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Based on medical record review and staff interview, the hospital failed to ensure nursing staff monitored one of ten sampled patients for fetal heart tones (Patient #3), monitored for decreasing hemoglobin levels (Patient #3) and failed to ensure nursing staff were qualified and had been judged competent to care for patients to whom they were assigned (Patient #3).

Findings included;

The medical record of Patient #3 was reviewed on 05/10/10. According to the nursing notes, Patient #3, 30 weeks and 2 days pregnant, was admitted on 03/02/10 at 08:38 A.M. with complaints of severe lower abdominal pain rated at a 10 out of 10 on a 0-10 pain scale and had a high risk factor of (prescribed) narcotic drug use during pregnancy.

Late decelerations in the fetal heart rate following contractions were noted on the fetal monitor strip at 09:15 A.M. There were no late decelerations noted in the nursing notes. At 09:45 A.M. the fetal heart rate baseline was documented at 130 beats per minute. At 10:03 A.M. the nursing notes indicated that the patient was sitting straight up in bed, refusing to lie back making it difficult to monitor the fetal heart rate baseline. At 10:09 A.M. the nursing notes stated that the patient reported the abdominal pain being "too severe to lay still." It was further noted that the registered nurse (RN), Employee D, contacted the physician to see if the patient could be taken off of the monitor.

According to the nursing notes, the physician agreed to let Employee D take the patient off of the monitor at 10:12 A.M. There was no documentation that the physician was notified at that time of Patient #3's continual complaint of severe pain. The patient was put back on the monitor at 10:33 A.M. according to the nursing notes. The physician was not notified of the every 2 to 3 minute contractions that registered on the fetal monitor strip at 9:15 A.M. until 10:38 A.M. when the contractions became every minute apart. This was approximately one hour and 33 minutes later. The physician was never notified of the late decelerations that began occurring at 9:15 A.M.

According to the nursing notes at 10:45 A.M. the physician was notified of the blood noted on Employee D's glove following the vaginal exam. The physician ordered the patient be transported to a higher level of care facility at 10:58 A.M. There was no further documentation regarding transferring the patient to a higher level of care facility after this time.

The Maternity Services Manager, Employee C, of the maternity unit was interviewed on 05/11/10 and reported being present on the maternity unit on 03/02/10 at approximately 11:00 A.M. and heard the fetal heart tones and "knew that there was something wrong" and instructed Employee D who was caring for the patient to call the physician. At 11:26 A.M. the physician was asked to return to the maternity unit. At 11:29 A.M. the nursing notes indicated that the physician was at the bedside of Patient #3 performing an ultrasound. It was further noted that the ultrasound revealed no fetal cardiac activity at 11:30 A.M. At 4:30 P.M. Patient #3, without a physician in attendance, delivered a female infant in the bed. The infant was deceased at the time of delivery with a tight nuchal cord noted and no resuscitation efforts were taken. According to the physician's delivery note, the placenta had a huge, adherent clot covering the vast majority of the placental surface consistent with complete abruption.

These facts were verified with the Director of Quality, Employee A, on 05/12/10 at approximately 6:00 P.M.

The Maternity Services Manager, Employee C, was interviewed on 05/11/10 and reported that the registered nurse, Employee D, who was listed as an orientee on the staffing assignment sheets, had been out of orientation for approximately one year but had recently asked to go back into orientation for more experience in Labor and Delivery. The Maternity Services Manager, Employee C, further explained that the registered nurse, Employee D, reported not feeling comfortable caring for labor and delivery patients and wanted more exposure during the day. It was verified with the Maternity Services Manager, Employee C, on 05/11/10 that the registered nurse, Employee D who remained in orientation, was not qualified to care for patients without a preceptor and that no qualified preceptor had been assigned to her on 03/02/10.

Please refer to A397, 482.23(b)(5); Patient care assignments regarding the facility's failure to ensure staff were qualified to care for patients to whom they were assigned. This affected one of ten medical records reviewed, (Patient #3).

This substantiates the complaint.

Based on observations and staff interviews, the hospital failed to ensure the requirements of the Life Safety Code were met.

Findings included;

The facility lacked sprinklers are required by the building constructions type. See K12.
Penetrations were noted in smoke barriers. See K25.
The door in the smoke barrier needed to be on a self closer. See K27.
The egress exit access was not made safe to a paved common way. See K38
Emergency egress lights were not tested as required (building #2). See K46.

Smoke detectors were not tested as required (building #3). See K54.
Kitchen hood not UL-300 compliant. See K69.
The light switch in the medical gas storage was not located at least 5 foot from the floor. See K76.
Smoke detectors were located where air flow may obstruct their normal operation. See K130.

Based on medical record review and staff interview, the hospital failed to ensure the medical staff conducted a thorough and timely investigation into possible causative factors for two of two patients reviewed with negative outcomes (Patient #3 and #6) and failed to ensure medical staff completed medical records in a timely manner for one of ten medical records reviewed (Patient #6)

Findings included;

The medical record for Patient #6 was reviewed on 05/10/10. The medical record revealed the patient was admitted to the hospital on 03/05/10, for a scheduled vaginal hysterectomy (surgery). The operative note from this surgery stated, "During the course of dissection, I made a small hole in the anal mucosa just inside the anal verge." The operative note described the repair to this area by the surgeon. The medical record revealed the patient was transferred to the medical surgical unit 4:40 P.M. and was noted to have 10cc (approximately 1/3 of an ounce) of urine output. At 7:45 P.M., the patient was noted to have 30cc unit output. An IVP (test of urine flow from the kidneys) was performed on 03/06/10, (no time documented). This test showed "moderate to high grade bilateral obstruction of uncertain etiology. The patient was also given a CT (Computerized Tomography) scan which showed moderate distal ureteral obstruction. The nursing notes revealed the physician who performed the hysterectomy came to the facility to assess the patient at 3:06 A.M. The nursing notes stated the patient would be transferred to another hospital that has a urologist. The next nursing note in the record was at 7:40 A.M. and stated the surgical team "here to transport to OR" (operating room).

A consultation/operative note by the urologist was reviewed. The note indicated the left ureter was partially occluded with a stitch which was cut to open the left ureter. The right ureter was "totally transected". The operative note revealed the urologist was able to re-insert the right ureter. The surgery report also revealed stents were placed in both ureters. A third surgical procedure was required to remove the stents a month later.

Employee A presented surveyors with a Quality Assessment Referral. This document was presented as proof that a peer review had been completed. The document revealed the review of Patient #6's injury had been completed on 04/08/10. The injury was categorized as moderate with an increased length of stay. The issues were noted as "Clinical Technique" with a handwritten notation which stated, "Known potential complication." The physician reviewer's conclusions included the following options: "No quality of care concern identified, Quality of care concern identified, Opportunity for process improvement identified and Poor documentation." None of these options were checked. A handwritten note under the check box options stated; "Need to track." The Reviewer's action section also contained checkboxes. The two options for this area were: "No further action necessary and further committee review is needed." Neither option was marked. The surveyors requested further information regarding any contributing factors identified, corrective actions needed or taken and any further information. No documentation of the hospital's actions for follow up or actions taken to prevent recurrence of this type of injury was presented to the surveyors.

Employee A was interviewed on 05/11/10 at 9:15 A.M. and stated the results of the peer review determined this was a known complication and they would do trending. Employee A when questioned regarding what was done to prevent a recurrence, stated "Nothing" because this was felt to be a "known complication" and the reviewers "did not see there was anything deliberate done-it was an accident."

The medical record for Patient #6 lacked evidence of a discharge summary. Employee A confirmed on 05/12/10 at 8:32 A.M., that a discharge summary had not been completed for Patient #6. The medical staff by-laws were reviewed on 05/11/10. The by-laws revealed all medical records are to be complete at the time of discharge. Twenty days after discharge the physician is notified by regular mail and is given 10 days to complete the medical record. The physician is to be suspended if the medical records are not complete after that time. The physician responsible for the care of Patient #6 was noted to be providing patient care on 05/10/10 and was not under suspension per the requirements of the hospital's medical staff by-laws.

The medical record of Patient #3 was reviewed on 05/10/10. According to the nursing notes, Patient #3, 30 weeks and 2 days pregnant, was admitted on 03/02/10 at 08:38 A.M. with complaints of severe lower abdominal pain rated at a 10 out of 10 on a 0-10 pain scale and had a high risk factor of (prescribed) narcotic drug use during pregnancy. At 08:45 A.M. the nursing notes indicated that Patient #3 reported having been sick several times that morning. The patient stated: "the nausea is due to the pain." The nursing notes also indicated that the patient's abdomen palpated "soft" at this time. Palpation of the patient's abdomen was not documented again. The patient was noted to be 1 to 2 centimeters dilated at 08:45 A.M. The patient's heart rate was noted to be 112 at this time. The fetal heart rate baseline was noted to be 121 beats per minute at 09:00 A.M. The physician was noted to be at the bedside of the patient to perform an ultrasound at 09:00 A.M. There were no results of this ultrasound documented in the medical record. It was further noted in the nursing notes at 09:04 A.M. that the physician believed the patient was likely experiencing ligamentous pain or round ligament pain. According to the American College of Obstetricians & Gynecologists (ACOG), this pain is most often felt on the right side of the pelvis. According to the Medication Administration Record (MAR), the patient was medicated with 50 mg of Demerol (narcotic pain medication) and 25 mg of Phenergan (anti-emetic) intramuscularly in her thigh to relieve the pain and nausea at 09:15 A.M. The fetal monitor strip was reviewed on 05/10/10. Contractions were noted every 2 to 3 minutes beginning at 09:05 A.M. Contractions were not noted in the nursing notes until 10:38 A.M. Additionally, late decelerations in the fetal heart rate following contractions were noted on the fetal monitor strip at 09:15 A.M. There were no late decelerations noted in the nursing notes. At 09:45 A.M. the fetal heart rate baseline was documented at 130 beats per minute and it was further noted that the patient continued to vomit. At 10:03 A.M. the nursing notes indicated that the patient was sitting straight up in bed, refusing to lie back making it difficult to monitor the fetal heart rate baseline. At 10:09 A.M. the nursing notes stated that the patient reported the abdominal pain being "too severe to lay still." It was further noted that the registered nurse (RN), Employee D, contacted the physician to see if the patient could be taken off of the monitor.

The RN, Employee D, who cared for Patient #3 was interviewed on 05/12/10 at approximately 09:30 A.M. Employee D reported hearing the fetal heart rate "go down" at approximately 10:00 A.M. Employee D further explained that she went into the room in an attempt to reposition the monitor but the patient was being "difficult" and refused to let Employee D reposition the monitor to pick up the fetal heart rate. Employee D reported notifying the physician of the patient's refusal to be monitored. Employee D was asked if she notified the physician that she had heard the fetal heart rate go down and the RN replied that she had not notified the physician that she had heard the fetal heart rate go down. Prior to the conclusion of the interview, the Maternity Services Manager, Employee C, entered the room and declared to the surveyors that the interview with Employee D was over, therefore disrupting and interfering with the investigation.

According to the nursing notes, the physician agreed to let Employee D take the patient off of the monitor at 10:12 A.M. There was no documentation that the physician was notified at that time of Patient #3's continual complaint of severe pain and continued vomiting nearly one hour after the patient had received the Demerol and Phenergan. At 10:30 A.M. it was noted that the patient was again vomiting. A positive fetal fibronectin, indicating the possibility of premature delivery, was reported to the physician at 10:30 A.M. According to the nursing notes, when the physician was notified of the positive fetal fibronectin, the physician ordered Employee D to "perform a vaginal exam in a couple of hours." Patient #3 complained of worsening pain that was now intermittent and not constant. The patient was put back on the monitor at 10:33 A.M. according to the nursing notes. The physician was not notified of the every 2 to 3 minute contractions that registered on the fetal monitor strip at 9:15 A.M. until 10:38 A.M. when the contractions became every minute apart. This was approximately one hour and 33 minutes later. The physician was never notified of the late decelerations that began occurring at 9:15 A.M. Employee D noted blood on her glove during a vaginal exam at 10:45 A.M. The patient was noted to be further dilated to 2 to 3 centimeters. According to the nursing notes at 10:45 A.M. the physician was notified of the blood noted on Employee D's glove following the vaginal exam. The physician ordered the patient be transported to a higher level of care facility at 10:58 A.M. There was no further documentation regarding transferring the patient to a higher level of care facility after this time.

The fetal heart rate baseline was documented as 115 beats per minute at 11:00 A.M. The heart rate of Patient #3 was documented as 106 beats per minute at 11:21 A.M. and 119 beats per minute at 11:22 A.M. According to the nursing notes at 11:20 A.M. Patient #3 was given 10 liters of oxygen per face mask. It was further noted at 11:21 A.M. that the physician was notified of a moderate amount of blood in the bed but gave no new orders. The Maternity Services Manager, Employee C, of the maternity unit was interviewed on 05/11/10 and reported being present on the maternity unit on 03/02/10 at approximately 11:00 A.M. and heard the fetal heart tones and "knew that there was something wrong" and instructed Employee D who was caring for the patient to call the physician. At 11:26 A.M. the physician was asked to return to the maternity unit. At 11:29 A.M. the nursing notes indicated that the physician was at the bedside of Patient #3 performing an ultrasound. It was further noted that the ultrasound revealed no fetal cardiac activity at 11:30 A.M. At 4:30 P.M. Patient #3 without a physician in attendance delivered a female infant in the bed. The infant was deceased at the time of delivery with a tight nuchal cord noted and no resuscitation efforts were taken. According to the physician's delivery note, the placenta had a huge, adherent clot covering the vast majority of the placental surface consistent with complete abruption.

During an interview on 05/12/10, the Maternity Services Manager, Employee C, explained that the RN, Employee D, assigned to care for the patient was in orientation. Maternity Services Manager, Employee C, indicated that this RN, Employee D, had been oriented to labor and delivery but had recently approached her and asked if she could be re-oriented to labor and delivery during the day when there was an increased patient flow on the unit. The Maternity Services Manager, Employee C, indicated that the RN, Employee D, was comfortable with patients in the nursery and postpartum patients but was not comfortable with labor and delivery patients. Employee D was placed back in orientation on 01/27/10 and was still in this second orientation on 03/02/10.

The RN scheduled to be a preceptor called in ill on the morning of 03/02/10 leaving Employee D alone with a complicated and high risk patient.

These facts were verified with the Director of Quality, Employee A, on 05/12/10 at approximately 6:00 P.M.

The regular contractions and late fetal heart rate decelerations indicate that Patient #3 was in active labor with fetal distress as early as 9:15 A.M. Based on patient #3 being 30 weeks and 2 days pregnant, this would have required the patient be transferred to a higher level of care for treatment. The contractions, complaints of severe abdominal pain and late fetal heart rate decelerations indicate that Patient #3 was in active labor with fetal distress and possibly requiring a cesarean section. The patient was not transferred to a higher level of care facility, did not receive a cesarean section and experienced a complete placental abruption and an eventual stillborn birth.

An interview, conducted with Employee A on 05/11/10, revealed a peer review had been assigned for the medical record of Patient #3 but has not yet been completed. Employee A presented surveyors with a copy of the root cause analysis completed by the hospital. The root cause analysis revealed the following "human factors" were identified: "Physician knows patient. Patient has a history of chronic back pain and 'histrionics'. Physician states that this knowledge affected her (physician) thinking." No documentation or evidence of hospital follow up with the physician or actions taken to prevent a recurrence was presented to the surveyors.

These findings were reviewed with Employee A and C on 05/14/10 at 11:30 A.M. at the time of exit.

Based on personnel file review and staff interview, the facility failed to ensure staff were qualified to care for patients to whom they were assigned. This affected one of ten sampled medical records reviewed, (Patient #3).

Findings Include:

The medical record of Patient #3 was reviewed on 05/10/10. According to the nursing notes, Patient #3, 30 weeks and 2 days pregnant, was admitted on 03/02/10 at 08:38 A.M. with complaints of severe lower abdominal pain rated at a 10 out of 10 on a 0-10 pain scale and had a high risk factor of (prescribed) narcotic drug use during pregnancy. At 08:45 A.M. the nursing notes indicated that Patient #3 reported having been sick several times that morning. The patient stated: "the nausea is due to the pain." The nursing notes also indicated that the patient's abdomen palpated "soft" at this time. Palpation of the patient's abdomen was not documented again. The patient was noted to be 1 to 2 centimeters dilated at 08:45 A.M. The patient's heart rate was noted to be 112 at this time. The fetal heart rate baseline was noted to be 121 beats per minute at 09:00 A.M. The physician was noted to be at the bedside of the patient to perform an ultrasound at 09:00 A.M. There were no results of this ultrasound documented in the medical record.

It was further noted in the nursing notes at 09:04 A.M. that the physician believed the patient was likely experiencing ligamentous pain or round ligament pain. According to the American College of Obstetricians & Gynecologists (ACOG), this pain is most often felt on the right side of the pelvis. According to the Medication Administration Record (MAR), the patient was medicated with 50 mg of Demerol (narcotic pain medication) and 25 mg of Phenergan (anti-emetic) intramuscularly in her thigh to relieve the pain and nausea at 09:15 A.M.

The fetal monitor strip was reviewed on 05/10/10. Contractions were noted every 2 to 3 minutes beginning at 09:05 A.M. Contractions were not noted in the nursing notes until 10:38 A.M. Additionally, late decelerations in the fetal heart rate following contractions were noted on the fetal monitor strip at 09:15 A.M. There were no late decelerations noted in the nursing notes. At 09:45 A.M. the fetal heart rate baseline was documented at 130 beats per minute and it was further noted that the patient continued to vomit. At 10:03 A.M. the nursing notes indicated that the patient was sitting straight up in bed, refusing to lie back making it difficult to monitor the fetal heart rate baseline. At 10:09 A.M. the nursing notes stated that the patient reported the abdominal pain being "too severe to lay still." It was further noted that the registered nurse (RN), Employee D, contacted the physician to see if the patient could be taken off of the monitor.

The RN, Employee D, who cared for Patient #3 was interviewed on 05/12/10 at approximately 09:30 A.M. Employee D reported hearing the fetal heart rate "go down" at approximately 10:00 A.M. Employee D further explained that she went into the room in an attempt to reposition the monitor, but the patient was being "difficult" and refused to let Employee D reposition the monitor to pick up the fetal heart rate. Employee D reported notifying the physician of the patient's refusal to be monitored. Employee D was asked if she notified the physician that she had heard the fetal heart rate go down and the RN replied that she had not notified the physician that she had heard the fetal heart rate go down. Prior to the conclusion of the interview, the Maternity Services Manager, Employee C, entered the room and declared to the surveyors that the interview with Employee D was over, therefore disrupting and interfering with the investigation.

According to the nursing notes, the physician agreed to let Employee D take the patient off of the monitor at 10:12 A.M. There was no documentation that the physician was notified at that time of Patient #3's continual complaint of severe pain and continued vomiting nearly one hour after the patient had received the Demerol and Phenergan. At 10:30 A.M. it was noted that the patient was again vomiting. A positive fetal fibronectin, indicating the possibility of premature delivery, was reported to the physician at 10:30 A.M. According to the nursing notes, when the physician was notified of the positive fetal fibronectin, the physician ordered Employee D to "perform a vaginal exam in a couple of hours." Patient #3 complained of worsening pain that was now intermittent and not constant. The patient was put back on the monitor at 10:33 A.M. according to the nursing notes. The physician was not notified of the every 2 to 3 minute contractions that registered on the fetal monitor strip at 9:15 A.M. until 10:38 A.M. when the contractions became every minute apart. This was approximately one hour and 33 minutes later. The physician was never notified of the late decelerations that began occurring at 9:15 A.M. Employee D noted blood on her glove during a vaginal exam at 10:45 A.M. The patient was noted to be further dilated to 2 to 3 centimeters. According to the nursing notes at 10:45 A.M. the physician was notified of the blood noted on Employee D's glove following the vaginal exam. The physician ordered the patient be transported to a higher level of care facility at 10:58 A.M. There was no further documentation regarding transferring the patient to a higher level of care facility after this time.

The fetal heart rate baseline was documented as 115 beats per minute at 11:00 A.M. The heart rate of Patient #3 was documented as 106 beats per minute at 11:21 A.M. and 119 beats per minute at 11:22 A.M. According to the nursing notes at 11:20 A.M. Patient #3 was given 10 liters of oxygen per face mask. It was further noted at 11:21 A.M. that the physician was notified of a moderate amount of blood in the bed but gave no new orders. The Maternity Services Manager, Employee C, of the maternity unit was interviewed on 05/11/10 and reported being present on the maternity unit on 03/02/10 at approximately 11:00 A.M. and heard the fetal heart tones and "knew that there was something wrong" and instructed Employee D who was caring for the patient to call the physician. At 11:26 A.M. the physician was asked to return to the maternity unit. At 11:29 A.M. the nursing notes indicated that the physician was at the bedside of Patient #3 performing an ultrasound. It was further noted that the ultrasound revealed no fetal cardiac activity at 11:30 A.M. At 4:30 P.M. Patient #3 without a physician in attendance delivered a female infant in the bed. The infant was deceased at the time of delivery with a tight nuchal cord noted and no resuscitation efforts were taken. According to the physician's delivery note, the placenta had a huge, adherent clot covering the vast majority of the placental surface consistent with complete abruption.

During an interview on 05/12/10, the Maternity Services Manager, Employee C, explained that the RN, Employee D, assigned to care for the patient was in orientation. Maternity Services Manager, Employee C, indicated that this RN, Employee D, had been oriented to labor and delivery but had recently approached her and asked if she could be re-oriented to labor and delivery during the day when there was an increased patient flow on the unit. The Maternity Services Manager, Employee C, indicated that the RN, Employee D, was comfortable with patients in the nursery and postpartum patients but was not comfortable with labor and delivery patients. Employee D was placed back in orientation on 01/27/10 and was still in this second orientation on 03/02/10.

These facts were verified with the Director of Quality, Employee A, on 05/12/10 at approximately 6:00 P.M.

The RN scheduled to be a preceptor called in ill on the morning of 03/02/10 leaving Employee D alone with a complicated and high risk patient.

The regular contractions and late fetal heart rate decelerations indicate that Patient #3 was in active labor with fetal distress as early as 9:15 A.M. Based on patient #3 being 30 weeks and 2 days pregnant, this would have required the patient be transferred to a higher level of care for treatment. The contractions, complaints of severe abdominal pain and late fetal heart rate decelerations indicate that Patient #3 was in active labor with fetal distress and possibly requiring a cesarean section. The patient was not transferred to a higher level of care facility, did not receive a cesarean section and experienced a complete placental abruption and an eventual stillborn birth.

The personnel record of Employee D was reviewed on 05/11/10. It was noted that there were no preceptor initials next to the "Complicated Obstetrical Patient" skills including skills such as "Preterm Labor" and "Other Obstetrical Complications." These facts were verified with the Maternity Services Manager, Employee C, on 05/11/10 at approximately 11:45 A.M.

Maternity unit staffing assignment sheets for 03/01/10 through 03/03/10 were reviewed on 05/11/10. It was noted that a registered nurse, Employee D that was listed as an orientee on 03/01/10 was the nurse caring for three postpartum patients and one antepartum patient on 03/02/10. It was further noted that on 03/03/10, the same registered nurse, Employee D was again listed as an orientee. The Maternity Services Manager, Employee C, was interviewed on 05/11/10 and reported that the registered nurse, Employee D, who was listed as an orientee on the staffing assignment sheets, had been out of orientation for approximately one year but had recently asked to go back into orientation for more experience in Labor and Delivery. The Maternity Services Manager, Employee C, further explained that the registered nurse, Employee D, reported not feeling comfortable caring for labor and delivery patients and wanted more exposure during the day. It was verified with the Maternity Services Manager, Employee C, on 05/11/10 that the registered nurse, Employee D who remained in orientation, was not qualified to care for patients without a preceptor and that no qualified preceptor had been assigned to her on 03/02/10.

These findings substantiate the complaint.

Based on observations and staff interviews, the hospital failed to ensure the requirements of the Life Safety Code were met.

Findings included;

The facility lacked sprinklers are required by the building constructions type. See K12.
Penetrations were noted in smoke barriers. See K25.
The door in the smoke barrier needed to be on a self closer. See K27.
The egress exit access was not made safe to a paved common way. See K38
Emergency egress lights were not tested as required (building #2). See K46.

Smoke detectors were not tested as required (building #3). See K54.
Kitchen hood not UL-300 compliant. See K69.
The light switch in the medical gas storage was not located at least 5 foot from the floor. See K76.
Smoke detectors were located where air flow may obstruct their normal operation. See K130.

Observations of the maternity, medical/surgical and intensive care units were made on 05/10/10.

In room 58 of the maternity unit, the heater unit was noted to have rust colored material on the top grate surface, the sleeper chair in the room was noted to have three breaks in the surface on the left arm and two additional areas on the seat. The floor was noted to have a one foot square break in the surface with dust and debris collected in the area. The shower was noted to have a broken piece of metal on the surface of the shower enclosure, the light in the ceiling of the shower was noted to have a screw missing from the light fixture resulting in the fixture not being flush with the surface. The bottom drawer of the bedside stand was noted to have a large area of rust colored discoloration. The stool located in the room also had a break in the surface.

A sleeper chair was noted in the observation area of the unit which also had a break in the surface on the right arm of the chair. A section of the back wall of the observation area was noted to have paint and drywall loose which had been taped back into place.

Room 52 of the maternity unit was also noted to have a two foot square section of the floor with a broken surface. Dust and debris had collected in this area.

Warmer #1 was located inside the newborn nursery. It was located in the clean area and set up for use with a clean blanket on the mattress. The corners by the bottom shelf were noted to contain a thick brown substance. A thermometer probe was noted underneath the mattress in the x-ray tray. The thermometer probe contained a dried greenish brown discoloration on the insertion end which resembled meconium.

The medical/surgical unit was also observed on 05/10/10. The bedside table in room 16 contained a heavy buildup of a raised rust colored substance. The heater in room 17 contained a heavy buildup of dust and debris to the right corner. Room 19 had a geri-chair with a broken, unclean surface. Room 25 also contained a geri-chair with a broken, unclean surface. The area directly under the sink in the dirty utility room was noted to contain an electric fan, a container of bleach, the collection tub of a bedside commode, multiple flower vases and a sharps container which had part of syringe extending from the top of the container.

The main hallway contained a trash can next to the wall. The ceiling tiles above this area were removed and the wall was noted to be wet to the touch. An area was also noted outside the entrance to the medical/surgical unit with peeling paint and plaster. The medical/surgical unit had a pervasive damp, musty odor (like flood water) permeating the unit. Employee E was interviewed on 05/10/10 at 3:16 P.M. Employee E stated the hospital has been trying to get a new roof but does not have the capital to do so. Employee E confirmed the roof is leaking and that was the purpose of the trash can located in the medical/surgical hallway. Employee E stated they are "trying to capture as much (water) as possible". Employee E stated the medical/surgical unit is located in a "1960s wing" and has interior insulated duct work. He/she further stated the air handler system is in the basement and the odor is because it's an older system. Employee E stated tests were done for mold in 07/04 but have not been repeated since that time. He/she further stated the roof has been leaking "on and off for five years, chronic for a year". Employee E stated there is currently no time line for repairs.

A second observation of the unit on 05/13/10 revealed the trash can had been removed from the hallway and the ceiling tiles replaced. An area of the wall outside the entrance to the medical/surgical unit had a fresh drywall patch. These repairs had decreased the odor of the unit, although no mold studies were available to determine the safety of the area.

The intensive care unit was observed. Room CCU-B had plastic bags, and gloves under the sink. The veneer coating on the cabinets was noted to be loose or missing in multiple spots leaving the unclean particle board surface exposed. A work order was taped to the side of the cabinet. The work order was for the repair/replacement of the veneer and was dated 02/13/10.

Room CCU-D had multiple areas of the veneer coming off the cabinets.

The hallway outside room CCU-D was noted to contained an area approximately three feet square in which the paint was peeling and cracked and the sheet rock was exposed.

These findings were reviewed with Employee A and C on 05/14/10 at 11:30 A.M. at the time of exit.