HospitalInspections.org

Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have facilities free of life safety deficiencies. This deficiency would affect all of the 49 patients in the facility's two locations on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On 4/19/2010 surveyor #18107 observed that Building #1 had the following deficiencies: K11(Separation Wall), K15 (Room Finish), K18 (Corridor Door), K20 (Shaft), K38 (Egress), K44 (horizontal exit), K51 (Fire Alarm), K62 (Sprinklers), K77 (Med Gas), and K147 (Electrical). Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41.

2. On 4/21/2010 surveyor #18107 observed that Building #2 had the following life safety deficiencies: K11(Separation Wall), K12 (Construction Type), K17 (Corridor Walls), K18 (Corridor Doors), K27 (Smoke Doors), K29 (Hazardous Spaces), K45 (Egress Lighting), K56 (Sprinklers), K62 (Sprinklers), and K147 (Electrical). Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b).
______________________________________

Based on medical record review and staff interview the hospital failed to ensure all orders were dated, timed and authenticated promptly in 30 out of 30 (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) records reviewed.

Findings include:

From 4-19-2010 through 4-22-2010 Surveyors #26390 and #26711 review of medical records revealed for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30 there were numerous physician orders, physician consults, progress notes, pharmacy orders and History & Physicals with missing time and dates.

Surveyor #26711 reviewed the medical records for Patients #9, 10, 11, 12, 13, 14, 15, 16, 17 ,18, 19, 20, 21, 22, 23, and 24 between 4-19-2010 and 4-22-2010 and found the following:

Findings by Surveyor #26711:

A medical record review was completed on 4/20/2010 at 1:10 p.m. on Patient #9's open medical record. Patient #9 was admitted to the hospital on 2/27/2010. These findings were discovered during the medical record review:
1. No date or time for the physician (MD) signature on the history and physical
2. Three MD orders not timed
3. Ten pharmacy orders not cosigned by the MD
4. One progress note not timed
5. Twelve pre-printed progress notes not timed
These findings were confirmed by the Director of Nursing (DON) B on 4/20/10 at 2:50 p.m.

A medical record review was completed on 4/20/2010 at 3:00 p.m. on Patient #10's open medical record. Patient #10 was admitted to the hospital on 4/9/2010. These findings were discovered during the medical record review:
1. Four MD orders not timed
2. Four progress notes not timed by the MD
3. Three diabetic record flow sheets that do not include the credentials of the signers
4. Four pre-printed progress notes not timed
These findings were confirmed by DON B on 4/20/10 at 4:30 p.m.

A medical record review was completed on 4/21/2010 at 8:00 a.m. on Patient #11's open medical record. Patient #11 was admitted to the hospital on 3/25/2010. These findings were discovered during the medical record review:
1. Two MD orders not timed
2. Two progress notes not timed by the MD
3. Three pre-printed progress notes not timed
4. One order written by a (Registered Nurse) RN that does not have a time
These findings were confirmed by DON B on 4/21/10 at 1:30 p.m.

A medical record review was completed on 4/21/2010 at 10:20 a.m. on Patient #12's open medical record. Patient #12 was admitted to the hospital on 3/11/2010. These findings, during the time period of 4/1/10-4/21/10 were discovered during the medical record review:
1. The MD signature for the history and physical is not dated or timed
2. One MD orders not dated, timed, or signed
3. One MD order not dated or timed
4. Four MD orders not timed by the MD
5. Three pre-printed progress notes not timed by the MD
6. One diabetic record flow sheet that does not include the credentials of the signers
7. Two progress notes not timed by the MD
These findings were confirmed by DON B on 4/21/10 at 1:30 p.m.

A medical record review was completed on 4/21/2010 at 11:35 a.m. on Patient #13's open medical record. Patient #13 was admitted to the hospital on 4/7/2010. These findings were discovered during the medical record review:
1. Thirteen pre-printed progress notes not timed by the MD
2. Two progress notes not timed by the MD
3. Three orders written by a Pharmacist, not co-signed by the MD
These findings were confirmed by DON B on 4/21/10 at 1:30 p.m.

A medical record review was completed on 4/21/2010 at 3:40 p.m. on Patient #14's open medical record. Patient #14 was admitted to the hospital on 4/13/2010. These findings were discovered during the medical record review:
1. Five MD orders that are not timed
2. Four progress notes not timed by the MD
3. Two diabetic record flow sheets that do not contain the credentials of the signers
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/21/2010 at 2:20 p.m. on Patient #15's closed medical record. Patient #15 was admitted to the hospital on 9/10/2009 and discharged on 9/24/2009. These findings were discovered during the medical record review:
1. Ten MD orders that are not timed
2. Five progress notes not timed by the MD
3. Four pre-printed MD progress notes without a time for the MD signature
4. Four diabetic record flow sheets that do not contain the credentials of the signers
These findings were confirmed by DON B on 4/21/10 at 3:30 p.m.

A medical record review was completed on 4/21/2010 at 4:00 p.m. on Patient #16's closed medical record. Patient #16 was admitted to the hospital on 9/22/2009 and died on 10/29/2009. These findings were discovered during the medical record review:
1. There is no date or time on the history and physical for the MD signature
2. Three MD orders that are not timed
3. Four progress notes not timed by the MD
4. Five pre-printed MD progress notes without a time for the MD signature
5. One order by an RN that does not indicate a time
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/21/2010 at 2:20 p.m. on Patient #17's closed medical record. Patient #17 was admitted to the hospital on 3/27/2009 and discharged on 4/28/2009. These findings were discovered during the medical record review:
1. Two MD orders that are not timed
2. Fourteen dialysis orders that are not dated or timed by the MD3. Two orders by an RN that do not indicate a time
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/22/2010 at 8:00 a.m. on Patient #18's closed medical record. Patient #18 was admitted to the hospital on 12/4/2009 and died on 12/14/2009. These findings were discovered during the medical record review:
1. Three MD orders that are not timed
2. Two progress notes not timed by the MD
3. Two pre-printed MD progress notes without a time for the MD signature4. Four orders by an RN that do not indicate a time
5. One order by a Registered Dietician that does not indicate a time
6. One physician's assistant progress note that is not timed
7. One RN Progress note that is not timed
8. One Diabetic record flow sheet that does not include the credentials of the signers
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/22/2010 at 9:00 a.m. on Patient #19's closed medical record. Patient #19 was admitted to the hospital on 11/12/2009 and discharged on 12/8/2009. These findings were discovered during the medical record review:
1. Eighteen MD orders that are not timed
2. Twenty nine progress notes not timed by the MD
3. Four pre-printed MD progress notes without a time for the MD signature
4. Five dialysis orders that are not dated or timed by the MD; one that is not signed5. One RN progress note that is not timed
6. Four Diabetic record flow sheets that do not include the credentials of the signers
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 10:04 a.m. on Patient #20's closed medical record. Patient #20 was admitted to the hospital on 7/20/2009 and died on 10/3/2009. These findings were discovered during the medical record review:
1. The history and physical does not include a date or time of the MD signature
2. The discharge summary does not include a date or time of the MD signature
3. There are six consults from other physicians that do not include dates or times of the MD signatures
4. Eleven MD orders that are not timed
2. Twenty seven progress notes not timed by the MD
3. Five pre-printed MD progress notes without a time for the MD signature
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 11:30 a.m. on Patient #21's closed medical record. Patient #21 was admitted to the hospital on 2/1/2010 and discharged to hospice on 3/10/2010. These findings were discovered during the medical record review:
1. The history and physical does not include a date or time of the MD signature
2. The discharge summary does not include a date or time of the MD signature
3. There are three consults from other physicians that do not include dates or times of the MD signatures
4. Three MD orders that are not timed
5. Six progress notes not timed by the MD
6. One Registered Dietician order that is not timed
7. Ten Diabetic record flow sheets that do not include the credentials of the signer
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:15 p.m. on Patient #22's closed medical record. Patient #22 was admitted to the hospital on 1/21/2010 and left against medical advice (AMA) on 2/2/2010. These findings were discovered during the medical record review:
1. The history and physical does not include a date or time of the MD signature
2. The discharge summary does not include a date or time of the MD signature
3. There is one consult from another physician that does not include the date or time of the MD signature
4. Two MD orders that are not timed
5. Two progress notes not timed by the MD
6. Eleven pre-printed progress notes without a time for the MD signature
7. One RN order that is not timed
8. Four Diabetic record flow sheets that do not include the credentials of the signers
9. The AMA form is not on the chart despite documentation in the medical record stating that it was signed by the patient and placed in the record
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:30 p.m. on Patient #23's closed medical record. Patient #23 was admitted to the hospital on 5/7/2009 and transferred to another acute care facility on 5/14/2009. These findings were discovered during the medical record review:
1. The history and physical does not include a date or time of the MD signature
2. The discharge summary does not include a date or time of the MD signature
3. Three MD orders that are not timed, one that is not dated or timed
4. Five progress notes not timed by the MD
5. Ten pre-printed progress notes without a time for the MD signature
6. Three dialysis order sheets that do not include a time of the MD signature
7. Two Diabetic record flow sheets that do not include the credentials of the signers
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:55 p.m. on Patient #24's closed medical record. Patient #24 was admitted to the hospital on 6/6/2009 and transferred to a long term care facility on 6/17/2009. These findings were discovered during the medical record review:
1. The history and physical does not include a date or time of the MD signature
2. The discharge summary does not include a date or time of the MD signature
3. One consult from a physician that does not include the time or date for the MD signature
4. Seven progress notes not timed by the MD
5. One pre-printed progress notes without a time for the MD signature
6. One Diabetic record flow sheet that does not include the credentials of the signers
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

These findings along with additional timing and dating findings for Patients #1, 2, 3, 4, 5, 6, 7, 8, 25, 26, 27, 28, 29 and 30 were confirmed on 4-22-2010 by Director of Nursing (DON) B, at 1:20 PM.

Based on record review the hospital failed to ensure all verbal orders are authenticated within 48 hours in 24 out of 30 records reviewed.

Findings by Surveyor #26390:
A medical record review was completed on 4/19/2010 at 1:50 p.m. on Patient #1's open medical record. Patient #1 was admitted to the hospital on 4/2/2010. These findings were discovered during the medical record review:
Seven telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON F on 4/19/10 at 3:50 p.m.

A medical record review was completed on 4/19/2010 at 2:15 p.m. on Patient #2's open medical record. Patient #2 was admitted to the hospital on 3/30/2010. These findings were discovered during the medical record review:
Three telephone orders were not authenticated by the MD within 48 hours. These findings were confirmed by DON F on 4/19/10 at 3:50 p.m.

A medical record review was completed on 4/20/2010 at 3:00 p.m. on Patient #3's closed medical record. Patient #3 was admitted to the hospital on 3/10/2010. These findings were discovered during the medical record review:
Six telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/20/10 at 4:00 p.m.

A medical record review was completed on 4/21/2010 at 9:55 a.m. on Patient #4's open medical record. Patient #4 was admitted to the hospital on 4/9/2010. These findings were discovered during the medical record review:
Six telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/21/10 at 3:30 p.m.

A medical record review was completed on 4/21/2010 at 1:00 p.m. on Patient #5's closed medical record. Patient #5 was admitted to the hospital on 8/20/2009. These findings were discovered during the medical record review:
Four telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON F on 4/19/10 at 3:50 p.m.

A medical record review was completed on 4/21/2010 at 1:50 p.m. on Patient #6's closed medical record. Patient #6 was admitted to the hospital on 1/19/2010. These findings were discovered during the medical record review:
Ten telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 9:10 a.m.

A medical record review was completed on 4/22/2010 at 9:30 a.m. on Patient #7's closed medical record. Patient #7 was admitted to the hospital on 12/7/2009. These findings were discovered during the medical record review:
Review of physician orders from 12/7/2009 through 12/28/2009 revealed five telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 4:00 p.m.

A medical record review was completed on 4/22/2010 at 10:30 a.m. on Patient #8's closed medical record. Patient #8 was admitted to the hospital on 10/1/2009. These findings were discovered during the medical record review:
Ten telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 4:00 p.m.

Findings by Surveyor #26711:

A medical record review was completed on 4/20/2010 at 1:10 p.m. on Patient #9's open medical record. Patient #9 was admitted to the hospital on 2/27/2010. These findings were discovered during the medical record review:
Three Telephone orders not authenticated by the physician (MD) within 48 hours
These findings were confirmed by the Director of Nursing (DON) B on 4/20/10 at 2:50 p.m.

A medical record review was completed on 4/21/2010 at 8:00 a.m. on Patient #11's open medical record. Patient #11 was admitted to the hospital on 3/25/2010. These findings were discovered during the medical record review:
Three telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/21/10 at 1:30 p.m.

A medical record review was completed on 4/21/2010 at 10:20 a.m. on Patient #12's open medical record. Patient #12 was admitted to the hospital on 3/11/2010. These findings, during the time period of 4/1/10-4/21/10 were discovered during the medical record review:
Eight telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/21/10 at 1:30 p.m.

A medical record review was completed on 4/21/2010 at 3:40 p.m. on Patient #14's open medical record. Patient #14 was admitted to the hospital on 4/13/2010. These findings were discovered during the medical record review:
Two telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/21/2010 at 4:00 p.m. on Patient #16's closed medical record. Patient #16 was admitted to the hospital on 9/22/2009 and died on 10/29/2009. These findings were discovered during the medical record review:
Four telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/21/2010 at 2:20 p.m. on Patient #17's closed medical record. Patient #17 was admitted to the hospital on 3/27/2009 and discharged on 4/28/2009. These findings were discovered during the medical record review:
Six telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 9:20 a.m.

A medical record review was completed on 4/22/2010 at 9:00 a.m. on Patient #19's closed medical record. Patient #19 was admitted to the hospital on 11/12/2009 and discharged on 12/8/2009. These findings were discovered during the medical record review:
Nine telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 10:04 a.m. on Patient #20's closed medical record. Patient #20 was admitted to the hospital on 7/20/2009 and died on 10/3/2009. These findings were discovered during the medical record review:
Eleven telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 11:30 a.m. on Patient #21's closed medical record. Patient #21 was admitted to the hospital on 2/1/2010 and discharged to hospice on 3/10/2010. These findings were discovered during the medical record review:
Seven telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:15 p.m. on Patient #22's closed medical record. Patient #22 was admitted to the hospital on 1/21/2010 and left against medical advice (AMA) on 2/2/2010. These findings were discovered during the medical record review:
Two telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:30 p.m. on Patient #23's closed medical record. Patient #23 was admitted to the hospital on 5/7/2009 and transferred to another acute care facility on 5/14/2009. These findings were discovered during the medical record review:
Thirteen telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

A medical record review was completed on 4/22/2010 at 12:55 p.m. on Patient #24's closed medical record. Patient #24 was admitted to the hospital on 6/6/2009 and transferred to a long term care facility on 6/17/2009. These findings were discovered during the medical record review:
Three telephone orders not authenticated by the MD within 48 hours
These findings were confirmed by DON B on 4/22/10 at 1:20 p.m.

Findings by surveyor #26390:
A medical record review was completed on 4/22/2010 at 11:25 a.m. on Patient #25's open medical record. Patient #25 was admitted to the hospital on 4/14/2010. These findings were discovered during the medical record review:
Three telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 1:17 p.m.

A medical record review was completed on 4/22/2010 at 12:00 p.m. on Patient #27's open medical record. Patient #27 was admitted to the hospital on 4/17/2010. These findings were discovered during the medical record review:
Two telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 1:17 p.m.

A medical record review was completed on 4/22/2010 at 12:20 p.m. on Patient #28's open medical record. Patient #28 was admitted to the hospital on 4/14/2010. These findings were discovered during the medical record review:
Seven telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 1:17 p.m.

A medical record review was completed on 4/22/2010 at 12:38 p.m. on Patient #30's open medical record. Patient #30 was admitted to the hospital on 4/12/2010. These findings were discovered during the medical record review:
Two telephone orders not authenticated by the MD within 48 hours.
These findings were confirmed by DON B on 4/22/10 at 4:00 p.m.

Based on medical record review and staff interview, this facility does not ensure that all patients have a completed history and physical examination in the medical record within a 24 hour period of admission in 2 out of 30 medical records reviewed (Patient #23 & #28).

Findings include:

A medical record review was completed on Patient #23's closed medical record on 4/22/2010 at 12:30 p.m. Patient #23 was admitted to the hospital on 5/7/2009. The history and physical was not dictated by the physician until 5/22/2009, 15 days after Patient #23's admission.

A medical record review was completed on Patient #28's closed medical record on 4/22/2010 at 12:20 p.m. Patient #28 was admitted to the hospital on 3/22/2010. The history and physical was not dictated by the physician until 3/30/2010, 8 days after Patient #28's admission.


This finding was confirmed on 4/22/2010 at 1:20 p.m. by the Director of Nursing B.

Based on medical record review and staff interview this hospital failed to obtain properly executed consent forms in 29 out of 30 medical records reviewed (Patient's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30) by not including the time the consent form was signed by the patient or the patient's representative.

Findings include:

Medical record reviews were completed on Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, and 30 between 4/19/2010 and 4/22/2010. All of these patient's consent forms for treatment, resuscitation, blood products, and/or photographing did not include the time the consent was obtained thereby not establishing a chronological order.

These findings were discussed and confirmed with the Director of Nursing B at the time of the medical record reviews on 4/19/2010-4/22/2010.

Based on record review the hospital failed to ensure completion of medical records within 30 days following discharge for 2 of 12 (out of a total sample of 30) discharged patient records, patients #15 and #17.

Findings by Surveyor #26711:

A medical record review was completed on 4/21/2010 at 2:20 p.m. on Patient #15's closed medical record. Patient #15 was admitted to the hospital on 9/10/2009 and discharged on 9/24/2009. Patient #15's discharge summary was not completed until 10/27/2009, more than 30 days after discharge.
This was confirmed by the Director of Nursing (DON) B on 4/21/2010 at 3:30 p.m.

A medical record review was completed on 4/21/2010 at 4:30 p.m. on Patient #17's closed medical record. Patient #17 was admitted to the hospital on 3/27/2009 and discharged on 4/28/2009. Patient #17's history and physical was not signed by the physician until 5/12/2009 and the consent for the administration of blood products has not been signed by the physician as of 4/21/2010. Both examples are more than 30 days after discharge.
This was confirmed by DON B on 4/22/2010 at 9:20 a.m.

Based on tour of the facility, policy and procedure review, and staff interview, this facility failed to ensure outdated and unusable medications were not available for patient use. Also, staff was not able to identify the proper protocol for dating multi-dose vials according to their policy.

Findings include:

Facility policy titled, " Medication Administration " was reviewed on 4/22/10 in the morning. The policy states, on page 2 of 5, #14. " At the time when multi-use containers (vials) intended for injection are opened, these containers are marked with the date and time of expiration ....The vial is to be discarded on or before the expiration date. "

On 4/19/10 at 4:00 p.m. a tour of the hospital was conducted by Surveyor #26711 and the Director of Nursing (DON) B. In the medication room the following items were found:
1. An empty undated bottle of Gastrografin (a solution used when performing scans of the abdominal area to highlight the tract internally) in an upper cupboard.
2. A vial of Tuberculin serum in the refrigerator with the date of 3/16 written on the label.
3. A vial of Influenza vaccination in the refrigerator that was not dated.
DON B stated the Gastrografin bottle should not have been in the cupboard, and should have been dated when it was opened and discarded it. DON B also acknowledged that the Tuberculin serum was expired, the date written on the vial being the date it was opened, and that the Influenza vaccine did not have a date written on it, and discarded both of these items.

On 4/21/10 at 9:22 a.m. Surveyor #26711 returned to the medication room with Surveyor #14941 and Pharmacist J. A vial of Tuberculin serum was discovered in the same area of the refrigerator as on 4/19/10 with a date of 1/29 written on it. This date was verified by Surveyor #14941 at the time of discovery and again at 12:40 p.m., and the vial was discarded in the presence of Pharmacist J.

On 4/21/10 around 9:30 a.m. Pharmacist J returned to the conference room where Surveyors #26711 and # 14941 were located, and was accompanied by Pharmacy Technician (tech) K. Pharmacy Tech K stated that the date written on the vial was 4/26 and was the expiration date-as per policy-and therefore would not expire until 4/26.

In an interview with Registered Nurse (RN) L on 4/21/10 at 11:00 a.m., RN L stated that the date written on the multi-dose vials is the date the vial is opened and that the medication would expire 30 days after that date.

The date written on multi-dose medication vials was verified by DON B, DON F, and Director of Quality C on 4/21/10 at 3:05 p.m. as being the date the vial was opened.

On 4/22/10, after reviewing the policy regarding dating of medication vials and discussing this with DON B, it was determined that the staff is not following the policy and the medications were still expired.

Based on interview and record review, the hospital did not report medication errors to the attending physician in 10 of 21 reports reviewed. In addition the hospital was given three incident reports which indicated physician notification was documented in the medical record. In 3 of 3 incident reports provided, no physician notification was documented.

This is evidenced by the following:

On April 21, 2010, medication error reports were reviewed for errors that occurred from September 2009 through December 2009. A total of 21 medication error reports were identified during this period. The form the facility uses has a section to document notification of the attending physician. Of the 21 medication errors documented ten of the reports did not have the name of the physician and the date and time the physician was notified.

Of the 10 medication error reports that did not document physician notification, the errors identified included:

September 2009
9/1/09 No order for the drug colistemethate. Given in error.
9/19/09 Omission error for Zosyn.
09/27/09 Omission error for Cubicin
09/30/09 Wrong dose of sliding scale insulin

October 2009
10/20/09 Wrong patient for Zosyn

November 2009
11/8/09 Wrong medication (Unasyn given instead of ampicillin).
11/19/09 Omission of Cefipime
11/23/09 Wrong dose of metoprolol

December 2009
12/19/09 Omission of Duoneb for 33 doses.
12/27/09 Omission of Tygacil

A review of the facility Medication Errors integrated manual reference M03-P Issued on 1/2000 and last revised on 2/2006 indicates that the attending physician is to be notified so the patient can be examined for adverse effects, if necessary. Attempts to notify the physician should be noted in the patient ' s permanent medical record.

In an interview with Staff C, Director of Quality Assurance, on 4/21/2009 at 2:05 p.m. it was stated to surveyor #14941, that the hospital policy does indicate physician notification is to be documented in the permanent record. Sometimes the documentation is on the incident form that is used for medication errors and other incidents. Staff C was specifically asked about antibiotic and other medication omissions and physician notification. Staff C indicated that physician notification documentation is inconsistent.

As a follow up, surveyor #26711 provided the hospital three incident reports that would require physician notification. The incident reports did not have physician notification documented on the form however Staff C indicated the medical record should have been documented. In an interview with Staff C on 4/21/10 at 4:15 p.m., Staff C stated to surveyor #26711: there was no documentation in three out of three medical records regarding contact to the physician.

The hospital is not consistently documenting physician notification for medication errors and other incidents occurring to patients.

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 fully insulated pipes, counters free of damage, caulk joint free of damage, and walls and floors free of damage. This deficiency occurred in 3 of the 3 smoke compartments in Building #1 and 1 of 4 smoke compartments in Building #2, and would affect all of the 49 patients in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On 4/19/2010 at 10:05 am surveyor #18107 observed on the 4th floor in the 4127-Closet, located in the 4-Central smoke compartment, that a portion of piping was missing insulation. Two copper pipes were observed missing insulation after receiving repairs. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select Spec. Hosp.-Corp Fac. Dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. Dept.).

2. On 4/19/2010 at 10:15 am surveyor #18107 observed on the 4th floor in the 4013-Nourishment Room, located in the 4-Central smoke compartment, that a portion of the counter was damaged and in need of repair. The plastic laminate counter top was delaminating and found to have porous surface at some locations. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. Luke's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

3. On 4/19/2010 at 10:25 am surveyor #18107 observed on the 4th floor in the toilet rooms of all inpatient wings, located in the 4-North & 4-West smoke compartment, that a portion of a caulk joint was damaged and in need of repair. The surveyor observed throughout the survey tour that the caulking around toilet fixtures was pulling away from the toilet and tile. The surveyor observed there was dark residue of dirt and other particles between the caulk and the fixture. This situation occurred in all inpatient, outpatient and staff toilet room spaces. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

4. On 4/19/2010 at 10:28 am surveyor #18107 observed on the 4th floor in the 4102A-Patient Toilet Room, located in the 4-West smoke compartment, that a portion of a wall was damaged and in need of repair. Surveyor observed in the wall adjacent to the hand washing fixture holes from previously removed screws and other supports were not filled. There were also damaged surfaces from objects hitting the wall. A number of past repairs were left with bare drywall compound patches that were not prime-painted and sealed with washable paint. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

5. On 4/19/2010 at 10:30 am surveyor #18107 observed on the 4th floor in the 4102-Conference Room, located in the 4-West smoke compartment, that a portion of the counter was damaged and in need of repair. The window sill was covered by a plastic laminated sill cover plate that was beginning to delaminate at the windows edge. The sill cover was separated 3/4 inch to 1 inch from the window frame itself, allowing mold and other infectious build-up within the cavity. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

6. On 4/19/2010 at 10:37 am surveyor #18107 observed on the 4th floor in the 4108-Staff Lounge Room, located in the 4-West smoke compartment, that a portion of the counter was damaged and in need of repair. The edges of the plastic laminated counter tops were delaminating in an approximate 4 different locations across the entire surface and backsplash. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr .PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

7. On 4/19/2010 at 10:40 am surveyor #18107 observed on the 4th floor in the 4108B-Storage Closet, located in the 4-West smoke compartment, that a portion of piping was missing insulation. A 12 inch piece of hot water pipe insulation in the ceiling was missing at the end of the pipe. Surveyor #18107 learned during an interview with Staff P that a sink was removed at this location and the remaining piping was not re-insulated. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

8. On 4/19/2010 at 10:50 am surveyor #18107 observed on the 4th floor in the 4112-Isolation Anteroom, located in the 4-West smoke compartment, that a portion of a wall was damaged and in need of repair. Two walls were damaged from several holes caused by screws of other projectiles into the wall. These openings were not repaired or covered. This area is a highly infectious area where airborne contaminates may be present when used by an infected inpatient. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

9. On 4/19/2010 at 10:55 am surveyor #18107 observed on the 4th floor in the 4112A-Isolation Room, located in the 4-West smoke compartment, that a portion of a caulk joint was damaged and in need of repair. The toilet fixture at the floor was missing caulk around approximately 1/3 of the toilet perimeter and was collecting dirt. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

11. On 4/19/2010 at 11:25 am surveyor #18107 observed on the 4th floor in the 4015-Soiled Utility Room, located in the 4-Central smoke compartment, that a portion of a caulk joint was damaged and in need of repair. The clinic service sink fixture at the floor was missing caulk and was collecting dirt. The lavatory was missing caulk at places and collecting dirt. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

12. On 4/19/2010 at 11:30 am surveyor #18107 observed on the 4th floor in the 4015-Soiled Utility Room, located in the 4-Central smoke compartment, that a portion of a wall was damaged and in need of repair. The acrovyn wall material was peeling away from the walls in several locations at meeting edges. This observed situation was not compliant with CFR 482.41(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

13. On 4/19/2010 at 5:12 p.m. surveyor #18107 observed on the 2nd floor in the 275-Soiled Holding Rm., located in the North smoke compartment, that a portion of the flooring was damaged and in need of repair. The flooring material near the door was damaged and cracked and allowed a build-up of contaminated particles. It presented a potential for tripping hazard. This observed situation was not compliant with CFR 482.41(a). This deficiency was confirmed at the time of discovery by a concurrent observation and interview with The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Corporate Facilities Director).

Based on observation, review of maintenance documents, and staff interviews the facility did not construct, install and maintain the building systems to ensure a life safety environment in the buildings to meet the minimum requirements of the 2000 Edition of the Life Safety Code for Chapter 19, "Existing Health Care Occupancy," in Building #1 and for Chapter 18, "New Health Care Occupancy," in Building #2. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the 7 smoke compartments in the two surveyed facilities, and would affect all of the 49 inpatients and outpatient in the facility on the day of the survey, as well as staff and visitors.

FINDINGS INCLUDE:
1. On 4/19/2010 surveyor #18107 observed that Building #1 had the following life safety deficiencies: K11(Separation Wall), K15 (Room Finish), K18 (Corridor Door), K20 (Shaft), K38 (Egress), K44 (horizontal exit), K51 (Fire Alarm), K62 (Sprinklers), K77 (Med Gas), and K147 (Electrical). Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b).

2. On 4/21/2010 surveyor #18107 observed that Building #2 had the following life safety deficiencies: K11(Separation Wall), K12 (Construction Type), K17 (Corridor Walls), K18 (Corridor Doors), K27 (Smoke Doors), K29 (Hazardous Spaces), K45 (Egress Lighting), K56 (Sprinklers), K62 (Sprinklers), and K147 (Electrical). Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with CFR 482.41(b).
______________________________________

Based on tours, observations, review of policy and procedures, and interviews with staff, the facility failed to : 1) maintain a sanitary environment through environmental cleanliness 2)ensure patients and visitors are protected from the spread of potential sources of infections 3) follow CDC cleaning guidelines and CDC separation guidelines, in 3 of the 3 smoke compartments, and would affect all of the 20 patients in the facility on the day of the survey, as well as staff and visitors. The facility had a licensed bed capacity of 29. Also, the facility ' s policy regarding hand washing does not follow the recommendations by the Centers for Disease Control (CDC).

Findings include:
1)As observed by surveyor #26390: On 4-19-2010 at 11:15 a.m. tour of the Hospital's St. Luke ' s location with Director of Clinical Services (DCS) F, revealed the following:
The hospital has two wings C&D.
The following observations were made during the tour:
Bathroom on the 4C wing outside the conference room was observed to have accumulated brown dirt around the entire bathroom where the tiled floor meets the wall.
Clean storage room on the same wing contained 10 unsecured oxygen tanks, 3 original shipping boxes, air return vent was covered with dirt and dust, and the doorway threshold had an accumulation of brown dirt where the floor meets the walls.
Gurney shower room had broken tiles on the corners, dirty floor tiles and the wall tiles near the floor were dirty.
Wound care supply closet had a dust and dirt covered vent.
Through out the hallways on wings C & D walls had multiple areas of crumbling drywall, an accumulation of dirt on the corners and where the floor meets the walls.
Medical record wall boxes (Wall-a-roos) were covered in a brown dust.
Medical supply room contained 4 original shipping boxes.
Respiratory Therapist office had a vent covered with dust and dirt.
Housekeeping closet contained 9 packets of Kin Vent Prep Packs, no separation of clean supplies from dirty supplies, was not locked, floor and walls were dirty.
Medication room behind the nurses station had dirty floor, walls with brown drips down to the floor. An accumulation of brown dirt, where the floor meets the walls.
Dirty storage room had accumulated brown dirt on the floor and walls.
Patient rooms with an accumulation of brown dirt where the floor meets the walls especially at doorway thresholds, air return vents were visibly covered in brown dirt and dust.
All the above observations were confirmed during the tour with DCS, F.

2)Surveyor #26711- Facility policy IC III-2, titled, "Hand Hygiene", was reviewed on 4/22/10 at 1:30 p.m. On page 2 of the policy, under the heading of "When", the following bullet points are noted: "When moving from high contamination patient care activities to cleaner activities; After any contact with body fluids, dressings, patient linen; Before any patient procedure or medication administration;

In the section titled "Other Important Considerations" of the same policy, the following bullet point is noted: "If caring for a C diff [Clostridium difficile, a highly contagious bacteria that can cause severe diarrhea] patient: use soap and water."

Within this same policy are entries which are in conflict with accepted standards of care from the CDC regarding hand hygiene in health care settings as recorded in the CDC's Morbidity and Mortality Weekly Report (MMWR) dated October 25, 2002/Vol. 51/No. RR-16.

Under the heading of "When," the following bullet points are not considered an appropriate standard of care for hand hygiene: "Between glove changes if the integrity of the glove has been breached (it has a hole) or the hands have become soiled-otherwise the gloves will be removed using proper technique so as not to contaminate hands and clean gloves placed." The CDC recommendation is: "Decontaminate hands after removing gloves."

Under this same heading, another bullet point not considered an appropriate standard of care by the CDC is: "If moving from a contaminated body site to a less contaminated body site (peri-care to trach care) if integrity of gloves was breached; otherwise changing of gloves is sufficient." The CDC recommendation is: "Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care."

These items were discussed with the Director of Quality C on 4/22/10 at 1:45 p.m. who made a copy of the CDC recommendations.

During a tour of the hospital with Director of Nursing (DON) B on 4/19/10 at 4:00 p.m., Surveyor #26711 found linens intended for patient use in an empty patient room in a cupboard. DON B explained that if the previous patient was not on isolation precautions, the linens are left in the room to be used on the next incoming patient. This practice does not protect the incoming patient from potential contamination by whomever may have touched these linens.

DON B agreed with Surveyor #26711's explanation.

During this same tour a bladder scan machine was found in the clean negative pressure room with a pair of dirty discarded gloves laying on the tray of the machine. The machine was now considered dirty and in need of decontaminating. DON B agreed with this finding.

On 4/21/10 at 9:38 a.m. Surveyor #26711 observed Registered Nurse (RN) L during medication administration. Upon entering the room of Patient #12, who was on isolation precautions for C. Diff and MRSA (Methicillin-resistant Staphylococcus Aureus, a bacteria that is highly resistant to antibiotics), RN L applied a gown and gloves after washing her hands. RN L then touched Patient #12's rectal tube, touched his arm/skin to check his arm band as he was unable to identify himself, and proceeded to prepare the medication by using a syringe and warm water to dissolve the medication to give it through a tube that enters the abdomen.

RN L went from touching areas of contamination to touching clean areas (medication preparation equipment) without changing her gloves or washing her hands, thereby potentially reinfecting Patient #12.

On 4/21/10 at 1:40 p.m. Surveyor #26711 observed Respiratory Therapist (RT) N deliver a respiratory treatment and complete closed system suctioning of a tracheostomy for Patient #28. Patient #28 was on isolation for C. Diff and hand washing required the use of soap and water. There was a sign at the door indicating these hand washing directions. On the four occasions that RT N changed gloves and washed her hands, alcohol based hand gel was used, not soap and water. RT N also brought the clip board containing Patient #28's RT notes into the room and set it on the soiled linen cart in the room, thereby contaminating the clip board. RT N picked up the clip board without gloves on and returned it to the cabinet outside of the room, thereby being a potential source of contamination for all staff who touch it.

These findings were discussed on 4/21/10 at 3:10 p.m. with DON B, Director of Quality C, and Administrator A, who acknowledge understanding.

3) On 4/19/2010 at 10:45 am surveyor #18107 observed on the 4th floor in the entire facility, located in the 4-West, 4-North, 4-South & 4-Central smoke compartment, that visible accumulation of dirt and dust were present in this health care environment. All return and supply grilles were observed dirty and dusty. The maintenance of the grilles are the responsibility of Aurora St. Luke's maintenance staff, per a contractual agreement between 'entities'. No reports of annual duct cleaning could be provided at the time of the survey exit. This observed situation was not compliant with CFR 482.42(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

On 4/19/2010 at 11:40 am surveyor #18107 observed on the 4th floor in the 4015-Soiled Utility Room, located in the 4-Central smoke compartment, that clean and soiled areas were inter-mixed for storing items. The wall mounted storage cabinet above the counter in this soiled room contained over 25 clean flower vases that were intended for use in inpatient sleeping rooms. During interview with Staff F (RN) at 11:41 AM on 4/19/2010, surveyor #18107 confirmed that the vases were clean and would be placed in patient sleeping rooms without further cleaning. This observed situation was not compliant with CFR 482.42(a). The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff P (Select spec. hosp.-Corp Fac. dir.), Staff Q (Aurora St. luke's's Med. Ctr-Mgr. PO), Staff S (Aurora St. Luke's Med. Ctr.-Supervisor Maint. dept.).

Based on document review and staff interview the hospital failed to have a complete agreement and policy and procedure for notifying the Organ Procurement Organization.

Findings Include:

On 4/19/2010 at 10:32 AM review of Policy & Procedure titled Organ and Tissue Donation after Death, and the agreement with the OPO (Organ Procurement Organization) revealed no definition of imminent death. The Policy & Procedure does not include protocol for notifying the OPO of imminent death.

On 4/22/2010 at 8:53 AM interview with CEO A, Director of Quality C, and Director of Clinical Services (DCS) B, revealed the hospital does have procedures to follow when a death occurs but does not have a procedure for notifying the Organ Procurement Organization (OPO) of imminent death.

On 4/22/2010 at 7:45 AM interview with Charge Nurse, O revealed the staff do not notify the OPO of imminent death. Charge Nurse, O stated " we have to call when a patient passes away, not aware of any cases that we have called before they died. "

Based on a tour, observations, and staff interview, this facility fails to protect patient records from unauthorized individuals.

Findings include:

A tour of the medical record office was conducted on 4/19/10 at 2:30 p.m. with Surveyor #26711 and Medical Records staff (MR) G.

In the office, there were patient medical records sitting out on an open rack waiting for coding from the corporate office, according to MR G.

MR G stated that the housekeeping staff, a contracted department, clean this office after hours when no one from medical records is present. These unauthorized personnel have access to patient's confidential medical information.

This was confirmed on 4/20/10 at 4:15 p.m. with Director of Nursing B, Director of Quality C, and Administrator A.