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Based on interview and record review, the facility did not ensure the staff follow the facility policy for Code Blue documentation and nursing documentation related to the Code Blue for one closed record. This had the potential to affect all facility patients who had a medical emergency that required the immediate response of a team of hospital employees for a Code Blue.

Findings included:

Record review of Patient #32's medical chart revealed the patient was admitted to the facility on 1/29/10 for respiratory failure (inadequate gas exchange).

Record review of the patient's medical chart revealed the following information:
-The nursing documentation dated 2/14/10 at 4:17 a.m. revealed the following "Code blue called. immediate response. Pt sent to ICU per dr order."
-The nursing documentation dated 2/15/10 at 4:00 a.m. revealed the following "late entry. (with an arrow drawn to "For 2/14/10) Called in room. RT in with PT. Trach out. NG tube out. Pt non responsive. No pulse. Pt not breathing. RT attempting to bag pt. Code blue called."

Record review of the Code Blue Record dated 2/14/10 at 4:15 a.m. revealed in part the following information:
-The following areas were not completed:
Patient Name (stamp of patient information in upper right hand corner of form) Concluded at: no information in blank,
BP is blank,
Pulse is blank
Pupils is blank
Oral is blank
Size is blank
Disposition: Resuscitated is blank
Authorizing Physician and Respiratory Therapist did not sign under signatures.

Record review of the Confidential Incident Report dated 2/14/10 at 4:14 a.m. revealed the following information:
-Immediate Follow- Up: The yes/no boxes were not checked for: Did a physician examine patient? Were lab/diagnostic tests ordered? If fall, was family notified?
-No time was written for notification of the physician.
-No time was listed after Code team in second physician name slot.
-Family Member's Name, Date and Time is not listed .

Record review of the facilities Policy and Procedure CPR Code revised 2/1/02 revealed the following information:
POLICY:
Any staff member that finds a patient or visitor without adequate life signs or whose condition is deteriorating rapidly to a life-threatening situation, will initiate a call denoting a cardiac/respiratory arrest is in progress.
PROCEDURE:
A. Establish unresponsiveness and call for help by activating the cardiac/respiratory arrest process via the telephone in the patient room or the call system.
C. First available nurse/employee arriving after BLS (Basic Life Support) has been initiated should dial and activate cardiac/respiratory arrest process.
N. Code Critique sheet will be completed at the code with input from all personnel participating in the Code.

Record review of the facility's Policy and Procedure for Documentation Standards revised date 6/17/08 revealed in part the following information:
PURPOSE:
To provide clinical personnel with requirements for documentation that will:
1. Provide a current, complete and concise description of the patient's status with minimal duplication of information.
3. Provide useful information in a retrievable format.

During an interview on 3/4/10 at 10:30 a.m. the Director of Nursing (DON) F stated the charge nurse was called for the Code Blue but when he/she got up from the chair; she fell and hit her head and was unconscious and no code critique sheet was done. The DON also stated there was no documentation as cited in the Code Blue sheet.

Based on observation and interview, the facility failed to clean and maintain furniture, floors, painted door frames and painted wall surfaces in a condition that presents a clean, sanitary and safe environment to provide a surface that can be cleaned to assure a high quality of infection control and promotes safe patient care services in 21 of 21 patient rooms, clean and soiled utility rooms, two shower rooms and corridors of the third floor wing with a patient census of 28 patients.

Findings include:

1. Observation during tours on 3/1/10 at 1:38 P.M. through 3/3/10 at 4:30 P.M. showed walls and other painted surfaces in patient rooms 304 through 327 to be damaged in varying degrees of severity, gouged and scratched wall surfaces with some damages repaired and some damages painted over. Remnants of tape and tape residue remained on the walls of the 21 resident rooms marred the painted surfaces. Chips of paint missing from door frames exposed light colored paint underneath; floors were dusty, dull and streaked with smears, used Kleenex tissues, fuzz balls, Alochol prep pads, wrappers used gloves, yellow ribbon ties from paper gowns, pieces of paper and plastic wrappers. A brown line of accumulated unidentified soils extended along the cove base edge, from the entrance door around the perimeter of each room.

2. Observations on 3/1/10 at 2:30 P.M. through 4:00 P.M. showed several wet towels and used clothing items on the floor of two common shower rooms located north of the clean and soiled utility rooms. A partially detached drawer face hung from the bedside table used in the northwest common shower room.

3. Observations of the soiled utility room on 3/1/10 at 2:35 P.M. through 4:00 P.M. showed the following:
-Two feeding pumps/IV stands with legs and wheels soiled with dirt and dried liquid splatters.
- Brown stained hopper bowl with brown splatters around the rim.
-Chunks of red gooey residue that looked like gelatin candy and a green leaf of lettuce stuck to the lids, which were jammed open by a disposable plastic salad/deli tray.
- Medium sized bowel movement of brown stool on the seat of a portable toilet in front of the two basin sink. Several pieces of the BM were on the floor below the toilet.
-Both sink basins were inaccessible and drain boards of the two basin wash sink were filled with a bedside commode, milk crate; two isolation precaution dispensing stations containing boxes of gloves, paper gowns and other cloaking apparatus, two table top fans with fuzz on their blades, a black vinyl covered seat cushion.
-One of the two sink fixtures was dripping and had a sign taped on it "Do not use this please."

Observation the next morning on 3/2/10 at 8:45 A.M. showed the wet towels had been picked up from the two common shower rooms. The soiled utility room had been policed up, with fewer items piled on the sink and more of those items moved to the floor under the sink. The portable toilets had been moved or removed. However, several pea-sized chunks of brown fecal material still remained on the floor in front of the sink's drain board where it had fallen off the lid of the portable toilet. The wastepaper basket was full and lids blocked open with paper and plastic trash. Other items that were either in the sinks or on the drain boards the afternoon of 3/1/10, such as the milk crate, chair cushion and isolation precaution dispensers had simply been moved and stacked under the sink. A second large blue linen cart had been added and began to fill throughout the day until 4:20 P.M. when it was last observed.

Observation on 3/3/10 at 10:45 A.M., both of the large blue carts of soiled linen were still sitting in the soiled utility room and filled above the top. Observation prior to the noon meal at 12:00, revealed both carts full and two bags of soiled linen on the floor of the soiled utility room. The brown stained hopper basin and brown splatters around the rim did not appear to have been cleaned three days later prior to exit, on 3/3/10, shortly after 4:00 P.M.

Review of documents provided by the facility on 3/3/10 revealed the facility contracts with the host facility for housekeeping services to clean patient rooms and patient isolation rooms after they are notified of a patient discharge. The housekeeping service contract with the host facility does not cover cleaning and care of the soiled utility rooms on three west.

During an interview on 3/3/10 at the Director of Housekeeping Services (DHS) said the host facility housekeepers are scheduled on the wing twice daily for regular maintenance cleaning such as sweeping floors, dusting surfaces and emptying trash. She said housekeepers put on gowns, gloves and mask before entering any room labeled for contact precautions as. She said all her staff have received hazard awareness training by the Department of Transportation (DOT) and know how to differentiate between hazmat and non-biomedical trash. They routinely handle both during their regular duties cleaning patient rooms. She confirmed the host facility's provision of housekeeing services does not include the three west hospital's soiled utility room and clean utility room. She said the tennant facility is responsible for cleaning their own soiled utility and clean utility rooms.

She said for her floor crew to strip, wax and buff a floor in a patient room, they need approximately 24 hours turn time between patients occupying a room. She said the high occupancy rate of the wing has prevented them from doing anything but sweeping and mopping the floors, dusting and wiping furnishings, and emptying the trash.

The Director of Maintenance Services for the host facility said his contractual obligations with the facility are roughly the same as with the housekeeping department. He said they have made some wall repairs and address what work orders they can. However, for them to patch, sand and repaint a wall or walls in a patient room, they usually need about 48 hours. He said it is just as easy for them to do the whole room as it is one wall; however the problem is getting the facility to free up a room for more than one day, so maintenance has an opportunity to go in, repair damaged walls, paint and make any necessary repairs to equipment.




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4. Observation and interview on 03/01/10 at 2:12 p.m. revealed the facility crash cart, and equipment on top of the cart, including the Gomco suction machine was covered with dust. Interview with Registered Nurse staff member A revealed the facility had no schedule to clean the crash cart.

5. Observation on 03/01/10 at 3:40 p.m. revealed a pile of items on the floor, including trash, an opened lancet (used to stick a finger for blood sugar testing), supplies, kleenex, dirt, dust, etc. in Room #325.

6. Observation on 03/02/10 at 9:19 a.m. revealed a cotton ball with a dried red substance on it on the floor, and the window sill was dusty. There was also trash under the bed, including a straw and straw wrapper in Room #307.

7. Observation on 03/02/10 at 9:33 a.m. revealed a rubber glove, an alcohol pad, and an alcohol pad wrapper on the floor in Room #305.


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8. Observation on 3/1/10 at 2:20 p.m. revealed straws on floor of Room 311.

10. Observation on 3/1/10 at 2:45 p.m. revealed yellow ties on the floor by the bin used to dispose of gowns worn for contact isolation in Room 308.

11. Observation on 3/1/10 at 2:55 p.m. revealed yellow ties on the floor by the bin used to dispose of gowns worn for contact isolation in Room 317.

12. Observation on 3/1/10 at 2:55 p.m. revealed a Kleenex on the floor of Room 307.

Based on observation the facility failed to ensure medical records were maintained securely for four patient's records (Patients in rooms 306, 311, 314, and 315). The facility census was 28.

Findings Included:

1. Observation on 03/02/10 at 9:16 through 9:18 a.m. revealed records (entire medical record from admission through current date) for patients in room's 311, 314, and 315 were in an unlocked Wallaroo (small, lockable cabinet outside room that houses the patient's medical record) accessible to unauthorized persons.

2. Observation on 03/02/10 at 9:31 a.m. revealed the entire medical record for the patient in room # 306 in an unlocked Wallaroo, accessible to unauthorized persons.



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3. Observation on 03/02/10 at 9:38 A.M. through 10:35 A.M. revealed unlocked Wallaroo units containing medical records for patients in room #'s 305, 308, 311, 314, 315, 316, 317, 321, 324, 326, 327. A silver label at the top of each box admonished the user to "PLEASE KEEP LOCKED AT ALL TIMES."

Observation of the locking mechanism revealed the lock would not automatically latch when the spring loaded door was released. The tumblers had to be manually turned to reengage the hasp and secure the cabinet door.



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4. Observation of a wallaroo on 03/03/10 at 9:10 a.m. for Patient #10 revealed the wallaroo failed to be locked and contained the patient's clinical record, making the clinical record accessible to unauthorized persons.