no documentation to evidence that any analysis, evaluation or implementation of fall reduction activities were conducted to improve patient safety.

4. The above findings were discussed with Vice President of Nursing on 6/30/1 at approximately 2:45 PM.


B. Based on a review of Medication Errors report for 3 of 3 months in 2011 (March, April and May 2011), it was determined that the Hospital failed to ensure evaluation of dispensing errors by pharmacy

Findings include:

1. On 6/30/11 at approximately 2:45 PM, pharmacy medication errors of March, April and May 2011 Occurrence Reports were reviewed. On April 15, 2011 the pharmacy sent 8 mg (milligrams) of Coumadin to the nursing unit instead of 4 mg as ordered. On May 1, 2011 the pharmacy sent a 2 mg tablet of Requip to the nursing unit instead of 6 mg as ordered.

2. The Director of Pharmacy was interviewed on 6/30/11 at approximately 2:30 PM. The Director stated that individual pharmacy dispensing mistakes are evaluated in the department meeting minutes. However upon review of the minutes for 2011 the above medication errors were not mentioned or evaluated.

3. The above finding was discussed with the Director of Pharmacy during an interview on 6/30/11 at approximately 3:00 PM.

A. Based on observation and staff interview, it was determined that for 2 of 2 (3 oz.) bottles of sterile water observe, the Hospital failed to ensure that the sterile water had not expired.

Findings include:

1. On 6/27/11, at approximately 9:30 AM, a tour was conducted in the infant nursery. A drawer of 1 of 2 supply carts contained 2 (3 oz) bottles of infant sterile water with an expiration date of 3/2011.

2. The above findings were confirmed with the VP of Special Care Areas on 6/27/11 at approximately 10:00 AM.


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B. Based on observation, staff interview, and review of Hospital policy, it was determined that for 2 of 2 operating rooms (OR) (OR #4 and 7) observed, the Facility failed to ensure a sanitary environment.

Findings include:

1. An observational tour of Operating Rooms #4 and #7 was conducted on 6/28/11 between 6:30 AM and 8:00 AM. The following observations were made:

- At approximately 6:40 AM in OR #4 , 2 of 2 detachable arm rests for the surgical table contained tape residue on the surfaces. Seven of 9 rolling carts contained brown stains on the wheels (removable by wiping with Surgical Tech present). The floor contained brownish yellow stains around the surgical cart (removable by rubbing with Surgical Tech present).

- At approximately 6:50 AM in OR #7, the base of the surgical table and the electric cord contained tape residue.

2. The Hospital policy, entitled "Environmental Cleaning in the Surgical Setting", was reviewed on 6/28/11 at approximately 11:15 AM. This policy required "...Patients will be provided a safe and visibly clean surgical environment..."

3. The above findings were confirmed with the OR Clinical Nurse Manager on 6/28/11 at approximately 8:30 AM.

A. Based on Hospital policy review, an observational tour of the operating room suites (OR#s 1-9) and staff interview, it was determined that for 1 of 1 opened surgical packs observed (OR# #5), the Hospital failed to ensure the opened surgical packs were continuously monitored.

Findings include:

1. On 6/28/11 at approximately 1:30 PM, Facility policy titled,"Maintaining A Sterile Field" was reviewed. The policy included," A sterile field will be constantly monitored and maintained."

2. On 6/28/11 at approximately 6:50 AM, the surveyor observed laparoscopy packs opened and unattended in OR #5. According to the Clinical Nurse Manager, the packs were opened at 6:40 AM.

3. The above finding was confirmed with the Clinical Nurse Manager during an interview on 6/28/11 at approximately 6:50 AM


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B. Based on review of Hospital policy, observation,and staff interview it was determined that for 2 of 6 (E#4 and 5) staff members present in the Operating Room (OR), the Hospital failed to ensure adherence to the dress code policy for the operating room.

Findings include:

1. The Hospital policy, entitled "Dress Code for Surgical Environment", was reviewed on 6/27/11 at approximately 3:00 PM. The policy required "...Surgical head covers or hoods that confine all hair will be worn by all personnel entering the surgical environment...All persons entering restricted areas of the surgical environment will wear a mask...The mask will cover both mouth and nose and be secured in a manner that prevents venting..."

2. An observational tour of OR #4 was conducted on 6/28/11 between 6:30 AM and 8:00 AM. The following was observed during the tour:

- At approximately 7:05 AM, in OR #4, where sterile instruments were open, E #4 entered OR #4 with his face mask held in place with his hand and mask was untied.

Approximately 2 inches of hair to back of E #4's head was not covered by surgical head cover.

- At approximately 7:55 AM, E #5 entered OR #4 with her face mask held in place with her hand and mask was untied. Scrubbed personnel and open sterile items were present in OR #4 at this time.

3. The above findings were confirmed with the OR Clinical Nurse Manager on 6/28/11 at approximately 8:30 AM.