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Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community.

FINDINGS INCLUDED:
A-701: The facility did not have ceilings free of damage, and floors free of damage.

A-709: The facility failed to maintain a safe environment from fire based on the following K-tags.
· K-11 (separation of commonwall with another facility);
· K-20 (vertical floor separation or shaft);
· K-25 (smoke barrier);
· K-48 (written plan for fire emergency & evacuation);
· K-50 (fire drill requirements);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-70 (portable space heater devices);
· K-144 (inspection & maintenance of emergency generators);
· K-147 (electrical wiring, identification & equipment);
· K-154 (automatic sprinkler system out-of-service & fire watch requirements) and
· K-155 (fire alarm system out-of-service & fire watch requirements).

Based on the cumulative effects of the above findings, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
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Based on record review and interview, the facility failed to individualize patient plans of care in 21 of 21 (#1, 2, 6, 7, 8, 9, 10, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30) inpatient records reviewed. This deficiency potentially affects all inpatients at this facility.

Findings include:

During interview on 9/16/14 at 3:30 PM, RN H stated this facility does not have a policy on care planning.

During interview on 9/16/14 at 2:10 PM, Dir of Pt Services B stated their practice is to add only one careplan to each patient record. Although the careplans have blank areas labeled "other" to customized the careplan, Dir of Pt Services B stated they do not individualize the care plans as the plans are built to incorporate the needs of any patient coming to this facility. Dir of Pt Services B stated "all our patients are healthy." The careplans contain an area titled "related to" followed by options to choose from as to why the careplan applies to the individual patient. Dir of Pt Services B stated it is not their practice to customize this area as it was built to incorporate any patients needs.

Review of Pt #1's MR on 09/12/2014 at 09:20 AM revealed a careplan initiated on 09/12/2014 at 09:00 AM consisting of one problem titled, "Comfort, Alteration In - Postpartum". The careplan did not indicate reason for pain and, goals and interventions were not individualized to meet the needs of Pt #1.

Review of Pt #2's MR on 09/15/2014 at 09:00 AM revealed a careplan initiated on 09/13/2014 at 08:00 AM consisting of one problem titled, "Comfort, Alteration In - Postpartum". The careplan did not indicate reason for pain and, goals and interventions were not individualized to meet the needs of Pt #2.

Review of Pt #6's MR on 09/16/2014 at 11:25 AM revealed a careplan initiated on 07/04/2014 at 02:30 AM consisting of one problem titled, "Injury, Risk for -Postpartum". The careplan did not indicate reason for potential injury and, goals and interventions were not individualized to meet the needs of Pt #6.

Review of Pt #7's MR on 09/16/2014 at 11:55 AM revealed a careplan initiated on 06/12/2014 at 12:00 PM consisting of one problem titled, "Comfort, Alteration in - Postpartum". The careplan did not indicate the reason for pain and, goals and interventions were not individualized to meet the needs of Pt #7.

Review of Pt #8's MR on 09/16/2014 at 12:45 PM revealed a careplan initiated on 07/04/2014 at 14:00 PM consisting of one problem titled, "Injury, Risk for - Newborn". The careplan did not indicate reason for risk and, goals and interventions were not individualized to meet the needs of Pt #8.

Review of Pt #9's MR on 09/16/2014 at 09:05 AM revealed a careplan initiated on 09/12/2014 at 09:00 AM consisting of one problem titled, "Feeding, Risk for Ineffective Pattern - Newborn". The careplan did not indicate reason for feeding risk and, goals and interventions were not individualized to meet the needs of Pt #9.

Review of Pt #10's MR on 09/16/2014 at 09:25 AM revealed a careplan initiated on 09/13/2014 at 08:00 AM consisting of one problem titled, "Feeding, Risk for Ineffective Pattern - Newborn". The careplan did not indicate reason for feeding risk and, goals and interventions were not individualized to meet the needs of Pt #10.


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Review of Pt # 17's MR on 9/16/14 at 12:30 PM revealed a careplan initiated on 8/20/14 and titled "Comfort, Alteration in - Postpartum". The careplan did not indicate the reason for pain and, goals and interventions were not individualized to meet the needs of Pt #17.

Review of Pt # 18's MR on 9/16/14 at 12:45 PM revealed a careplan initiated on 8/19/14 and titled "Injury, Risk for - Postpartum". The careplan did not indicate any risks and, goals and interventions were not individualized to meet the needs of Pt #18.

Review of Pt # 19's MR on 9/16/14 at 1:30 PM revealed a careplan initiated on 8/4/14 and titled "Injury, Risk for - Postpartum". The careplan did not indicate any reason for risk and, goals and interventions were not individualized to meet the needs of Pt #19.

Review of Pt # 20's MR on 9/16/14 at 2:00 PM revealed a careplan initiated on 8/6/14 and titled "Injury, Risk for - Newborn". The careplan did not indicate any reason for risk and, goals and interventions were not individualized to meet the needs of Pt #20.


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Review of Pt # 21's MR on 9/16/2014 at 8:10 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Comfort, Alteration in - Postpartum". The careplan did not indicate reason for pain, and the goals and interventions were not individualized to meet the needs of Pt #21.

Review of P. # 22's MR on 9/16/2014 at 9:20 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Feeding, Risk for Ineffective Pattern-Newborn". The careplan did not indicate reason for feeding risk, and the goals or interventions were not individualized to meet the needs of Pt #22.

Review of Pt # 23's MR on 9/16/2014 at 10:00 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Comfort, Alteration in - Postpartum". The careplan did not indicate reason for pain, and the goals and interventions were not individualized to meet the needs of Pt #23.

Review of Pt # 24's MR on 9/16/2014 at 10:10 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Injury, Risk for - Newborn". The careplan did not indicate reason for risk, and the goals and interventions were not individualized to meet the needs of Pt #24.

Review of Pt # 25's MR on 9/16/2014 at 2:30 PM revealed a careplan initiated on 9/12/2014 consisting of one problem titled "Comfort, Alteration in - Postpartum". The careplan did not indicate reason for pain, and the goals and interventions were not individualized to meet the needs of Pt #25.

Review of Pt # 26's MR on 9/16/2014 at 10:20 AM revealed a careplan initiated on 9/12/2014 consisting of one problem titled "Injury, Risk for - Newborn". The careplan did not indicate reason for risk, and the goals and interventions were not individualized to meet the needs of Pt #26.

Review of Pt # 27's MR on 9/16/2014 at 10:40 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Comfort, Alteration in - Postpartum". The careplan did not indicate reason for pain, and the goals and interventions were not individualized to meet the needs of Pt #27.

Review of Pt # 28's MR on 9/16/2014 at 11:30 AM revealed a careplan initiated on 9/14/2014 consisting of one problem titled "Body Temperature, Risk for - Newborn". The careplan did not indicate reason for risk, and the goals and interventions were not individualized to meet the needs of Pt #28.

Review of Pt # 29's MR on 9/16/2014 at 12:50 PM revealed a careplan initiated on 9/15/2014 consisting of one problem titled "Comfort, Alteration in - Postpartum". The careplan did not indicate reason for pain, and the goals and interventions were not individualized to meet the needs of Pt #29.

Review of Pt # 30's MR on 9/16/2014 at 12:35 PM revealed a careplan initiated on 9/15/2014 consisting of one problem titled "Feeding, Risk for Ineffective Pattern-Newborn". The careplan did not indicate reason for feeding risk, and the goals and interventions were not individualized to meet the needs of Pt #30.

Based on record review and interview, staff failed to administer medication per policy to 3 of 5 infants (# 22, 24, 30) records reviewed. This could potentially affect all infants born at this facility.

Findings Include:

Per review on 9/16/2014 at 2:30 PM of policy titled Normal Newborn Nursery Protocol, policy # 500.34, dated 09/3013, stated under "VIII. A. Administer medications as ordered: 1. Erythromycin - administer at 1 hour of age."

Per interview with Director of Patient Services (DPS) B on 9/16/2014 at 9:30 AM, DPS B stated "Nurses are to be administering the Erythromycin ophthalmic ointment to eyes of baby within the first hour of age per policy."

Per review of Pt #22's MR on 9/16/2014 at 9:20 AM, Pt #22 was born on 9/14/2014 at 4:21 PM and erythromycin ophthalmic ointment was applied to eyes on 9/14/2014 at 5:47 PM.

Per review of Pt #24's MR on 9/16/2014 at 10:00 AM, Pt #24 was born on 9/15/2014 at 7:00 PM and erythromycin ophthalmic ointment was applied to eyes on 9/14/2014 at 9:19 PM.

Per review of Pt #30's MR on 9/16/2014 at 12:35 PM, Pt #30 was born on 9/15/2014 at 9:03 AM and erythromycin ophthalmic ointment was applied to eyes on 9/15/2014 at 11:09 AM. The above findings were shared with DPS B on 9/16/2014 at 2:35 PM.

Based on observation, staff interviews and review of maintenance records, the facility did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well being of patients. The facility did not have ceilings free of damage, and floors free of damage. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 09/15/2014 at 10:59 am, observation revealed on the Garden Terrace of Inpatient Smoke Compartment floor in the Clean Supply Room #G1540, that a portion of the ceiling was damaged and in need of repair. The ceiling was stained due to water from above the ceiling dripping onto the ceiling tile. This is a clean supplies room and all surfaces are required to be washable and cleanable. The hospital policy is to remove all damaged ceiling tiles if they cannot be cleaned. The last federal recertification survey was February, 2010. This observed situation was not compliant with 42 CFR 482.41(a). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

2. On 09/15/2014 at 11:02 am, observation revealed on the Garden Terrace of Inpatient Smoke Compartment floor in the Corridor outside the Clean Supply Room #G1540, that a portion of the ceiling was damaged and in need of repair. The ceiling was stained due to water from above the ceiling dripping onto the ceiling tile. The hospital policy is to remove all damaged ceiling tiles if they cannot be cleaned. The last federal recertification survey was February, 2010. This observed situation was not compliant with 42 CFR 482.41(a). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).

3. On 09/15/2014 at 10:58 am, observation revealed on the Garden Terrace of Inpatient Smoke Compartment floor in the Clean Supply Room #G1540, that a portion of the flooring was damaged and in need of repair. The sheet vinyl flooring material was pulling away from the wall edges at several walls and the sheet vinyl seam was coming apart at two locations in the middle of the floor. This damage renders this surface porous and non-cleanable. This observed situation was not compliant with 42 CFR 482.41(a). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff I (Manager Facilities).
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Based on observation, interview and review of record documentation, the facility failed to protect the patients, staff and visitors from fire.

FINDINGS INCLUDED:
The facility failed to protect the patients, staff and visitors from fire based on the following K-tags.
· K-11 (separation of commonwall with another facility);
· K-20 (vertical floor separation or shaft);
· K-25 (smoke barrier);
· K-48 (written plan for fire emergency & evacuation);
· K-50 (fire drill requirements);
· K-56 (installation of automatic sprinkler system);
· K-62 (maintenance of automatic sprinkler system);
· K-70 (portable space heater devices);
· K-144 (inspection & maintenance of emergency generators);
· K-147 (electrical wiring, identification & equipment);
· K-154 (automatic sprinkler system out-of-service & fire watch requirements) and
· K-155 (fire alarm system out-of-service & fire watch requirements).

Based on the cumulative effects of these findings, 42 CFR 482.41(b) Standard: Safety from Fire was NOT MET.

Greater detail may be found in each of the K-tags.
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Based on observation, record review and interview, the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection in 2 of 3 (surgery and anesthesia) areas observed.

Findings include:

Examples in Surgery:

During a tour of the surgical areas on 9/15/14 at 3:30 PM, accompanied by Dir of Services B, noted the following:

1) a waste collection cart OR 50 and OR 52 had large amounts of rust on the metal framing and wheels making the surface non-cleanable.
2) Papers and lamented sheets taped to the OR walls in OR 50, OR 51 and OR 52.
3) An uncovered cart containing supplies in OR 50.

Per interview with Dir of Services B on 9/15/14 at 3:45 PM, Dir of B stated the items on the supply cart would not be cleaned by housekeeping during terminal cleaning. Dir of B also stated the waste carts could be replaced and the tape could be removed from the walls.

Per interview with Housekeeper K on 9/15/14 at 10:30 AM during an observation of terminal cleaning in OR 50, Housekeeper K stated in reference to the waste carts "it's hard to know if it's rust or blood". Housekeeper K also stated the open, uncovered supply cart does not get touched during terminal cleaning.


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Examples in Anesthesia Supply Room:

Per observation of Anesthesia Supply room (G1641) on 9/15/2014 at 9:30 AM, found the following items; (1) bag of 100 mls 0.9% Sodium Chloride with expiration date of 8/1/2014, (15) bags of 50 mls of 0.9% Sodium Chloride with expiration date of 8/1/2014, (2) Nasopharyngeal Airways expired 1/2014 and 6/2014, (3) Laryngeal Masks with expiration date of 11/28/13, 10/28/2013, and 5/28/2014. Above findings were confirmed with DPS B at time of discovery.


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Per observation of Anesthesia Supply room on 09/15/2014 at 09:30 AM, found "Difficult Airway Cart" to have multiple items with compromised sterility. Drawer #2 revealed 3 McGill's oral airway guides (1 pink and 2 white) with no wrapping or packaging, 1 hemostat and 1 speculum with no wrapping or packaging, 8 laryngoscope blades (used to view larynx including the vocal cords during intubation) with no wrapping or packaging to determine sterility. Drawer #3 revealed 3 Laryngeal mask airways (used as an alternative to endotracheal tube) expired 1 on 5/28/2014 and 2 in 04/28/2014. DPS F stated, "open laryngoscopes may be a backup, I don't touch it, when I process (sterile processing) them, they go into a pink bucket, if they are flash sterilized they are in a package". When asked, who should be monitoring this cart? RN F stated, "the CRNA's should be monitoring this cart". Requested current P&P regarding expiration audits, CEO A stated, "we have no policy & procedure for that". DPS B produced a log on 09/16/2014 at 08:45 AM titled, "Expiration audit of par locations", which revealed that facility did the last audit on 08/13/2014.

During observation of 3 of 3 OR suites (OR #51, 52, 53) on 09/15/2014 at 03:30 PM, CRNA Staff D produced 3 Cricothyroidotomy sets (emergency procedure used to obtain an airway). 1 of 3 sets produced had an expiration date of 02/2013, 2 of 2 sets boxes appeared old, yellowed, and discolored but contained no expiration dates. DPS B stated, at the time of discovery, the items should be replaced.

Based on observation and interview, this facility failed to ensure required emergency medical equipment was easily accessible in 1 of 2 departments requiring emergency equipment (surgery department). This could potentially affect all patients having a medical emergency during an OR procedure.

Per observation on 09/15/2014 at 03:25 PM, found Dir of Pt Services B unable to locate required emergency medical equipment when asked. Dir B was unable to find required Tracheostomy set (procedure to gain an emergency airway), Thoracotomy set (procedure to gain access to the heart). Dir B stated, "I know we have them, I just can't find them." After 20 minutes, at 03:45 PM, Dir B located required Tracheostomy set and Thoracotomy set in the main supply closet located in OR hallway.

On 09/15/2014 at 03:45 PM during interview at time of discovery, Dir B stated, "we need to place these where staff know how to find them".